Source · CQC inspection
St Benedict's Hospice
Provider South Tyneside and Sunderland NHS FT
Type NHS Healthcare Organisation
Region North East
Last inspected 10 Jun 2020
Overall rating: Outstanding View full CQC report
Domain ratings
Safe
Good
Effective
Good
Caring
Good
Responsive
Outstanding
Well-led
Outstanding
Earlier inspection findings
Must-do actions (48)
Must-do action 1 of 48
Must do
Safe
The service must ensure that there are sufficient numbers of suitably skilled, qualified and experienced staff in line with best practice and national guidance.
Must-do action 2 of 48
Must do
Safe
The service must ensure that mandatory training compliance, including resuscitation and Mental Capacity Act and Deprivation of Liberty Safeguards training, meets the trust target.
Must-do action 3 of 48
Must do
Safe
The service must ensure mandatory training compliance meets the trust target.
Must-do action 4 of 48
Must do
Safe
The service must review designated mental health assessment rooms regularly to identify any changes that may impact on patient safety.
Must-do action 5 of 48
Must do
Safe
The service must ensure measures are implemented to control the spread of infections, in line with trust policy.
Must-do action 6 of 48
Must do
Well-led
The service must ensure that it continues to improve the processes to manage performance, efficiency and utilisation within the Durham diagnostic and treatment centre.
Must-do action 7 of 48
Must do
Safe
The service must ensure that all equipment conforms to the relevant safety standards. It must be regularly serviced and maintained in accordance with the manufacturer’s guidance, or if this equipment is no longer in use it should be removed from the department.
Must-do action 8 of 48
Must do
Safe
The service MUST ensure that all equipment conforms to the relevant safety standards. It must be regularly serviced and maintained in accordance with the manufacturer’s guidance.
Must-do action 9 of 48
Must do
Safe
The service MUST ensure all staff are aware of and consistently follow the trust policy to safely prescribe, administer, record and store and dispose of medicines.
Must-do action 10 of 48
Must do
Safe
The service MUST ensure staff recognise the use of mechanical or pharmacological as restraint and ensure this is incident reported.
Must-do action 11 of 48
Must do
Effective
The service MUST ensure staff always follow national guidance when patients lack capacity to give consent. Staff must always use measures that limited patients' liberty appropriately.
Must-do action 12 of 48
Must do
Well-led
The service must review and revise the maternity dashboard so that performance can be easily benchmarked against regional or peer-group averages, and national and trust targets (where applicable).
Must-do action 13 of 48
Must do
Well-led
The service must ensure a robust audit plan is in place and key audits are conducted, including record keeping, medicines management and infection prevention and control audits.
Must-do action 14 of 48
Must do
Well-led
The service must ensure they have an up to date and robust risk register in place, and there is appropriate oversight and management of this.
Must-do action 15 of 48
Must do
Safe
The service must ensure all staff are engaged with and participate in all steps of the World Health Organisation (WHO) surgical safety checklist, the checklist is fully completed, and observational and record audits are undertaken to monitor compliance.
Must-do action 16 of 48
Must do
Safe
The service must ensure daily checks of emergency equipment (including adult and neonatal resuscitation equipment, and the difficult airway trolley), are undertaken and robustly documented, and equipment is replenished when required.
Must-do action 17 of 48
Must do
Safe
The service must ensure there are enough qualified midwives to meet minimum staffing levels and improve compliance with one-to-one care in labour. Community midwives escalated into the hospital must receive an induction to the area(s) they are required to cover.
Must-do action 18 of 48
Must do
Safe
The service must ensure simulations of obstetric emergencies are undertaken on the hospital site (such as staff responding to an emergency buzzer or alert); and conduct a baby abduction drill.
Must-do action 19 of 48
Must do
Well-led
The service must revise and review maternity and obstetric dashboards so that performance can be easily benchmarked against regional or peer-group averages, and national and trust targets (where applicable).
Must-do action 20 of 48
Must do
Well-led
The service must ensure a robust audit plan is in place and key audits are conducted, including record keeping, medicines management and infection prevention and control audits. The service must ensure relevant actions identified by local audits are acted on.
Must-do action 21 of 48
Must do
Well-led
The service must monitor the reporting of staffing related incidents in an objective and reliable manner; and should consider implementing more robust (NICE ‘red flag’) recording and monitoring procedures that do not rely on individual reporting by staff.
Must-do action 22 of 48
Must do
Well-led
The service must ensure they have an up to date and robust risk register in place, and there is appropriate oversight and management of this.
