Source · CQC inspection
Chase Farm Hospital
Provider Royal Free London NHS Foundation Trust
Type NHS Healthcare Organisation
Region London
Last inspected 10 May 2019
Overall rating: Good View full CQC report
Domain ratings
Safe
Requires Improvement
Effective
Good
Caring
Good
Responsive
Good
Well-led
Good
Earlier inspection findings
Must-do actions (11)
Must-do action 1 of 11
Must do
Safe
The trust must ensure that its restraint policy follows best practice guidance as set out in Positive and Proactive Care: Reducing the Need for Restrictive Interventions (Department of Health, 2014) and Violence and aggression: short-term management in mental health, health and community settings (National Institute for Health and Care Excellence, 2015). This includes ensuring that there is a rigorous process so that mechanical restraint such as mittens are only used in exceptional circumstances, and that ongoing monitoring of all restrictive interventions is in place.
Must-do action 2 of 11
Must do
Safe
The trust must review escalation processes in the Private Patients Unit for calling the RMO assistance to ensure the RMO is available to attend to patients when required.
Must-do action 3 of 11
Must do
Well-led
The trust must reinforce the use of an up to date risk register that includes all risks and comprehensive mitigations.
Must-do action 4 of 11
Must do
Safe
The trust must ensure that equipment has regular preventative maintenance and there is a replacement programme for out of date equipment.
Must-do action 5 of 11
Must do
Safe
The trust must ensure staff follow the trust medication policy and procedures in the safe storage of medicines and safe disposal of expired medicines.
Must-do action 6 of 11
Must do
Safe
The trust must ensure medical staff complete consent forms appropriately. All forms must be signed and dated and the role of the doctor must be clearly specified.
Must-do action 7 of 11
Must do
Safe
The trust must ensure all medicines are stored safely and securely, and at the correct temperature. Intravenous fluids are never stored in mixed boxes. There is regular checking and timely replacement of out of date medicines, including transfer and anaphylaxis kits.
Must-do action 8 of 11
Must do
Responsive
The trust must ensure there is a sustainable plan and action is taken to improve the quality of service in relation to delayed discharges, and patient experiences staying in an inappropriate environment and discharge transfers out of hours
Must-do action 9 of 11
Must do
Well-led
The trust must ensure all risks are accurately assessed and regularly monitored with timely mitigating actions taken to address issues, including the safe and secure storage of medicines and intravenous fluids
Must-do action 10 of 11
Must do
Safe
The trust must ensure that staff follows the trust’s record management policies concerning safe storage and security of patient and staff records
Must-do action 11 of 11
Must do
Safe
The trust must act to ensure staff follow-up with patients that leave the Urgent Care Centre before being seen, particularly with vulnerable children and adults
Should-do actions (82)
Should-do action 1 of 82
Should do
Well-led
The trust should ensure there are clear lines of medical patient responsibility in the adult assessment unit.
Should-do action 2 of 82
Should do
Safe
The trust should ensure that mandatory training rates including safeguarding training, for nursing and medical staff are compliant with the trust standard.
Should-do action 3 of 82
Should do
Safe
The trust should ensure that there is consistent record keeping for emergency department patients in the adult assessment unit.
Should-do action 4 of 82
Should do
Effective
The trust should ensure there is an action plan to address 2016/17 Royal College of Emergency Medicine (RCEM) moderate and acute severe asthma and consultant sign-off audit results.
Should-do action 5 of 82
Should do
Well-led
The trust should ensure that appraisal rates for nursing and medical staff are compliant with the trust standard.
Should-do action 6 of 82
Should do
Responsive
The trust should ensure the needs of all patients who require additional support are met.
Should-do action 7 of 82
Should do
Safe
The trust should review the training of security officers and security protocols in the hospital, including patrols and one-to-one patient supervision.
Should-do action 8 of 82
Should do
Safe
The trust should ensure staff have the knowledge and skills to de-escalate threatening or aggressive patients, visitors and relatives.
Should-do action 9 of 82
Should do
Safe
The trust should ensure staff in the PPU wards fully utilise trust safeguarding policies and referral pathways including for international patients.
Should-do action 10 of 82
Should do
Responsive
The trust should improve staff access to information on securing mental health support for patients.
Should-do action 11 of 82
Should do
Well-led
The trust should review the processes in place to support staff with effective conflict management.
Should-do action 12 of 82
Should do
Well-led
The trust should implement strategies to address the strict hierarchies that staff described, which affect morale, performance and patient safety.
Should-do action 13 of 82
Should do
Safe
The trust should ensure ward teams fully comply with the Control of Substances Hazardous to Health (COSHH) Regulations (2002) in reference to safe and secure storage of chemicals.
Should-do action 14 of 82
Should do
Safe
The trust should ensure the review of Never Events and serious incidents are undertaken by senior clinical staff and robust actions should be documented and monitored.
