Source · CQC inspection
Bridlington Hospital
Provider York and Scarborough Teaching Hospitals NHS Foundation Trust
Type NHS Healthcare Organisation
Region Yorkshire & Humberside
Last inspected 16 Oct 2019
Overall rating: Good View full CQC report
Domain ratings
Safe
Good
Effective
Good
Caring
Good
Responsive
Good
Well-led
Requires Improvement
Earlier inspection findings
Must-do actions (26)
Must-do action 1 of 26
Must do
Well-led
The trust must ensure it has a robust process for identifying learning from deaths and serious incidents and ensure this is systematically shared across the organisation.
Must-do action 2 of 26
Must do
Safe
The service must ensure all medical staff in its urgent and emergency care service at Scarborough hospital are compliant with all aspects of mandatory training.
Must-do action 3 of 26
Must do
Safe
The service must ensure all medical and nursing staff in urgent and emergency care services at Scarborough hospital complete the required specialist paediatric life support training to enable them to safely care for children in the department.
Must-do action 4 of 26
Must do
Safe
The service must ensure it has enough, suitably qualified, competent and experienced medical and nursing staff in its urgent and emergency care service at Scarborough hospital, to meet the RCEM recommendations, including enough staff who are able to treat children in an emergency care setting.
Must-do action 5 of 26
Must do
Safe
The service must ensure medicines are managed safely in its urgent and emergency care service at Scarborough hospital.
Must-do action 6 of 26
Must do
Well-led
The service must ensure that computer screens showing patient identifiable information, are not left unlocked when not in use, in its urgent and emergency care service at Scarborough hospital.
Must-do action 7 of 26
Must do
Well-led
The service must ensure it takes action to improve its performance in the RCEM standards in its urgent and emergency care service at Scarborough hospital.
Must-do action 8 of 26
Must do
Well-led
The service must ensure all nursing staff have an up to date appraisal each year in its urgent and emergency care service at Scarborough hospital.
Must-do action 9 of 26
Must do
Responsive
The service must ensure they continue to work to improve the following performance standards for its urgent and emergency care service at Scarborough hospital: ▪ the median time from arrival to treatment. ▪ the percentage of patients admitted, transferred or discharged within four hours. ▪ the monthly percentage of patients that left before being seen.
Must-do action 10 of 26
Must do
Well-led
The service must ensure the processes for the management of risks, issues and performance, and the governance and oversight of these processes are fully embedded within its urgent and emergency care service at Scarborough hospital.
Must-do action 11 of 26
Must do
Safe
The service must ensure that all medical staff complete mandatory training and safeguarding training modules in accordance with trust policy.
Must-do action 12 of 26
Must do
Safe
The service must ensure that the quality of medical record keeping improves and that medical staff maintain accurate and contemporaneous records for all patients, in accordance with professional standards and trust policy.
Must-do action 13 of 26
Must do
Effective
The service must ensure that all medical and nursing staff receive annual performance appraisals, in accordance with professional standards and trust policy.
Must-do action 14 of 26
Must do
Well-led
The service must ensure that all records are secure when unattended.
Must-do action 15 of 26
Must do
Safe
The service must ensure that sufficient numbers of suitably qualified, competent, skilled and experienced medical staff are deployed overnight for medicine wards on the Scarborough Hospital site to promote safe care and treatment of patients.
Must-do action 16 of 26
Must do
Safe
The service must ensure that sufficient numbers of suitably qualified, competent, skilled and experienced registered nursing staff are deployed across the medicine wards on the Scarborough Hospital site to promote safe care and treatment of patients.
Must-do action 17 of 26
Must do
Safe
The service must ensure that all staff on medicine wards at the Scarborough Hospital site are maintaining securely an accurate, complete and contemporaneous record in respect of each service user, including a record of the care and treatment provided to the service user and of decisions taken in relation to the care and treatment provided.
Must-do action 18 of 26
Must do
Safe
The service must ensure that substances hazardous to health are stored securely and used in a safe way to avoid potential or actual harm to patients.
Must-do action 19 of 26
Must do
Safe
The service must ensure that all medical staff complete mandatory training and safeguarding training modules in accordance with trust policy.
