Download Appendix 2 CQC Actions - Action the hospital MUST and “SHOULD

Appendix 2
CQC Actions - Action the hospital MUST and “SHOULD DO” take to improve
BTUH MUST DO
None
MEHT MUST DO
• The provider must ensure that HSA4 forms are sent to the Chief Medical Office, within the 14 days in line with the Abortion Act 1967.
• The provider must ensure that patient records in orthopaedic clinic are stored securely
• The provider must ensure that medication, specifically paracetamol is prescribed clearly including route of administration. The provider must ensure that
patient’s weight is recorded for patient’s prescribed VTE prophylaxis and follows the National Institute of Health and clinical Excellent (NICE) guidelines.
• Ensure that staff are provided with appraisals, that are valuable and benefit staff development.
• Improve mandatory training rates, particularly in the emergency department, around (but not exclusive to) advanced adult and paediatric life support in line with
the Royal College of Nursing “Health care service standards in caring for neonates, children and young people”
• Ensure that rapid discharge of patients at the end of their life is monitored, targeted and managed appropriately.
• The provider should ensure that all resuscitation equipment have identified expiry dates.
SUHFT MUST DO
Emergency Department Services
• Improve the response rates of FFT
• Improve the security arrangements to ensure that staff and patients are protected.
Medical Services
• There must be sufficient and appropriate staff available to provide care and treatment for patients.
• The trust must review the arrangements and effectiveness of morbidity and mortality meetings.
• A daily record is made of the temperature of medicine storage rooms and for medicine refrigerators to ensure that medicines were stored within safe
temperature ranges.
• A review of the safe and effective use of two medicine prescribing systems is undertaken.
• Patient records must be fully and appropriately completed.
• The trust must ensure that all staff have the required and identified level of “both adult and children’s safeguarding training”.
• The use of whiteboards/handovers in public place that include confidential patient information should stop.
• Ward staff must all be aware of procedures to review patients who are “outliers” and when required able to escalate any concerns.
• Staff must have appropriate and suitable training opportunities to develop their practice and knowledge.
Surgery
• The trust must ensure that governance systems with pharmaceutical oversight are in place to ensure that patients are protected from the risk of harm resulting
from medication errors on the wards.
• The trust must ensure that there is clinical input into decisions to cancel operations.
Appendix 2
Critical Care
• The trust must take action to ensure sufficient numbers of suitably qualified and experience nurses are deployed on ARCU to meet standard 1.2.2 of the Faculty
of Intensive Care Medicine’s Core Standards for Intensive Care Units.
CYP
• Review and improve the robustness of complete, comprehensive, legible, chronological hard copy notes for children and young people. – Regulation 17 (2c).
• Ensure that there is an emergency plan for all children’s and young people’s areas, and that regular training is completed for awareness and preparation. –
Regulation 12 (2e)s.
• Develop and introduce a robust system for holding discussions with patients or their families where appropriate, in relation to consent and ensuring that this is
documented appropriately within the patient notes. – Regulation 12 (2h)
• Ensure that staff are sufficiently trained to be able to correctly severity grade clinical incidents, providing timely duty of candour where necessary. – Regulation
12 (2b)
EoLC
• The trust must take action to ensure mortuary facilities are secure and suitable for the purpose for which they are being used.
• The trust must take action to ensure all mortuary equipment in use is safe for use and capable of effective cleansing.
• The trust must take action to ensure sufficient numbers of suitably qualified, competent, skilled and experienced nurses are available at all times on wards caring
for palliative and end of life patients and there are sufficient end of life care consultants available to the trust.
• The trust must take action to ensure that risks presented by the flexible use of beds in specialist wards caring for palliative and end of life patients are managed
to avoid patients missing regular treatment or being displaced to wards without the skilled staff to care for them.
• The trust must take action to ensure all DNACPR Orders state whether the patient had the capacity to make decisions.
• The trust must take action to ensure deceased patient’s need for dignity and the reasonable expectations of relatives are met by the environment of the
mortuary.
• The trust must take action to ensure it improves the quality and safety of palliative and EoLC Services by identifying all risks and mitigating all identified risks in a
timely way.
OPD
• The trust must take action to ensure that learning from serious incidents in ophthalmology is shared with all outpatient departments.
• The trust must take action to ensure that the back log patients waiting for follow up appointments in ophthalmology and respiratory services are managed in a
timely manner.
• The trust must take action to improve compliance of the WHO checklist in diagnostic imaging.