Should-do action 15 of 82
Should do
Safe
The trust should ensure medical and nursing staff have access to mandatory training.
Should-do action 16 of 82
Should do
Safe
The trust should ensure they continue to work with other external agencies to put systems in place to reduce the number of never events taking place.
Should-do action 17 of 82
Should do
Safe
The trust should review how medicines were stored and accessed in the operating theatres.
Should-do action 18 of 82
Should do
Safe
The trust should develop a rolling programme of equipment replacement.
Should-do action 19 of 82
Should do
Well-led
The trust should ensure work continues to move to a full electronic patient record system.
Should-do action 20 of 82
Should do
Well-led
The trust should ensure all staff have access to an annual appraisal.
Should-do action 21 of 82
Should do
Responsive
The trust should continue to work towards a system which allows patients to arrive for their surgery in a timelier manner.
Should-do action 22 of 82
Should do
Responsive
The trust should ensure patients are cared for in the recovery area for the minimal amount of time. Patients should not be experiencing overnight stays in the recovery for non-clinical reasons.
Should-do action 23 of 82
Should do
Well-led
The trust should ensure staff do not experience bullying by any other member of staff.
Should-do action 24 of 82
Should do
Caring
The trust should embed the collection of feedback from patients and relatives to improve patient experience.
Should-do action 25 of 82
Should do
Well-led
The trust should review the benefits of an electronic patient in ICU that avoids the pitfalls of the system that was introduced and abandoned previously.
Should-do action 26 of 82
Should do
Well-led
The trust should consider developing firm plans to realise the vision for the service.
Should-do action 27 of 82
Should do
Safe
The trust should monitor medical staffing levels during the expansion of the unit to ensure they meet FICM standards.
Should-do action 28 of 82
Should do
Safe
The trust should seek to reduce the reliance on bank staff to cover band 6 vacancies.
Should-do action 29 of 82
Should do
Safe
The trust should ensure all staff have up to date mandatory training and ensure the trust’s 85% target is met.
Should-do action 30 of 82
Should do
Safe
The trust should ensure all staff have up to date adults and children’s safeguarding training at all level and ensure the trust’s 85% target is met.
Should-do action 31 of 82
Should do
Responsive
The trust should ensure there is sufficient seating and space in the A&E waiting areas for patients and visitors.
Should-do action 32 of 82
Should do
Effective
The trust should ensure staff understand how and when to assess whether a patient with mental health needs has the capacity to make decisions about their physical care and treatment.
Should-do action 33 of 82
Should do
Responsive
The trust should ensure waiting times from referral to treatment and decisions to admit patients are in accordance with best practice recommendations.
Should-do action 34 of 82
Should do
Well-led
The trust should ensure that risks identified on the risk register are being dealt with in a timely way.
Should-do action 35 of 82
Should do
Safe
The trust should ensure mandatory training for staff meets the trust target of 85%.
Should-do action 36 of 82
Should do
Safe
The trust should ensure appropriate checks are undertaken on patients wearing mittens.
Should-do action 37 of 82
Should do
Safe
The trust should ensure they review processes for the management of medicines used in emergencies and the systems for the monitoring of temperatures of medicines storage areas.
Should-do action 38 of 82
Should do
Safe
The trust should ensure hand hygiene compliance meets the trust targets across all the wards.
Should-do action 39 of 82
Should do
Safe
The trust should ensure potential trip hazards in corridors are removed across all the wards.
Should-do action 40 of 82
Should do
Safe
The trust should ensure there is proper recording of the decisions for restraint and there is clear guidance for staff on when an application for Deprivation of Liberty Safeguards (DoLS) should be made.
Should-do action 41 of 82
Should do
Responsive
The trust should ensure they focus on getting patients a bed on a ward for their speciality to reduce the number of patient moves at night.
Should-do action 42 of 82
Should do
Responsive
The trust should ensure they follow best practice and not discharge patients at night. There was a high number of patients being discharged at night which did not reflect best practice.
Should-do action 43 of 82
Should do
Responsive
The trust should ensure they reduce the average length of stay for medical non-elective patients, to meet the England average.
Should-do action 44 of 82
Should do
Safe
The trust should ensure all staff complete mandatory training.
Should-do action 45 of 82
Should do
Safe
The trust should develop, and staff should adhere to at all times, a clear procedure for order and priority of patients undergoing emergency surgery.
Should-do action 46 of 82
Should do
Safe
The trust should address the high turnover rate amongst nursing staff and ensure all of the shifts are covered at all times.
Should-do action 47 of 82
Should do
Safe
The trust should fill the vacancies for medical staff to ensure there is sufficient number of doctors available to provide patient’s care and treatment.
