Sunderland Royal Hospital

The trust must ensure directors have an appropriate disclosure and barring service check and ensure this is repeated where required or the risks of not repeating checks are considered and assessed.

The trust must maintain effective records to evidence adherence to the fit and proper persons regulation for directors.

The trust must implement an effective system to assess, monitor, and drive improvement in the quality and safety of the services provided, including the quality of the experience for people using the service in line with the regulations

The trust must ensure risks in services are appropriately recorded, assessed, escalated to the trust’s board where required, and regularly reviewed.

The trust must ensure risk assessments including clinical service risk assessments are up to date, thoroughly assessed and documented and benchmarked against national statutory and best practice guidance. The trust must ensure records of risk assessments are effectively maintained.

The trust must implement an effective system to identify and report incidents including the severity of harm. The system must ensure incidents are appropriately reported to internal and external systems within appropriate timescales. The system must ensure incidents are effectively reviewed, lessons and actions are identified and shared with staff.

The trust must implement an effective system to ensure that medical, nursing and midwifery staff have the skills, knowledge, and experience to care for and meet the needs of service users within their service area. Training must include but is not limited to cardiotocograph (CTG) interpretation, multidisciplinary skills and drills training including infant abduction, the needs of service users presenting with mental health needs and learning disability and the use of restraint.

The trust must ensure there is effective oversight of the quality and safety of care provided to patients with mental health needs.

The trust must ensure staff undertake assessments for patients who have a learning disability, care needs are assessed and planned to meet their individual needs.

The trust must ensure any patient presenting and assessed by staff as having a learning disability regardless of whether this is identified on GP systems have their individual needs assessed and reviewed by specialist learning disability staff.

The trust must implement an effective system to identify, report and learn from incidents involving the use of restrictive interventions including restraint and rapid tranquilisation.

The trust must implement an effective system to ensure the assessment, prevention and management of infection prevention and control in the physical environment, this is recorded, monitored, and audited with actions taken to improve compliance.

The trust must implement an effective system to learn from deaths which ensures deaths are appropriately and consistently screened, further review is undertaken where required and lessons learnt are effectively identified and shared with teams.

The trust must ensure all staff have an appropriate disclosure and barring service check and ensure this is repeated where required or the risks of not repeating checks are considered and assessed.

The trust must ensure staff appropriately monitor, assess, and escalate when service users’ physical health deteriorates in line with best practice, this should be monitored and audited with actions taken to improve compliance.

The trust must ensure staff appropriately monitor, assess, and escalate when service users’ mental health deteriorates.

The trust must ensure staff undertake and appropriately record intentional rounding of all service users and ensure this is recorded, monitored, and audited with actions taken to improve compliance.

The trust must implement an effective system to ensure patients receive timely medicines reconciliation.

The trust must ensure staff understand and work within the requirements of the Mental Capacity Act 2005 whenever they work with people who may lack the mental capacity to make specific decisions.

The trust must ensure staff appropriately record mental capacity assessments and decisions made in service users' best interests.

The trust must ensure service user records are audited appropriately to evidence ongoing compliance with the requirements of the Mental Capacity Act 2005 and to identify missed opportunities to safeguard service users.

The trust must ensure staff undertake assessments for patients who have a learning disability, where care needs are assessed and planned to meet their individual needs.

The trust must implement an effective system to assess, monitor, and drive improvement in the quality and safety of the services provided, including the quality of the experience for people using the service in line with the regulations

The trust must ensure that persons employed receive such appropriate support, training, professional development, supervision and appraisal as is necessary to enable them to carry out the duties they are employed to perform and be enabled where appropriate to obtain further qualifications appropriate to the work they perform.

The trust must ensure staff appropriately monitor, assess, and escalate when service users’ physical health deteriorates in line with best practice, this should be monitored and audited with actions taken to improve compliance.

The trust must ensure staff appropriately monitor, assess, and escalate when service users’ mental health deteriorates.

The trust must ensure staff undertake and appropriately record intentional rounding of all service users and ensure this is recorded, monitored, and audited with actions taken to improve compliance.

The trust must ensure staff understand and work within the requirements of the Mental Capacity Act 2005 whenever they work with people who may lack the mental capacity to make specific decisions.

The trust must ensure staff appropriately record mental capacity assessments and decisions made in service user’s best interests.

The trust must ensure service user records are audited appropriately to evidence ongoing compliance with the requirements of the Mental Capacity Act 2005 and to identify missed opportunities to safeguard service users.

The trust must ensure staff undertake assessments for patients who have a learning disability, where care needs are assessed and planned to meet their individual needs.

The trust must implement an effective system to assess, monitor, and drive improvement in the quality and safety of the services provided, including the quality of the experience for people using the service in line with the regulations

The trust must ensure that persons employed receive such appropriate support, training, professional development, supervision and appraisal as is necessary to enable them to carry out the duties they are employed to perform and be enabled where appropriate to obtain further qualifications appropriate to the work they perform.

The trust must ensure staff undertake cardiotocographies (CTGs) and ensure this is recorded, assessed, monitored and escalated as appropriate with fresh eyes assessments.

The trust must ensure staff complete the WHO safety checklist when required, and ensure this is recorded, monitored, and audited with actions taken to improve compliance.

The trust must ensure medicines are stored appropriately, and records of medication including controlled drugs, are maintained appropriately.

The trust must implement systems to ensure that midwifery staff are suitably qualified, skilled and competent to care for and meet the needs of patients within all areas of the maternity services, including in the community.

The trust must implement an effective system to assess, monitor, and drive improvement in the quality and safety of the services provided, including the quality of the experience for people using the service in line with the regulations

The trust must ensure risk assessments including clinical service risk assessments are up to date, thoroughly assessed and documented and benchmarked against national statutory and best practice guidance. The trust must ensure records of risk assessments are effectively maintained.

The trust must implement an effective system to identify and report incidents including the severity of harm. The system must ensure incidents are appropriately reported to internal and external systems within appropriate timescales. The system must ensure incidents are effectively reviewed, lessons and actions are identified and shared with staff.

The trust must implement an effective system to ensure the assessment, prevention and management of infection prevention and control in the physical environment, this is recorded, monitored, and audited with actions taken to improve compliance.

The trust must implement an effective system to ensure service users in established labour receive one to one care in line with best practice.

The trust must ensure effective risk and governance systems are implemented that supports safe, quality care.

The trust must ensure audit information is up to date, accurate and properly analysed, areas for improvement are identified and action is taken to make improvements to the quality and safety of care