Source · CQC inspection

The Royal Free Hospital

Provider Royal Free London NHS Foundation Trust Type NHS Healthcare Organisation Region London Last inspected 6 Jan 2021

Overall rating: Requires Improvement View full CQC report

Domain ratings

Five CQC key questions

Safe

Requires Improvement

Effective

Good

Caring

Good

Responsive

Requires Improvement

Well-led

Requires Improvement

Earlier inspection findings

pre-2024 framework · 4 must-do 1 should-do

Must-do actions (4)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 4

Must do

Safe

The trust must ensure that all consultants meet the trust target for training in modules relating to resuscitation and immediate life support.

Regulation: Regulation 12(2)(c)

⚠ Not all medical staff had completed training in key skills, including safeguarding training. The hospital was not achieving its 90% target for mandatory training. Low compliance rates with some essential training topics such as resuscitation, safeguarding and infection control.

Must-do action 2 of 4

Must do

Safe

The trust must ensure that all paediatric resuscitation trolleys have consistent regular checks.

Regulation: Regulation 12(2)(e)

⚠ A paediatric trolley in the main theatres area was not checked since mid-December 2022, and even when it was checked, this was done on three occasions for the entire month.

Must-do action 3 of 4

Must do

Well-led

The trust must ensure that there is regular audit of compliance of staff with processes for managing sepsis.

Regulation: Regulation 17(2)(a)

⚠ The provider had not completed an audit of sepsis compliance since 2019. The service did not assess compliance with the national guidance in relation to the recognition, diagnosis, and management of sepsis.

Must-do action 4 of 4

Must do

Well-led

The trust must ensure that the risk register entry relating to the purchase of new ketone machines, covers the clinical risk and mitigations around the shortage of the machines.

Regulation: Regulation 17(2)(b)

⚠ The clinical risks around the shortage of ketone machines had not been fully recorded in the trust risk register. Two of the three wards visited didn’t have their own ketone machines and staff had to borrow these from another ward. Elevated levels of ketones in patient’s blood or urine can …