Should-do action 48 of 82
Should do
Safe
The trust should ensure medicines are stored in accordance with published guidance and there is a system to identify where guidance is not adhered to by staff.
Should-do action 49 of 82
Should do
Safe
The trust should ensure all medical staff complete mandatory training, with compliance monitored.
Should-do action 50 of 82
Should do
Effective
The trust should ensure patients are reviewed by a consultant within 12 hours of admission to critical care.
Should-do action 51 of 82
Should do
Safe
The trust should ensure staff have clear guidance and take appropriate action when temperature is outside optimal levels for medicine storage in drug fridges and storage rooms.
Should-do action 52 of 82
Should do
Safe
The trust should ensure contents, including medicines, in transfer bags are regularly checked and records kept.
Should-do action 53 of 82
Should do
Effective
The trust should ensure critical care staff receives sufficient training to enable them to confidently use the new hospital EPR system as needed.
Should-do action 54 of 82
Should do
Safe
The trust should ensure there is a thorough review of medical staffing at weekends and allied healthcare provision for the service, as part of a wider review of adherence to guidelines for provision of intensive care standards.
Should-do action 55 of 82
Should do
Well-led
The trust should ensure there is a governance process to ensure most up to date, approved, protocols and guidelines are in circulation and use by staff.
Should-do action 56 of 82
Should do
Well-led
The trust should ensure the data submitted to external bodies is accurate, particularly in relation to delayed discharges and mixed sex breaches.
Should-do action 57 of 82
Should do
Well-led
The trust should ensure patients, staff and wider stakeholders are involved in developing a critical care strategy and turning it into action.
Should-do action 58 of 82
Should do
Safe
The trust should address the high vacancy rates, high sickness rates and high turnover rates for nursing staff and healthcare assistants in the service.
Should-do action 59 of 82
Should do
Responsive
The trust should review the facilities and service provision on signage, leaflets and translation services so they meet the needs of the patients using them.
Should-do action 60 of 82
Should do
Effective
The trust should improve the health promotion provision in UCC.
Should-do action 61 of 82
Should do
Responsive
The trust should review the facilities provided in the urgent care centre so they meet the needs of children and patients with visual and hearing impairments or complex needs.
Should-do action 62 of 82
Should do
Effective
The trust should implement a formal teaching programme for medical and nursing staff.
Should-do action 63 of 82
Should do
Well-led
The trust should provide local appraisals for middle grade doctors within the service.
Should-do action 64 of 82
Should do
Well-led
The trust should ensure policies and guidelines available in hard copies are regularly reviewed and updated.
Should-do action 65 of 82
Should do
Safe
The trust should improve the provision arrangement of children in the service and paediatric outpatient area to ensure there are adequate toys and children are safe while waiting in the paediatric outpatient waiting area especially during out of hours.
Should-do action 66 of 82
Should do
Caring
The trust should improve the reception area in the urgent care centre and paediatric outpatients to ensure patient confidentiality.
Should-do action 67 of 82
Should do
Well-led
The trust should implement a formal process for reception staff to highlight issues in the waiting areas.
Should-do action 68 of 82
Should do
Responsive
The trust should ensure service provision meet patients individual needs particularly those with complex needs and disabilities.
Should-do action 69 of 82
Should do
Responsive
The trust should ensure people knew how to make a complaints or compliment about their care and treatment.
Should-do action 70 of 82
Should do
Well-led
The trust should improve the patient engagement in the service.
Should-do action 71 of 82
Should do
Responsive
The trust should improve the signage to the entrance to the UCC.
Should-do action 72 of 82
Should do
Safe
The trust should improve staff education of incident reporting.
Should-do action 73 of 82
Should do
Safe
The trust should ensure there are sufficient allied staff to support patient rehabilitation.
Should-do action 74 of 82
Should do
Responsive
The trust should continually review referral to treatment times to ensure it is in line with national standards.
Should-do action 75 of 82
Should do
Well-led
The trust should ensure they engage with staff effectively.
Should-do action 76 of 82
Should do
Well-led
The trust should review processes for risk management to ensure all risks are identified and dealt with appropriately.
Should-do action 77 of 82
Should do
Safe
The trust should ensure staff complete mandatory training, including safeguarding training.
Should-do action 78 of 82
Should do
Safe
The trust should ensure action is taken to prevent avoidable patient safety incidents from reoccurring.
Should-do action 79 of 82
Should do
Safe
The trust should ensure all five steps of the safer surgery checklist are appropriately completed and documented in line with national guidelines.
Should-do action 80 of 82
Should do
Safe
The trust should review processes to provide assurance that medicines are stored at the correct temperature to remain effective.
Should-do action 81 of 82
Should do
Safe
The trust should review security of medicines storage areas.
Should-do action 82 of 82
Should do
Safe
The trust should ensure the trust’s consent policy is followed and that all stages of the consent process are appropriately documented.