Source · CQC inspection
Poole Hospital
Provider Poole Hospital NHS Foundation Trust
Type NHS Healthcare Organisation
Region South West
Last inspected 8 Sep 2020
Overall rating: Good View full CQC report
Domain ratings
Safe
Requires Improvement
Effective
Good
Caring
Outstanding
Responsive
Good
Well-led
Good
Earlier inspection findings
Must-do actions (6)
Must-do action 1 of 6
Must do
Well-led
Ensure the organisation can meet the compliance targets for both mandatory training and annual performance reviews (appraisals). We nevertheless recognise this is against a high benchmark for this trust, which could be considered for a review. Alongside this, review and determine if dementia training should be mandatory given the needs of the local population. The importance and value of the trust providing staff with an annual review must be recognised and provide assurance staff are providing safe and quality care. There are areas such as safeguarding training and infection control training which are not meeting compliance. This is despite it being a requirement of the safeguarding report in the previous year, and a significant outbreak of an infection across the hospital. This is of particular concern with the medical staffing group.
Must-do action 2 of 6
Must do
Well-led
Provide effective and interactive governance. Review the learning and actions from complaints and serious incidents to provide assurance, and report this is undertaken and is effective. Provide the board with assurance that this and all elements of governance around learning and change are both interactive across the trust, effective, and making a difference to patient care. Through this, look again at the trust’s annual complaints report and determine if the questions it responds to around patients’ complaints are effectively answered. Ensure local governance arrangements are consistent and in line with trust expectations around content and response.
Must-do action 3 of 6
Must do
Safe
Assess all risks to patients health and safety to prevent them receiving unsafe care and treatment. Care plans and risk assessments must be personalised to each patient.
Must-do action 4 of 6
Must do
Safe
Ensure staff recognise medicine errors and include omitted doses. All medicine errors must be recognised, reported, investigated, monitored and discussed fully.
Must-do action 5 of 6
Must do
Safe
Ensure patients are re-assessed using venous thromboembolism assessments within 24 hours of admission in line with best practice guidance.
Must-do action 6 of 6
Must do
Safe
Ensure staff secure patient record trolleys so confidential patient records are stored securely when not in use, so they cannot be accessed by unauthorised people.
Should-do actions (60)
Should-do action 1 of 60
Should do
Well-led
Consider whether a number of the trust board reports are given the attention required for information to be current and demonstrate learning and a good pace of change. In the safeguarding and complaints annual reports, the same actions and wording in some areas around change and learning had been repeated in different reports from 2017/18 to 2018/19 with no evidence of actions taken.
Should-do action 2 of 60
Should do
Well-led
Have improved evidence to show how effective challenge is given to the trust board by the non-executive directors.
Should-do action 3 of 60
Should do
Well-led
Capture more effectively the visits of senior executives around the trust so it is possible to see their visibility and where and when they have visited with departments and staff. This is to avoid some areas or staff being met with or visited rarely.
Should-do action 4 of 60
Should do
Well-led
Consider how to link the more specific strategies, such as those relating to dementia and learning disabilities either to the main strategy, or into a framework which monitors their progress and documents assurance and success. This was of specific concern as the trust did not have a specialist lead nurse for learning disabilities and did not provide dementia training for staff as mandatory training.
Should-do action 5 of 60
Should do
Well-led
Bring the EDS2 report to more prominence in the work around equality, diversity and inclusion to include actions on those areas assessed as developing. Determine if the reporting on WRES standards is reflective of the areas where there has been a deterioration in experiences of BME staff.
Should-do action 6 of 60
Should do
Well-led
Work with the volunteers to address their feelings of not always being valued and supported, particularly when meeting challenging members of the public and dealing with issues such as the new signage. Ask whether a mentor might help new volunteers find their feet.
Should-do action 7 of 60
Should do
Well-led
Consider how the website should be used to present documents, policies and communication to the public and interested parties. Ensure documents are current and consider which should be in the public domain.
Should-do action 8 of 60
Should do
Well-led
Review the way staff were feeling about their well being and whether the number of meetings provide a balance with patient care responsibilities, alongside pressures on administration and management time.