Must-do action 20 of 26
Must do
Responsive
The service must ensure the backlogs and overdue appointments in the trust is addressed and improved.
Must-do action 21 of 26
Must do
Responsive
The service must ensure improvements are made where the service is not meeting the 18-week referral to treatment time target and cancer waiting times so that patients have access to timely care and treatment.
Must-do action 22 of 26
Must do
Safe
The service must ensure that all medical staff complete mandatory training and safeguarding training modules in accordance with trust policy.
Must-do action 23 of 26
Must do
Effective
The service must ensure that all medical staff receive annual performance appraisals, in accordance with professional standards and trust policy.
Must-do action 24 of 26
Must do
Well-led
The service must ensure that electronic records are secure (screens locked) when unattended.
Must-do action 25 of 26
Must do
Responsive
The service must ensure the backlogs and overdue appointments in the trust is addressed and improved.
Must-do action 26 of 26
Must do
Responsive
The service must ensure improvements are made where the service is not meeting the 18-week referral to treatment time target and cancer waiting times so that patients have access to timely care and treatment.
Should-do actions (50)
Should-do action 1 of 50
Should do
Well-led
The trust should formalise written guidance for fulfilment of the requirement of the Fit and Proper Persons Test (FPPT) for Directors.
Should-do action 2 of 50
Should do
Well-led
The trust should develop a sustainable clinical strategy at pace building on the outcomes of the east coast acute services review and ensure it dovetails with the care group plans.
Should-do action 3 of 50
Should do
Well-led
The trust should ensure there is a clear accountability framework setting out the governance arrangements for the care group structure.
Should-do action 4 of 50
Should do
Well-led
The trust should continue its work to improve its reporting of performance information to enable easier oversight and governance and continue its work to improve its digital systems and processes.
Should-do action 5 of 50
Should do
Well-led
The trust should continue its review of the Board members skills and prioritise its planned board development activities.
Should-do action 6 of 50
Should do
Safe
The service should consider having a designated ligature free room in its urgent and emergency care service at Scarborough hospital for patients suffering from mental health illnesses.
Should-do action 7 of 50
Should do
Safe
The service should consider having a designated paediatric area within the first assessment and major’s areas of its urgent and emergency care service at Scarborough hospital.
Should-do action 8 of 50
Should do
Safe
The service should ensure all equipment is cleaned and labelled to indicate when it was last cleaned in its urgent and emergency care service at Scarborough hospital.
Should-do action 9 of 50
Should do
Effective
The service should ensure an embedded system of clinical supervision is in place in its urgent and emergency care service at Scarborough hospital.
Should-do action 10 of 50
Should do
Responsive
The service should ensure it continue to look at new ways of working to improve patient flow from its urgent and emergency care service at Scarborough hospital.
Should-do action 11 of 50
Should do
Responsive
The service should ensure it improves the availability of written information available in other languages and formats for patients using its urgent and emergency care service at Scarborough hospital.
Should-do action 12 of 50
Should do
Safe
The service should ensure there is consistent use of labelling to show when equipment has been cleaned.
Should-do action 13 of 50
Should do
Well-led
The service should ensure quality dashboard information is displayed in public areas.
Should-do action 14 of 50
Should do
Effective
The service should ensure that they can demonstrate nursing staff receive regular, formal clinical supervision, in accordance with professional guidelines and trust policy.
Should-do action 15 of 50
Should do
Responsive
The service should ensure that they continue their work to improve patient access and flow to reduce referral to treatment times and patient cancellation rates.
Should-do action 16 of 50
Should do
Safe
The service should ensure that storage areas temperatures are monitored to demonstrate medicines are always stored in accordance with manufacturer’s minimum and maximum temperature guidelines.
Should-do action 17 of 50
Should do
Well-led
The service should continue to implement and embed the new governance structure and processes.
Should-do action 18 of 50
Should do
Safe
The service should ensure that resuscitation trollies are checked in accordance with the trust’s policy and action is taken and improvement monitored when this is found not to be so.
Should-do action 19 of 50
Should do
Safe
The service should ensure the resuscitation trolley is checked consistently and as required.
