Source · CQC inspection
Heatherwood Hospital
Provider Frimley Health NHS Foundation Trust
Type NHS Healthcare Organisation
Region South East
Last inspected 13 Mar 2019
Overall rating: Good View full CQC report
Domain ratings
Safe
Good
Effective
Good
Caring
Good
Responsive
Good
Well-led
Good
Earlier inspection findings
Must-do actions (2)
Must-do action 1 of 2
Must do
Safe
In maternity at Frimley Park Hospital and Wexham Park Hospital, the trust must take action to ensure midwifery staffing meets the acuity level set out in the Birthrate Plus tool on all shifts.
Must-do action 2 of 2
Must do
Safe
The trust must increase compliance with mandatory training to meet its 85% standard in all topics.
Should-do actions (25)
Should-do action 1 of 25
Should do
Well-led
The trust should check that all director personnel files contain all the information relevant to fit and proper persons requirements on an ongoing basis.
Should-do action 2 of 25
Should do
Responsive
The trust should consider how it can ensure the patient voice is heard throughout the organisation through implementing a coherent and consistent approach.
Should-do action 3 of 25
Should do
Well-led
The trust should consider how it can embed a consistent and unified approach to quality improvement.
Should-do action 4 of 25
Should do
Safe
The trust should review recommendations from incidents to include addressing underlying system issues or human factors.
Should-do action 5 of 25
Should do
Effective
The trust should review its procedures for Deprivation of Liberty Safeguards to be assured they meet legislative requirements.
Should-do action 6 of 25
Should do
Responsive
The trust should take steps to improve the timeliness of responses to complaints to meet trust guidance.
Should-do action 7 of 25
Should do
Well-led
The trust should make plans that enable all staff to have an annual appraisal.
Should-do action 8 of 25
Should do
Safe
The trust should take and record appropriate actions when ambient room temperatures and fridges storing medicines are outside of the required temperature range
Should-do action 9 of 25
Should do
Safe
The trust should check premises restricted to staff such as those storing substances subject to control of substances hazardous to health standards and sharp equipment are always kept locked.
Should-do action 10 of 25
Should do
Safe
The trust should keep storerooms and trolleys where controlled medicines locked when not occupied by a member of staff.
Should-do action 11 of 25
Should do
Safe
The trust should ensure treatment rooms are suitable and have adequate space to safely prepare medication.
Should-do action 12 of 25
Should do
Safe
The trust should check signs to identify resuscitation and difficult airway equipment are clearly labelled and visible.
Should-do action 13 of 25
Should do
Safe
The trust should manage changes to the theatre list consistently and in line with their policy.
Should-do action 14 of 25
Should do
Well-led
The trust should plan junior doctor’s rotas in a timely way and have a designated guardian of safe working hours.
Should-do action 15 of 25
Should do
Safe
The trust should close the fire exit in the corridor to pre-assessment and monitor this.
Should-do action 16 of 25
Should do
Effective
The trust should check where policies are printed into hard copy, they are in date and the correct version and should take action to review and update all policies outside of their review date in a timely way.
Should-do action 17 of 25
Should do
Safe
The trust should ensure that cleaning checklists are consistently documented.
Should-do action 18 of 25
Should do
Safe
The trust should ensure that clinical waste is appropriately labelled in line with Health Technical Memorandum (HTM) 07-01 safe management of healthcare waste.
Should-do action 19 of 25
Should do
Safe
The trust should take action so all daily checks of critical equipment are completed.
Should-do action 20 of 25
Should do
Safe
The trust should take action to ensure out of date controlled drugs are promptly removed from clinical areas for denaturation by pharmacy staff.
Should-do action 21 of 25
Should do
Effective
The trust should take action to review and update all policies outside of their review date in a timely way.
Should-do action 22 of 25
Should do
Responsive
The trust should take action to continue to improve patient flow throughout the maternity department.
Should-do action 23 of 25
Should do
Safe
The trust should implement processes to ensure learning from incidents is shared with all staff members, regardless of whether they attend meetings.
Should-do action 24 of 25
Should do
Safe
The provider should introduce tools and processes to ensure the ward is cleaned daily in line with the relevant internal requirements and guidance and that cleaning is recorded for auditing and evidential purposes.
Should-do action 25 of 25
Should do
Effective
The provider should ensure that computers are available so staff can access trust policies, procedures and training regardless of location.