Should-do action 9 of 60
Should do
Well-led
Look at how to improve junior doctor exception reporting and the culture around how this is perceived. Review how to encourage attendance at the junior doctors’ forum. Complete the actions from the NHSI eight high impact actions project.
Should-do action 10 of 60
Should do
Well-led
Review the finance risk register in relation to the costs of agency staff and consider why this was not represented considering the significant risk described.
Should-do action 11 of 60
Should do
Well-led
Review how the trust governors are given the opportunities to fulfil their role in providing feedback from members of the public and their constituencies, and how they hold the non-executive directors to account.
Should-do action 12 of 60
Should do
Well-led
Working with the new equality and diversity lead, establish a wider equality and diversity strategy which looks at the support and needs of both staff and people who use the services. Build on the work already done and bring this together to provide assurance of a strong and dynamic strategy. Consider induction and ongoing training for staff around caring for people living with a learning disability or mental health problems.
Should-do action 13 of 60
Should do
Well-led
Provide improved assurance at board level on progress and problems with technology and digital information systems, including possible poor quality of data.
Should-do action 14 of 60
Should do
Well-led
Develop an action plan to capture the various strands of the work to develop an effective mortality and morbidity programme and to learn from the death or failings in care of patients. This should include bringing consistency, use of the structured judgement review, the standardisation of mortality and morbidity meetings and how they take place. It will need improved reports to the board placed more prominently for the public to see. Include within this how bereaved families are supported and included in any investigations and learning.
Should-do action 15 of 60
Should do
Well-led
Continue to move the quality improvement (QI) and action plan forward. Be able to show a correlation through governance between areas picked up at audit, from incidents, complaints or elsewhere and the QI projects and their outcomes.
Should-do action 16 of 60
Should do
Well-led
Have a line of sight from the board to the research team to be assured the work of the team is both recognised and assured.
Should-do action 17 of 60
Should do
Well-led
Consider how to improve the feedback to staff who report incidents and how feedback from staff on other matters can be shown to be gathered and acted upon.
Should-do action 18 of 60
Should do
Safe
Patients nursing records should be completed in full to enable an accurate picture of their health, well being and risks
Should-do action 19 of 60
Should do
Effective
Continue to improve compliance with malnutrition universal screening tool assessments to meet trust targets.
Should-do action 20 of 60
Should do
Safe
De-clutter the lounge on Portland ward and address the damp and mould issues to make it a pleasant environment for patients to use.
Should-do action 21 of 60
Should do
Safe
Make sure all the labels are completed in full on sharps bins for safety.
Should-do action 22 of 60
Should do
Effective
Maintain records following a best interest meeting to make sure the decision and actions are followed.
Should-do action 23 of 60
Should do
Safe
Review the safety of storing emergency resuscitation equipment behind locked doors.
Should-do action 24 of 60
Should do
Caring
Review the times of meals on some wards as some were provided cold and late.
Should-do action 25 of 60
Should do
Safe
Improve the process for patients to enable them to take their discharge medicines with them when they leave the hospital.
Should-do action 26 of 60
Should do
Safe
Embed the revised process for safeguarding particularly when women are transferred from another healthcare provider.
Should-do action 27 of 60
Should do
Safe
Continue to review nursing staffing to meet planned levels and recruit to fill vacancies. Continue to review the use of agency to limit the high numbers of agency staff on the same ward at one time.
Should-do action 28 of 60
Should do
Safe
Continue to review junior staffing levels and vacancies.
Should-do action 29 of 60
Should do
Safe
Consider the risks and manage the appropriateness of side rooms which did not contain a clinical sink to provide handwashing facilities for staff.
Should-do action 30 of 60
Should do
Safe
Continue to embed infection control practice in theatres. Staff should be reminded to use alcohol hand gel, and encourage patients to do so, when entering theatre areas.
Should-do action 31 of 60
Should do
Safe
Remind staff to complete and record appropriate checks of specialist and emergency equipment, and consumables, equipment and products stored and used.
