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The Clatterbridge Cancer Centre

Type NHS Healthcare Organisation Region North West Last inspected 16 Apr 2019

Overall rating: Good  View full CQC report

Domain ratings

Five CQC key questions
Safe
Good
Effective
Good
Caring
Outstanding
Responsive
Good
Well-led
Good

Earlier inspection findings

pre-2024 framework · 14 must-do 19 should-do

Must-do actions (14)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 14
Must do
Well-led
The trust must ensure that people who have director level responsibility for the quality and safety of care, and for meeting the fundamental standards are fit and proper to carry out this important role.
Regulation: Regulation 5
⚠ At the time of our inspection we had concerns regarding the trust’s fit and proper person process, a legal requirement. We were not assured that disclosure and barring service checks were in place for nine of the trust’s 17 directors.
Must-do action 2 of 14
Must do
Well-led
The trust must ensure that their systems and processes ensure that implementation of the new strategy can be appropriately monitored.
Regulation: Regulation 17
⚠ The trust’s governance systems did not enable the trust leadership to have oversight of issues that impacted on patient care, outcomes, allow them to sufficiently address risks and the early identification of shortfalls in care and performance. We did not find clear business plans across all strategic priorities that outlined …
Must-do action 3 of 14
Must do
Well-led
The trust must ensure it has appropriate governance arrangements for the dementia strategy.
Regulation: Regulation 17
⚠ The trust’s governance systems did not enable the trust leadership to have oversight of issues that impacted on patient care, outcomes, allow them to sufficiently address risks and the early identification of shortfalls in care and performance.
Must-do action 4 of 14
Must do
Well-led
The trust must ensure that Deprivation of Liberty Safeguards are recorded within patients’ records.
Regulation: Regulation 17
⚠ The trust’s governance systems did not enable the trust leadership to have oversight of issues that impacted on patient care, outcomes, allow them to sufficiently address risks and the early identification of shortfalls in care and performance.
Must-do action 5 of 14
Must do
Well-led
The trust must ensure it has an effective system to record staff training completion.
Regulation: Regulation 17
⚠ The trust didn’t have a process in place at the time to evidence that there were always enough suitably qualified, competent and experienced staff with relevant levels of life support training (including basic, immediate and advanced life support) deployed within the service at all times. The system the trust used …
Must-do action 6 of 14
Must do
Well-led
The trust must ensure that all risks are assessed, recorded on the risk register at the right level and mitigated appropriately in a timely way.
Regulation: Regulation 17
⚠ The trust’s governance systems did not enable the trust leadership to have oversight of issues that impacted on patient care, outcomes, allow them to sufficiently address risks and the early identification of shortfalls in care and performance. The trust had systems and processes for monitoring and managing risks, however, these …
Must-do action 7 of 14
Must do
Well-led
The trust must ensure all staff have relevant competencies allocated to them and an effective system to monitor them.
Regulation: Regulations 17 and 18
⚠ The trust didn’t have a process in place at the time to evidence that there were always enough suitably qualified, competent and experienced staff with relevant levels of life support training (including basic, immediate and advanced life support) deployed within the service at all times. The systems in place did …
Must-do action 8 of 14
Must do
Safe
The trust must ensure there is always enough suitably qualified, competent and experienced staff with relevant levels of life support training (including basic life, immediate life support and advanced life support) deployed within the service at all times.
Regulation: Regulation 18
⚠ The trust didn’t have a process in place at the time to evidence that there were always enough suitably qualified, competent and experienced staff with relevant levels of life support training (including basic, immediate and advanced life support) deployed within the service at all times. At this inspection, we were …
Must-do action 9 of 14
Must do
Safe
The service must ensure that there are sufficient numbers of suitably qualified staff with basic life support and immediate life training on each shift in each area.
Regulation: Regulations 18(1)
⚠ We were concerned about the levels of basic, immediate and advanced life support training completion. All of these were below 65% and had compliance had gone down since our last inspection. We were not assured there was a trained member of staff able to provide life support in each clinical …
Must-do action 10 of 14
Must do
Effective
The service must ensure that there are sufficient numbers of suitably competent staff on each shift in each clinical area.
Regulation: Regulations 18(1)
⚠ Competency compliance training evidence available on inspection was poor. We were not assured there were competent staff on duty each shift in some areas. In medicine we were not assured that there were competent staff on each shift in each clinical area.
Must-do action 11 of 14
Must do
Well-led
The service must ensure that where risks are identified, mitigation is put in place in a timely manner.
Regulation: Regulation 17(2)(b)
⚠ In relation to risks, at the time of our inspection we were concerned that the service had not addressed and mitigated risks sufficiently.
Must-do action 12 of 14
Must do
Safe
The service must ensure records are securely stored.
Regulation: Regulation 17(2)(c)
⚠ Patient records were not always stored securely. This meant that patient information was accessible to the public in some areas. Records were also openly stored at the Liverpool site meaning visitors could see patient’s personal information.
Must-do action 13 of 14
Must do
Safe
The service must ensure that relevant identification and safety checks are completed prior to initiating exposure to radiation and that images are reported on in a timely manner so that patient’s care and treatment is not subject to undue delay.
Regulation: Regulation 12(2)(a)
⚠ We observed that radiographers carrying out computed tomography scans did not routinely carry out a ‘pause and check’ in line with best practice. This could lead to the wrong patient having the wrong procedure or being exposed to radiation unnecessarily. Diagnostic images were not automatically archived. There were not always …
Must-do action 14 of 14
Must do
Well-led
The service must ensure that where risks are identified, mitigations are put in place in a timely manner.
Regulation: Regulation 17(2)(b)
⚠ There were systems in place to identity and manage risk within the service although we found examples when some actions to mitigate risk had been delayed. Action taken to mitigate risk was not always taken without delay.