Must-do action 23 of 48
Must do
Safe
The service must ensure that children and young people with a mental health condition are risk assessed for their mental health needs, self-harm or suicide and are cared for in a safe environment that has been appropriately risk assessed.
Must-do action 24 of 48
Must do
Safe
The service must ensure that staff are appropriately trained in caring for children and young people with mental health conditions.
Must-do action 25 of 48
Must do
Safe
The service must ensure that nursing staff on paediatric wards have sepsis awareness training and have access to recognised sepsis tools.
Must-do action 26 of 48
Must do
Effective
The service must ensure staff have access to up to date evidence-based policies and procedures.
Must-do action 27 of 48
Must do
Well-led
The service must ensure they have the systems and processes to assess, monitor and mitigate risks.
Must-do action 28 of 48
Must do
Safe
The service must ensure they meet national standards for paediatric nurse staffing.
Must-do action 29 of 48
Must do
Safe
The service must ensure they meet national standards for paediatric medical staffing.
Must-do action 30 of 48
Must do
Safe
The service must ensure that staff caring for children and young people have completed training/competencies to enable them to care for children and young people.
Must-do action 31 of 48
Must do
Safe
The service must ensure that nurse staffing meets national guidance.
Must-do action 32 of 48
Must do
Safe
The service must ensure that there is a member of staff trained in advanced paediatric life support (APLS) on every shift.
Must-do action 33 of 48
Must do
Safe
The service must ensure there are formal arrangements in place for paediatric assistance and transfer if required.
Must-do action 34 of 48
Must do
Safe
The service must ensure the environment where children and young people are cared for is secure and access limited to those who need it.
Must-do action 35 of 48
Must do
Safe
The service must ensure that tools used to identify deteriorating patients are embedded.
Must-do action 36 of 48
Must do
Responsive
The service must comply with Accessible Information Standards by identifying, recording, flagging, sharing and meeting the information and communication needs of people with a disability/sensory loss.
Must-do action 37 of 48
Must do
Well-led
Senior managers must ensure robust systems and processes are in place to identify, manage, mitigate and if appropriate escalate risks for the service. This must ensure senior managers and the board members have clear oversight of service risks.
Must-do action 38 of 48
Must do
Well-led
Senior managers must ensure that plans to improve management and leadership capacity within the service are fully implemented.
Must-do action 39 of 48
Must do
Well-led
The trust must ensure staff team meetings take place on a regular basis.
Must-do action 40 of 48
Must do
Well-led
The trust must consider how to reduce the isolation of the learning disabilities team and explore ways to develop understanding of the learning disability service amongst other teams within the trust.
Must-do action 41 of 48
Must do
Safe
The service must provide appropriate environmental risk assessment and mitigation for the wards of all ligature risks including the use of ligature cutters and staff trained to use these, if required.
Must-do action 42 of 48
Must do
Safe
The service must ensure patients are provided with an appropriate system to call staff in the event of an emergency.
Must-do action 43 of 48
Must do
Safe
The service must risk assess for emergency equipment including emergency medication required on the ward for resuscitation in line with the patient group and current national guidance. Where risks are identified, the trust must ensure this is equipment is provided safely for staff to use.
Must-do action 44 of 48
Must do
Effective
The service must ensure staff receive regular formal clinical supervision in accordance with trust policy.
Must-do action 45 of 48
Must do
Well-led
Senior managers must ensure robust systems and processes are in place to identify, manage, mitigate and if appropriate escalate risks for the new safe haven unit. This must ensure senior managers and the board members have clear oversight of service risks.
Must-do action 46 of 48
Must do
Well-led
Senior managers must ensure that plans to improve management and leadership capacity within the service are fully implemented.
Must-do action 47 of 48
Must do
Well-led
The service must ensure staff team meetings take place on a regular basis.
Must-do action 48 of 48
Must do
Well-led
The service must consider how to reduce the isolation of the learning disabilities team and explore ways to develop understanding of the learning disability service amongst other teams within the trust.
Should-do actions (133)
Should-do action 1 of 133
Should do
Well-led
The trust should continue to embed and develop understanding of community services within the executive team to enable them to fully understand the challenges and integrate the different teams.
Should-do action 2 of 133
Should do
Well-led
The trust should continue to embed and strengthen governance processes to ensure these were robust in all areas and services.
Should-do action 3 of 133
Should do
Well-led
The trust should ensure that all risks to services are captured with mitigation in place and that risks are reviewed.