TRUST
• The duty of candour regulation were not being met, there was a lack of records to demonstrate that the regulations were within root cause analysis
Appendix 2
•
investigations. We saw that letters did not always have an apology within it.
The trust must improve the response rates of FFT.
BTUH SHOULD DO
• Improve the mandatory training rates for the critical care outreach team.
• Ensure all staff receive updated equipment competency training.
• Reduce the delayed discharges over four hours from the critical care unit to the main wards.
• Reduce the number of transfers out of hours between 10pm and 7am.
• Improve the management of medicines across the medical care directorate. There is particular need to improve the recording of medicines administration and
storage and prescription of oxygen.
• Improve the governance from the top at executive level to the local wards and departments and ensure that risk assessments and service plans are available to
staff providing direct patient care in escalation areas.
• Continue to work and improve on the skill mix and staffing levels throughout the hospital.
MEHT SHOULD DO
• Safety plan and increase consultant cover in the emergency department from 11 to 16 hours per day as recommended by The Royal College of Emergency
Medicine.
• The provider should take action to improve MRSA screening for elective and emergency patients.
• The provider should improve Referral to Treatment Times (RTT) for elective patients. The provider must ensure that the trusts referral to treatment (RTT) times
are achieved in the four surgical specialities of general surgery, trauma and orthopaedics, ophthalmology and plastic surgery.
• The provider should take action to reduce the number of cancelled elective plastic surgery operations and monitor cancellation rates for trauma patients.
• The provider should improve the percentage of patients receiving treatment within 62 days of referral.
• The provider should ensure that glucometers are checked as per hospital policy.
SUHFT SHOULD DO
Medicine Service
• Staff should receive training in the principle of duty of candour and procedures that relate to it.
• A review of the environment on the AMU should be undertaken to ensure that there is sufficient space to safely access and exit the ward,
• Care pathways are in place for endoscopy procedures.
• The competencies required of staff to work in AMU staff should be reviewed.
Surgery
• Full implementation of the electronic prescribing system should be expedited across all wards to reduce delays in the dispensing of medications and to increase
safety through the removal of the dual prescribing system in place at the time of inspection.
• Encourage and act on feedback via the NHS FFT to ensure that the service is achieving the average national percentage of 95% for those who would recommend
the service.
• When surgical operations are cancelled and a patient is not treated within 28 days of the cancellation, the trust should investigate the causes and implement
Appendix 2
actions to address them.
Critical Care
• The trust should ensure data from ARCU is submitted to the Intensive Care National Audit and Research Centre (ICNARC) or similar national audits.
Maternity & Gynaecology
• The trust should review medical presence on the labour ward to meet best practice recommendations.
• The trust should improve attendance at mandatory training.
• The trust should have a maternity and gynaecology strategy.
• The trust should store medical records securely and are not accessible to the public.
• The trust should inform the people using the service how to complain.
• The trust should review and reduce the amount of operations that are cancelled.
• The trust should display maternity outcomes for staff to see.
• The trust should improve the completion of risk assessments on the gynaecology ward.
• The trust should review the gynaecology ward handovers.
• The trust should ensure patients are not identifiable on boards that are in view of the public.
CYP
• Ensure that bathroom cleaning schedules are adhered to, in order to promote health and well-being. – Regulation 12 (2h)
• The service must be able to assure itself that all reasonable steps are being taken to minimise paediatric waiting lists, ensuring there is a robust at and fair system
implemented for trust decision changes to patient appointments.
• Provide assurance that children’s and young people’s staff members are all familiar with both Gillick competence and Fraser guidelines. – Regulation 11, (1,3).
• Be able to provide assurance that having surgical adult patients located within the children’s ward for recovery purposes does not cause a safety issue for
children on the unit. Regulation 12 (b)
EoLC
• The trust should consider improving assessment of the spiritual needs of patients, relatives of friends.
• The trust should ensure end of life patients can be discharged quickly to their preferred place of death.
• The trust should ensure the practice of “flipping” areas of specialist wards to care for general medical patients when the hospital is under pressure is put under
review.
• Arrangements for attendance by a consultant haematologist to the weekly multidisciplinary palliative care meetings should be reviewed.
OPD
• The trust should take action to improve the levels of medical staffing in respiratory and ophthalmology services.
• The trust should take action to improve the level of radiographer and radiologist staffing levels.
• The trust should take action to ensure equipment in the diagnostic imaging service equipment is replaced in a timely manner.
Appendix 2
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The trust should improve update of audit within the departments of outpatients and diagnostic imaging.