Should-do action 20 of 50
Should do
Safe
The service should ensure the services assess risk in patients waiting beyond the recommended appointment dates.
Should-do action 21 of 50
Should do
Responsive
The service should consider ways to reduce the number of cancelled clinics in outpatients.
Should-do action 22 of 50
Should do
Safe
The service should ensure clear cleaning guidance of the cuffs is in place when fabric blood pressure cuffs are used.
Should-do action 23 of 50
Should do
Safe
The service should obtain advise from the infection prevention team about the use and storage of non-packaged cottonwool balls.
Should-do action 24 of 50
Should do
Safe
The service should ensure that community equipment which requires calibration has this completed as per maintenance schedule.
Should-do action 25 of 50
Should do
Safe
The service should ensure that staff responsible for cleaning of the pool are shown the correct cleaning procedure/guidelines for this piece of equipment.
Should-do action 26 of 50
Should do
Safe
The service should ensure single use equipment is within its expiry date.
Should-do action 27 of 50
Should do
Safe
The service should ensure that all entries to women’s records are legible.
Should-do action 28 of 50
Should do
Safe
The service should ensure that patients recordstrolleys are locked.
Should-do action 29 of 50
Should do
Effective
The service should ensure that all staff have their annual appraisals.
Should-do action 30 of 50
Should do
Effective
The service should audit MEOWS so that they are assured the system is being using effectively.
Should-do action 31 of 50
Should do
Safe
The service should ensure that daily checks on the resuscitation trolley are completed as per Trust policy.
Should-do action 32 of 50
Should do
Safe
The service should ensure that daily checks on medicine fridges are carried out as per Trust policy.
Should-do action 33 of 50
Should do
Safe
The service should ensure that all patient group direction paperwork has authorisation signatures against those staff names who are able to administer patient group direction medicines.
Should-do action 34 of 50
Should do
Safe
The service should ensure labelling is used to show when equipment has been cleaned.
Should-do action 35 of 50
Should do
Well-led
The service should display quality dashboard information in public areas.
Should-do action 36 of 50
Should do
Effective
The service should ensure that they can demonstrate nursing staff receive regular, formal clinical supervision, in accordance with professional guidelines and trust policy.
Should-do action 37 of 50
Should do
Safe
The service should ensure that storage areas temperatures are monitored to demonstrate medicines are always stored safely in accordance with manufacturer’s minimum and maximum temperature guidelines.
Should-do action 38 of 50
Should do
Well-led
The service should continue to implement and embed the new governance structure and processes.
Should-do action 39 of 50
Should do
Responsive
The service should investigate and respond to complaints in accordance with trust policy.
Should-do action 40 of 50
Should do
Safe
The service should replace or repair broken equipment in a timely manner and safety equipment is available to meet the needs of the patients.
Should-do action 41 of 50
Should do
Safe
The service should make certain that staff adhere to record keeping policies and follow record keeping guidance in line with their registered professional standards.
Should-do action 42 of 50
Should do
Effective
The service should complete mental capacity assessments on patients in a timely way where there is any doubt a patient is able to make an informed decision about their care and treatment. Assessments and outcomes should be documented in care records.
Should-do action 43 of 50
Should do
Effective
The service should have a range of tools available to assess patients where their communication may be impaired.
Should-do action 44 of 50
Should do
Responsive
The service should work towards reducing length of stay for non-elective patients.
Should-do action 45 of 50
Should do
Responsive
The service should take action to improve complaints response times to bring them in line with their complaints policy.
Should-do action 46 of 50
Should do
Responsive
The service should consider developing documented admission criteria for the ward.
Should-do action 47 of 50
Should do
Well-led
The service should develop robust governance processes including performance dashboards, that local risks are identified, regularly reviewed and actions developed.
Should-do action 48 of 50
Should do
Safe
The service should ensure the resuscitation trolley is checked consistently and as required.
Should-do action 49 of 50
Should do
Safe
The service should ensure the services assess risk in patients waiting beyond the recommended appointment dates.
Should-do action 50 of 50
Should do
Responsive
The service should consider ways to reduce the number of cancelled clinics in outpatients.