Should-do action 4 of 133
Should do
Well-led
The trust should ensure Duty of Candour requirements are clearly documented and undertaken in a timely way.
Should-do action 5 of 133
Should do
Well-led
The trust should continue to develop dashboards and data collection across all services to support effective analysis of staff and service performance.
Should-do action 6 of 133
Should do
Effective
The service should ensure that all nursing staff receive an appraisal.
Should-do action 7 of 133
Should do
Effective
The service should ensure that all medical and nursing staff have opportunities for ongoing supervision.
Should-do action 8 of 133
Should do
Safe
The service should ensure all building work is completed to ensure patient and staff safety within the department.
Should-do action 9 of 133
Should do
Safe
The service should ensure all risk assessments are completed fully to ensure patient and staff safety.
Should-do action 10 of 133
Should do
Effective
The service should ensure it can demonstrate participation in all national level audits.
Should-do action 11 of 133
Should do
Safe
The service should ensure all staff follow trust policy with regard to infection prevention and control.
Should-do action 12 of 133
Should do
Well-led
The service should ensure that all staff are aware of the vision and strategy for the department.
Should-do action 13 of 133
Should do
Responsive
The service should ensure it has current, ongoing action plans to address the failure to meet national performance standards.
Should-do action 14 of 133
Should do
Safe
The service should ensure patients receive antibiotics within one hour of a sepsis diagnosis, in line with trust policy.
Should-do action 15 of 133
Should do
Safe
The service should review processes to ensure patients waiting in the emergency department for long periods of time have access to their irregular medicines.
Should-do action 16 of 133
Should do
Responsive
The service should ensure initial assessment times are in line with national guidance.
Should-do action 17 of 133
Should do
Effective
The service should ensure all staff access the most up to date guidance on the intranet, which reflects current trust practice.
Should-do action 18 of 133
Should do
Effective
The service should have a Mental Health Act policy to provide trust specific support to staff.
Should-do action 19 of 133
Should do
Effective
The service should ensure all nursing staff receive an annual appraisal.
Should-do action 20 of 133
Should do
Responsive
The service should aim to bring waiting times from arrival to treatment and arrangements to admit, treat and discharge patients in line with national standards.
Should-do action 21 of 133
Should do
Safe
The trust should ensure that mandatory training compliance, including resuscitation training, meets the trust target for all staff.
Should-do action 22 of 133
Should do
Responsive
The trust should aim to bring arrival to treatment times in line with national standards.
Should-do action 23 of 133
Should do
Safe
The trust should ensure expiry dates of consumable stock are checked regularly.
Should-do action 24 of 133
Should do
Safe
The service should continue to ensure that there are sufficient numbers suitably skilled, qualified and experienced staff in line with best practice and national guidance taking into account patients dependency levels.
Should-do action 25 of 133
Should do
Effective
The service should ensure that there is a standardised process that is understood and applied consistently by all staff when applying for Deprivation of Liberty Safeguards.
Should-do action 26 of 133
Should do
Effective
The service should ensure that all nursing staff receive an appraisal.
Should-do action 27 of 133
Should do
Safe
The service should ensure that there is a robust system to safely prescribe, administer, record and store medicines.
Should-do action 28 of 133
Should do
Responsive
The service should have a plan to review and improve the referral to treatment time for admitted pathways for thoracic medicine and rheumatology which were below the England average for admitted RTT (percentage within 18 weeks).
Should-do action 29 of 133
Should do
Safe
The service should review the processes in relation to the ordering of medicines to ensure patients receive their medicines when prescribed.
Should-do action 30 of 133
Should do
Safe
The service should continue to ensure that there are sufficient numbers suitably skilled, qualified and experienced staff in line with best practice and national guidance taking into account patients dependency levels.
Should-do action 31 of 133
Should do
Safe
The service should ensure that confidential records are stored securely in line with national guidance.
Should-do action 32 of 133
Should do
Effective
The service should ensure that there is a standardised process that is understood and applied consistently by all staff when applying for Deprivation of Liberty Safeguards.
Should-do action 33 of 133
Should do
Effective
The service should ensure that all nursing staff receive an appraisal.
Should-do action 34 of 133
Should do
Responsive
The service should continue to monitor the average length of stay for elective and non-elective patients to improve performance standards measured against the England average.
Should-do action 35 of 133
Should do
Safe
The service should ensure training compliance for medical staff, particularly in resuscitation and Adult Basic Life Support, is improved.
Should-do action 36 of 133
Should do
Safe
The service should ensure learning from never events is shared with all staff.
