Source · CQC inspection

University Hospital North Durham

Provider County Durham and Darlington NHS Foundation Trust Type NHS Healthcare Organisation Region North East Last inspected 12 Jun 2026

Overall rating: Good View full CQC report

Domain ratings

Five CQC key questions

Safe

Requires Improvement

Effective

Good

Caring

Good

Responsive

Good

Well-led

Good

Current CQC assessment

Single Assessment Framework

From 2024 CQC rates services through ongoing assessments rather than comprehensive inspections.

Good Assessed 12 June 2026

The service is performing well and meeting our expectations.

County Durham and Darlington NHS Foundation Trust provides healthcare services to a population of 650,000 people across County Durham and Darlington, and surrounding areas. It sits within the North East and North Cumbria Integrated Care System (ICS). It is registered to provide the following regulated activities: Treatment of Disease, Disorder or Injury, Surgical Procedures, Diagnostic and Screening Procedures. University Hospital North Durham (UHND) has approximately 528 beds and provides a range of NHS hospital services. This assessment looked at surgery services due to aged rating and emerging risk. We conducted …

Ratings by service

Surgery

Requires Improvement

Jun 2025

Urgent and emergency services

Good

Jun 2024

Regulatory breaches & enforcement

Current-framework "must do" equivalent

Breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, stated verbatim in the CQC assessment.

Warning notice Overall

We took enforcement action and served a Warning Notice under Section 29A of the Health and Social Care Act 2008, which requires the trust to make significant improvement to the quality of healthcare provided.

· 12 Jun 2026 · CQC source

Breaches identified (1)

Breach Safe

We found breaches of the regulations in relation to safe care and treatment, safe staffing and governance.

Regulation: Regulation 12 (Safe care and treatment) · 12 Jun 2026

Earlier inspection findings

pre-2024 framework · 6 must-do 5 should-do

Must-do actions (6)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 6

Must do

Safe

The service must ensure that staff complete all maternity mandatory training, including but not limited to, role specific training modules and skill and drills.

Regulation: Regulation 18(2)(a)

⚠ The service still did not make sure everyone completed mandatory training and essential skills and drills, although compliance had improved since our last inspection. Trust compliance targets for other mandatory training were still not always met. For example, deteriorating patient and resuscitation training compliance by midwifery staff was 69% and …

Must-do action 2 of 6

Must do

Safe

The service must ensure staff complete all environmental and emergency equipment safety checks in accordance with trust policy.

Regulation: Regulation 15(1)(e)(2)

⚠ Staff did not always complete environmental safety checks and emergency equipment checks in accordance with trust policy, and compliance remained poor. For example, for the period November 2023 to 23 January 2024, the neonatal emergency resuscitation equipment trolley daily check compliance was 54.7%. We found an expired intravenous normal saline …

Must-do action 3 of 6

Must do

Safe

The service must ensure that systems and processes for maternity triage are conducted in accordance with national guidance and embedded, so to deliver a safe service.

Regulation: Regulation 17(2)(a)(b)(c)

⚠ The service recognised the triage process was not yet fully embedded. The new standard operating procedure (SOP) for triage was due to be reviewed in October 2023 and was currently being amended. Staff did not know where to access specific guidelines to be used in accordance with the SOP for …

Must-do action 4 of 6

Must do

Well-led

The service must ensure effective governance processes and systems to identify and manage incidents, risk, issues, and performance, are embedded. Progress must be monitored through completion of audits, actions and improvements and reduce the recurrence of incidents and harm, including, but not limited to, delayed inductions of labour.

Regulation: Regulation 17(1)(2)(a)(b)(e)(f)

⚠ Effective governance processes and systems to identify and manage incidents, risk, issues, and performance were not yet fully embedded. New systems and processes implemented to improve delays to induction of labour were not yet fully embedded, and the service still did not always provide timely inductions of labour to meet …

Must-do action 5 of 6

Must do

Safe

The service must ensure there are enough suitably qualified, competent, skilled and experienced midwives in order to provide safe care and treatment across the service and reduce delays in provision of safe care to reduce the risk of harm for women, birthing people, and babies.

Regulation: Regulation 18(1)

⚠ The service still did not always have enough maternity staff with the right qualifications, skills, training, and experience to ensure safe care and treatment for women, birthing people, and babies. The number of midwives and healthcare assistants did not always match the planned numbers, and consistently suboptimal numbers of staff …

Must-do action 6 of 6

Must do

Safe

The service must ensure the proper and safe storage and management of medicines and there is a robust system in place to ensure service users do not receive expired items and expired medicines.

Regulation: Regulation 12(2)(g)

⚠ The service did not always use systems and processes to safely prescribe, administer, record and store medicines. We found mixed ampoules of injectable emergency medicines stored together in a plastic carton and not in original packaging. Ambient room temperatures where medicines were stored were not monitored. On PAU, we found …

Should-do actions (5)

Recommended improvements to enhance service quality.

Should-do action 1 of 5

Should do

Caring

The service should consider ways to ensure women’s privacy and dignity are always protected when in theatre.

Should-do action 2 of 5

Should do

Safe

The service should consider formal risk assessment of safestorage of products containing latex, including but not limited to surgical gloves and gauntlets.

Should-do action 3 of 5

Should do

Well-led

The service should consider ways to improve security of the theatre register.

Should-do action 4 of 5

Should do

Well-led

The service should continue to define and develop maternity vision and values and work to embed them into practice.

Should-do action 5 of 5

Should do

Well-led

The service should consider ways to strengthen data capture within the trust maternity dashboard.