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Wexham Park Hospital

Provider Heatherwood and Wexham Park Hospitals NHS Foundation Trust Type NHS Healthcare Organisation Region South East Last inspected 27 Jun 2014

Overall rating: Inadequate  View full CQC report

Domain ratings

Five CQC key questions
Safe
Inadequate
Effective
Requires Improvement
Caring
Requires Improvement
Responsive
Inadequate
Well-led
Inadequate

Earlier inspection findings

pre-2024 framework · 16 must-do 7 should-do

Must-do actions (16)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 16
Must do
Safe
Ensure that patients are appropriately risk assessed particularly for falls and pressure ulcers including those patients who are in the A&E department for a prolonged period.
⚠ We found that there were no nursing risk assessments being undertaken when patients were admitted or throughout their time in the A&E department for pressure sores or falls, despite many patients staying over 12 hours. Falls risk assessments were inconsistently filled out on medical wards, and no risk assessments for …
Must-do action 2 of 16
Must do
Responsive
Ensure that patient flow is addressed as a priority (and escalation procedures adhered to) to improve the poor performance in the four hour A&E target, high number of surgical cancellations and delayed discharges from the critical care unit. This will require engagement with all departments within the trust, improvement to discharge planning, access to radiology and ambulatory care pathways.
⚠ The hospital consistently failed to meet the four-hour A&E target, with patients waiting between four and 12 hours for admission. Lack of capacity and delayed discharges led to medical patients being placed on surgical wards, resulting in numerous patient moves, cancelled operations, and delayed care.
Must-do action 3 of 16
Must do
Safe
Ensure that there is a robust system in place to assess the numbers and skill mix of medical and nursing staff for all wards. Ensure that establishments are increased to reflect this.
⚠ Unsafe staffing levels were a consistent theme across almost all clinical disciplines, with agreed staffing establishments not being met on many wards. This led to patients being at risk of not receiving safe and appropriate care and treatment.
Must-do action 4 of 16
Must do
Well-led
Address workforce recruitment and retention plans to reduce the dependency on locum and agency staff.
⚠ There was a high use of agency and locum staff across nursing and medical staffing due to high turnover and recruitment challenges, impacting continuity of care and quality.
Must-do action 5 of 16
Must do
Safe
Ensure, where agency and locum staff are employed, relevant background and competency checks are undertaken, and they receive appropriate local induction prior to commencing work on the ward.
⚠ Agency staff were not consistently being appropriately checked or given an induction on arrival to wards, leading to concerns about their knowledge of ward surroundings and ability to provide safe treatment.
Must-do action 6 of 16
Must do
Well-led
Encourage and support an incident reporting culture, so that it is seen as a mechanism to learn rather than attribute blame. This needs to be present throughout all directorates and at all levels of staff.
⚠ Staff did not always report incidents or concerns because they felt there was a lack of feedback and subsequent change, leading to lost opportunities for improvement and a culture that discouraged reporting.
Must-do action 7 of 16
Must do
Well-led
Ensure that the investigation of incidents is carried out in a fair, openly transparent, and consistent manner, regardless of the level of seniority of staff involved. Multidisciplinary involvement needs to be seen as essential. The outcomes and areas for improvement need to be developed and disseminated trust wide.
⚠ Some incidents, particularly those involving senior consultants, were not investigated fairly or consistently, and learning from serious incidents was not always shared or implemented across the trust.
Must-do action 8 of 16
Must do
Responsive
Ensure the radiology service is able to meet the needs of people who use the service in a timely way.
⚠ Lack of resources and staffing in radiology resulted in significant delays for diagnostic procedures and reporting of results, impacting patient diagnosis, treatment, and discharge times.
Must-do action 9 of 16
Must do
Effective
Ensure policies and procedural guidance are updated so that staff have access to up to date evidence based guidelines. Ensure that audits are regularly undertaken to check clinical compliance (in particular medicine managements).