Should-do action 37 of 133
Should do
Effective
The service should ensure nursing staff have an understanding of the Mental Capacity Act and Deprivation of Liberty Safeguards.
Should-do action 38 of 133
Should do
Responsive
The service should ensure theatres are effectively utilised.
Should-do action 39 of 133
Should do
Well-led
The service should ensure systems to manage performance are consistently used to improve performance and that all risks are identified and escalated appropriately with clear mitigating actions.
Should-do action 40 of 133
Should do
Well-led
The service should ensure all staff feel fully engaged in service developments to plan and manage services.
Should-do action 41 of 133
Should do
Safe
The service should work towards replacing theatre equipment to ensure it is fit for purpose.
Should-do action 42 of 133
Should do
Safe
The service should work to replace decontamination equipment within the urology and head and neck service.
Should-do action 43 of 133
Should do
Safe
The service should ensure hand hygiene audit data is collected and submitted each month.
Should-do action 44 of 133
Should do
Safe
The service should ensure learning from never events is shared with all staff.
Should-do action 45 of 133
Should do
Effective
The service should ensure mental Capacity Assessments are completed in line with trust and best practice guidance.
Should-do action 46 of 133
Should do
Responsive
The service should continue to work to improve theatre utilisation.
Should-do action 47 of 133
Should do
Caring
The service should work to reduce the number of patient moves at night.
Should-do action 48 of 133
Should do
Well-led
The service should review the risk registers and those risks that have been in place for a number of years and ensure updated actions are in place.
Should-do action 49 of 133
Should do
Well-led
The service should continue to engage with staff and patients to inform service developments.
Should-do action 50 of 133
Should do
Well-led
The service should improve its engagement with patients, staff, equality groups, the public and local organisations to plan and manage services.
Should-do action 51 of 133
Should do
Safe
The service should improve its monitoring of surgical safety checklists.
Should-do action 52 of 133
Should do
Safe
The service should ensure that records are detailed showing all patients’ care and treatment.
Should-do action 53 of 133
Should do
Safe
The service should ensure the plans to upgrade the department are prioritised to make the unit compliant with relevant health building note guidelines.
Should-do action 54 of 133
Should do
Safe
The service should ensure it has sufficient numbers of registered nurses within the establishment.
Should-do action 55 of 133
Should do
Safe
The service should ensure medicines are not overstocked.
Should-do action 56 of 133
Should do
Safe
The service should ensure all staff are fully compliant with all aspects of mandatory training.
Should-do action 57 of 133
Should do
Effective
The service should ensure all staff have an up to date appraisal.
Should-do action 58 of 133
Should do
Safe
The service should ensure the damage to the flooring in the unit is repaired.
Should-do action 59 of 133
Should do
Safe
The service should ensure that all substances subject to control of substances hazardous to health regulations are kept in a locked room.
Should-do action 60 of 133
Should do
Safe
The service should ensure they have sufficient numbers of allied health professionals to meet the guidelines for the provision of intensive care services (GPICS) standards.
Should-do action 61 of 133
Should do
Safe
The service should ensure they have sufficient numbers of dedicated pharmacists in line with the GPICS standards.
Should-do action 62 of 133
Should do
Effective
The service should ensure it has enough clinical educators, in line with the GPICS standards, to support staff with their education and development.
Should-do action 63 of 133
Should do
Effective
The service should ensure guidance documents are reviewed and kept up to date. The service should ensure where possible staff use the intranet to access documents.
Should-do action 64 of 133
Should do
Well-led
The service should ensure the strategy to turn the vision into action is developed.
Should-do action 65 of 133
Should do
Safe
The service should ensure all staff are fully compliant with all aspects of mandatory training.
Should-do action 66 of 133
Should do
Safe
The service should ensure the damage to the flooring in the unit is repaired.
Should-do action 67 of 133
Should do
Safe
The service should ensure they have sufficient numbers of allied health professionals staff to meet the GPICS standards.
Should-do action 68 of 133
Should do
Safe
The service should ensure they have sufficient numbers of dedicated pharmacists in line with GPICS standards.
Should-do action 69 of 133
Should do
Effective
The service should ensure guidance documents are reviewed and kept up to date. The service should ensure where possible staff use the intranet to access documents.
Should-do action 70 of 133
Should do
Well-led
The service should ensure the strategy to turn the vision into action is developed.
Should-do action 71 of 133
Should do
Effective
The service should ensure all staff have an up to date appraisal.