Should-do action 32 of 60
Should do
Safe
Continue to record theatre temperatures and escalate issues with air conditioning units.
Should-do action 33 of 60
Should do
Safe
Consider the management of estate issues in surgical wards and theatres and how these are prioritised to fix or replace in a timely manner.
Should-do action 34 of 60
Should do
Safe
Review and risk assess ligature risks for the new ward environments following the reconfiguration.
Should-do action 35 of 60
Should do
Safe
Review the use of national early warning score throughout the surgical pathway and its use in theatre recovery in line with best practice.
Should-do action 36 of 60
Should do
Safe
Document in patient records any action taken as a result of high national early warning scores which require additional monitoring or escalation, so there is a clear auditable trail.
Should-do action 37 of 60
Should do
Safe
Review the approach to auditing the five steps to safer surgery surgical safety checklist to gain assurance from independent auditing rather than within own theatre teams.
Should-do action 38 of 60
Should do
Safe
Standardise the use of the surgical safety checklist so this is applied consistently across theatres.
Should-do action 39 of 60
Should do
Safe
Remind staff on good practice for clearly documenting patient care within nursing and medical patient notes.
Should-do action 40 of 60
Should do
Safe
Confirm controlled drug records and audits are being completed in accordance with trust policy.
Should-do action 41 of 60
Should do
Safe
Remind staff to record the date of opening for liquid medicines.
Should-do action 42 of 60
Should do
Safe
Remind staff to report gaps and discrepancies in medicine refrigerator temperatures so these are investigated in line with trust policy.
Should-do action 43 of 60
Should do
Safe
Continue to embed the policy for drug preparation in theatres and be assured staff are following trust policy.
Should-do action 44 of 60
Should do
Safe
Review the process for administering intravenous medications when not able to prepare with the medicine trolley fixed laptop.
Should-do action 45 of 60
Should do
Effective
Review staff understanding and compliance against best practice guidance for the measurement and documentation of core temperature when patients are in theatre and in recovery.
Should-do action 46 of 60
Should do
Effective
Review best practice for recording and signing for enteral feed prescriptions and relevant updates to the policy.
Should-do action 47 of 60
Should do
Effective
Review compliance with the completion of food and fluid charts and the recording of any escalation or actions.
Should-do action 48 of 60
Should do
Effective
Improve performance for the percentage of patients screened for nutrition within 24-hours of admission.
Should-do action 49 of 60
Should do
Effective
Review the process for recording mental capacity assessments for patients in line with the trust’s mental capacity act policy.
Should-do action 50 of 60
Should do
Responsive
Consider how to improve the theatre environments to be more appealing to children.
Should-do action 51 of 60
Should do
Responsive
Consider how to make environments within the surgical care directorate more dementia friendly to meet the needs of the population the hospital serves.
Should-do action 52 of 60
Should do
Responsive
Continue to review the fractured neck of femur pathway to improve performance with getting patients who had a fractured neck of femur to theatre within 36-hours of admission.
Should-do action 53 of 60
Should do
Responsive
Continue to review the theatre capacity and performance to improve referral to treatment performance within 18-week and 52-week wait breaches.
Should-do action 54 of 60
Should do
Responsive
Continue to review the surgical flow within the hospital to limit the number of patients outlying on non-surgical or non-specialty wards.
Should-do action 55 of 60
Should do
Well-led
Clearly document the surgical care group’s vision and strategy, with workable plans to achieve this.
Should-do action 56 of 60
Should do
Safe
Remind staff of the importance of information governance, and to not leave computers unlocked when not supervised.
Should-do action 57 of 60
Should do
Safe
Consider the access to IT systems for agency staff and how this complies with information governance and data protection rules.
Should-do action 58 of 60
Should do
Well-led
Continue to aim for trust targets for training and appraisals compliance.
Should-do action 59 of 60
Should do
Responsive
Review the ritual washing facilities provided by the mortuary.
Should-do action 60 of 60
Should do
Well-led
Continue to develop the end of life performance dashboard to capture information to ensure access and flow.