⚠ A significant number of policies and guidelines (over 27%) were out of date, and the hospital was not consistently acting on audit results to identify improvements, implement change, or monitor its effectiveness.
Must-do action 10 of 16
Must do
Well-led
Ensure that the governance structures are reviewed and standardised trust wide.
⚠ Governance processes were not robust enough to assure the trust board of safe care, and risk management structures were neither standardised nor consistent across departments or divisions.
Must-do action 11 of 16
Must do
Well-led
Improve staff engagement across clinical and managerial disciplines to promote a learning and safety culture where patient experience is paramount.
⚠ There were low levels of staff satisfaction and widespread reports of a 'bullying and harassment' culture, leading to disempowerment and a lack of belief in managers, hindering a learning and safety culture.
Must-do action 12 of 16
Must do
Effective
Ensure that there is a consistent and standardised approach to multidisciplinary meetings and mortality and morbidity meetings trust wide
⚠ Multidisciplinary working and mortality and morbidity meetings lacked consistency and standardisation across the trust, with some specialties not holding regular meetings or adequately discussing cases to learn and improve patient care.
Must-do action 13 of 16
Must do
Responsive
Ensure that patients are not inappropriately moved (especially out of hours) for non-medical reasons.
⚠ Patients were frequently moved from ward to ward, often out of hours and for non-medical reasons, which caused distress, disorientation, and impacted continuity of care, especially for elderly and frail patients.
Must-do action 14 of 16
Must do
Safe
Ensure where escalation areas are opened that there are clear admission criteria that are strictly adhered to and audited. Senior oversight of the ward needs to provide assurance that patients are seen appropriately and in a timely way and that nursing staff are aware of individual patient needs.
⚠ Newly created 'escalation' wards, such as Snowdrop, were not suitable environments for patient care, lacked appropriate equipment and sufficient permanent staff, and admission criteria were not strictly adhered to, leading to patients being placed inappropriately and not receiving timely care.
Must-do action 15 of 16
Must do
Responsive
Review the outpatient booking system to ensure that it meets the needs of the outpatients service.
⚠ The outpatient booking system was not working effectively, leading to significant delays for appointments, frequent cancellations, and patients attending follow-up appointments without diagnostic procedures being completed.
Must-do action 16 of 16
Must do
Safe
Ensure that the World Health Organisation Surgical Safety Checklist is mandatory practice and consistently completed. Comprehensive audits must be undertaken regularly.
⚠ The World Health Organisation surgical safety checklist was not consistently completed, with significant gaps identified in audits, and staff not always understanding its value or participating in required checks, contributing to never events.

Should-do actions (7)

Recommended improvements to enhance service quality.

Should-do action 1 of 7
Should do
Effective
Ensure there is a robust system in place to review the decision when a caesarean section is to be performed.
Should-do action 2 of 7
Should do
Safe
Ensure the recovery unit is used appropriately and that patients are not accommodated overnight in the recovery area.
Should-do action 3 of 7
Should do
Responsive
Ensure there are clear processes in place for the collection of patient feedback and responding to complaints.
Should-do action 4 of 7
Should do
Caring
Ensure the nutritional needs of patients who are in the A&E department for prolonged periods are met and they are offered food and drink if appropriate.
Should-do action 5 of 7
Should do
Caring
Review the food provision service to enable patients’ cultural needs and preferences are respected.
Should-do action 6 of 7
Should do
Safe
Ensure patient records are complete and accurate to ensure the safe delivery of care and treatment.
Should-do action 7 of 7
Should do
Caring
Ensure that all staff are able to respond to the needs of vulnerable groups such as people with dementia or a learning disability.

Location details

CQC ID: RD750
Local authority: Slough
Region: South East

Inspection report

Type: Quality Report
Date: 27 June 2014
Rating: Inadequate
Actions: 16 must-do 7 should-do
AI-extracted 3 Jun 2026