Should-do action 72 of 133
Should do
Effective
The service should ensure it has enough clinical educators, in line with GPICS standards, to support staff with their education and development.
Should-do action 73 of 133
Should do
Safe
The service should monitor and manage compliance with mandatory training, including safeguarding children level two training, and attain compliance targets within designated timescales.
Should-do action 74 of 133
Should do
Well-led
The service should consider reviewing and revising the electronic system used by managers to monitor appraisal compliance and attain compliance targets within designated timescales.
Should-do action 75 of 133
Should do
Safe
The service should monitor and manage compliance with mandatory training, including safeguarding children level two training, and attain compliance targets within designated timescales.
Should-do action 76 of 133
Should do
Well-led
The service should consider reviewing and revising the electronic system used by managers to monitor appraisal compliance and attain compliance targets within designated timescales.
Should-do action 77 of 133
Should do
Well-led
The service should consider working to ensure that midwives in the hospital and community have the opportunity and capacity to attend staff meetings.
Should-do action 78 of 133
Should do
Responsive
The service should consider reviewing out of hours (community midwifery) cover for the home birth service.
Should-do action 79 of 133
Should do
Well-led
The service should consider revising and reviewing maternity and obstetric dashboards so that performance can be easily benchmarked against regional or peer-group averages, and national and trust targets (where applicable).
Should-do action 80 of 133
Should do
Safe
The service should consider developing a standard operating procedure in place for use of the second emergency theatre on delivery suite, so that processes are formalised.
Should-do action 81 of 133
Should do
Effective
The service should continue to monitor the proportion of Apgar scores of less than seven at five minutes, and implement processes and documentation controls to bring it into line with or below the England average.
Should-do action 82 of 133
Should do
Safe
The service should work to ensure that a situation, background, assessment, recommendation (SBAR) handover is used in all areas in the maternity service, including theatres, in line with trust policy.
Should-do action 83 of 133
Should do
Safe
The service should ensure that staff clearly document when the paediatric early warning scores are escalated.
Should-do action 84 of 133
Should do
Safe
The service should ensure staff correctly follow infection control procedures.
Should-do action 85 of 133
Should do
Safe
The service should assess the environment on the neonatal unit to ensure it is suitable for the purpose for which it is being used.
Should-do action 86 of 133
Should do
Well-led
The service should ensure that children’s services take formal responsibility for the children managed at the eye infirmary.
Should-do action 87 of 133
Should do
Caring
The service should consider acquiring a concealment cover for bariatric patients so that they can be transported to the mortuary in a dignified manner.
Should-do action 88 of 133
Should do
Well-led
The service should ensure the draft end of life strategy is ratified and embedded within the existing governance processes.
Should-do action 89 of 133
Should do
Well-led
The service should ensure that improvement plans for end of life care services have agreed timescales for implementation.
Should-do action 90 of 133
Should do
Well-led
The service should ratify the end of life strategy.
Should-do action 91 of 133
Should do
Responsive
The service should seek to further collate and review patient and family feedback to improve services.
Should-do action 92 of 133
Should do
Responsive
The service should record and monitor referral to treatment times and national care of the dying audit data to ensure services are in line with provider targets.
Should-do action 93 of 133
Should do
Well-led
The service should ratify the end of life strategy.
Should-do action 94 of 133
Should do
Well-led
The service should ensure clinical governance activities are formalised and embedded across outpatients’ departments at all sites.
Should-do action 95 of 133
Should do
Responsive
The service should continue working to reduce the number of patients overdue their review appointment across all specialties and sites within the trust and continue thorough oversight of all patients waiting for appointments.
Should-do action 96 of 133
Should do
Effective
The service should continue to improve the compliance with appraisals across the outpatient department.
Should-do action 97 of 133
Should do
Safe
The service should consider ways to ensure the storage room is secure and clean.
Should-do action 98 of 133
Should do
Responsive
The service should ensure signage is made and installed to help people find areas of the department more easily.
Should-do action 99 of 133
Should do
Responsive
The service should continue to ensure the waiting time for urgent appointments and cancer appointments at Sunderland Royal Hospital meet national requirements.
Should-do action 100 of 133
Should do
Responsive
The service should continue working to reduce the number of patients without a review appointment across all specialties and sites within the trust and continue thorough oversight of all patients waiting for appointments.
Should-do action 101 of 133
Should do
Responsive
The service should continue to develop the clinic utilisation tool to identify and improve capacity for clinics across all sites.
Should-do action 102 of 133
Should do
Well-led
The service should ensure the outpatients strategy and plans for the future are shared effectively with all outpatients staff.
