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St Hugh's Hospital

Grading:  - Requires Improvement

Overall we rated safe as inadequate. There was a lack of robust systems and processes in place to manage patient safety. However there was evidence that a review of governance arrangements had started prior to inspection. We did not find evidence of thorough and robust incident investigations and there was a lack of assurance that learning from incidents was shared throughout the surgical service. There was a lack of evidence that action plans following the investigation of incidents were complete and evidence of root cause analysis was weak. Staff demonstrated an understanding of being open with patients when things went wrong but did not have a full understanding of the requirements of the statutory Duty of Candour.