Should-do action 103 of 133
Should do
Well-led
The service should ensure clinical governance activities are formalised and embedded across outpatients departments at all sites.
Should-do action 104 of 133
Should do
Responsive
The service should consider patient needs when appointments are rearranged at short notice and at a different site from their original appointment.
Should-do action 105 of 133
Should do
Responsive
The service should consider working to reduce the number of patients without a review appointment across all specialties and sites within the trust and continue thorough oversight of all patients waiting for appointments.
Should-do action 106 of 133
Should do
Well-led
The service should ensure senior managers from the theatres directorate are engaged, supportive and available to staff and endeavour to understand the full role and function of the outpatients service.
Should-do action 107 of 133
Should do
Responsive
The service should consider developing the clinic utilisation tool to identify and improve capacity for further clinics and avoid underuse of DDTC.
Should-do action 108 of 133
Should do
Well-led
The service should ensure the outpatients strategy and plans for the future are shared effectively with outpatients staff.
Should-do action 109 of 133
Should do
Well-led
The service should ensure clinical governance activities are formalised and embedded across outpatients departments at all sites.
Should-do action 110 of 133
Should do
Safe
The service should ensure that all staff completed their mandatory training.
Should-do action 111 of 133
Should do
Effective
The service should ensure that annual appraisals are completed.
Should-do action 112 of 133
Should do
Safe
The service should review the system in place at Children’s centre Durham Road to ensure that clinical supplies are in date and audited to avoid out of date stock.
Should-do action 113 of 133
Should do
Safe
The service should ensure staff use personal protective equipment when providing clinical interventions.
Should-do action 114 of 133
Should do
Caring
The service should review the arrangements at Palmer community hospital in relation to confidentiality when two physiotherapy sessions are taking place simultaneously.
Should-do action 115 of 133
Should do
Well-led
The service should continue with the plans of monitoring caseloads and introducing additional management support to ensure the 0-19 service improves the compliance with the developmental reviews for children.
Should-do action 116 of 133
Should do
Well-led
The service should continue to address the challenges of the organisational structural differences for community services for children and young people across Sunderland and South Tyneside to improve communication and consistency.
Should-do action 117 of 133
Should do
Well-led
The service should consider applying for accreditation for children and young people’s services provided.
Should-do action 118 of 133
Should do
Responsive
The service should review the resources available for the occupational therapy department and explore options for improving the environment at Palmer Community Hospital to ensure they meet the needs of children accessing the service.
Should-do action 119 of 133
Should do
Safe
The service should ensure that slings are stored appropriately.
Should-do action 120 of 133
Should do
Effective
The service should consider collecting formal therapy outcome data or using specific rehabilitation measures to assess outcomes.
Should-do action 121 of 133
Should do
Well-led
The service should develop a vision and future plan for intermediate care.
Should-do action 122 of 133
Should do
Well-led
The service should improve data quality and collection of clinical data.
Should-do action 123 of 133
Should do
Responsive
The service should continue to develop triage processes and consider implementing a consistent triage system across all locations.
Should-do action 124 of 133
Should do
Well-led
The service should consider ways of strengthening and developing joint governance systems for the services within the trust to provide oversight of performance and risk as a whole.
Should-do action 125 of 133
Should do
Effective
The service should ensure that new policies, yet to be ratified, are ratified and embedded promptly.
Should-do action 126 of 133
Should do
Safe
The service should ensure that resus trolley checks are undertaken as per the trust’s planned schedule.
Should-do action 127 of 133
Should do
Caring
The service should consider displaying health promotion posters or information on the walls of the waiting area.
Should-do action 128 of 133
Should do
Responsive
The service should consider displaying notices in the reception area informing patients of translation services and tools which were available.
Should-do action 129 of 133
Should do
Safe
The trust should ensure that there are sufficient staff employed to meet the needs of patients, specifically in relation to physiotherapy and speech and language therapy.
Should-do action 130 of 133
Should do
Well-led
The trust should ensure that there are robust systems in place to engage and consult with staff on planned changes to the service.
Should-do action 131 of 133
Should do
Responsive
The trust should ensure that there are robust systems in place to monitor patients on waiting lists and review waiting times for access to assessment and treatment.
Should-do action 132 of 133
Should do
Well-led
The trust should continue to explore ways to improve access to electronic systems with the local mental health trust.
Should-do action 133 of 133
Should do
Safe
The service should ensure staff maintain all clear stickers to reflect the last calibrated and tested documentation in line with their process.