Should-do actions (19)

Recommended improvements to enhance service quality.

Should-do action 1 of 19
Should do
Responsive
The trust should ensure it continues to address its action plan in relation to complaints.
Regulation: Regulation 16
Should-do action 2 of 19
Should do
Well-led
The trust should consider how non-executive directors can gain oversight of information in relation to deaths within the haemato-oncology service.
Regulation: Regulation 17
Should-do action 3 of 19
Should do
Well-led
The trust should ensure that minutes and action logs clearly outline items discussed and actions.
Regulation: Regulation 17
Should-do action 4 of 19
Should do
Well-led
The trust should ensure that it implements a revised governance structure.
Regulation: Regulation 17
Should-do action 5 of 19
Should do
Well-led
The trust should ensure that staff understand and can describe the governance systems and processes.
Regulation: Regulation 17
Should-do action 6 of 19
Should do
Responsive
The trust should ensure its systems and processes ensure it has oversight of patients with additional needs.
Regulation: Regulation 17
Should-do action 7 of 19
Should do
Effective
The trust should consider how it can enable all staff to access training and development opportunities.
Regulation: Regulation 18
Should-do action 8 of 19
Should do
Well-led
The trust should consider developing a documented talent map or succession plan.
Should-do action 9 of 19
Should do
Well-led
The trust should continue developing the integration of the haemato-oncology services.
Should-do action 10 of 19
Should do
Well-led
The trust should consider using specific, measurable, attainable, realistic and timely principles in action plans.
Should-do action 11 of 19
Should do
Well-led
The trust should continue to work on equality and diversity including oversight of their workforce demographic.
Should-do action 12 of 19
Should do
Well-led
The trust should consider developing groups for those with protected characteristics.
Should-do action 13 of 19
Should do
Well-led
The service should continue to build on existing working relationships with external providers to maintain oversight and governance of patient pathways and staff training.
Regulation: Regulation 17
Should-do action 14 of 19
Should do
Responsive
The service should ensure there is set criteria for accepting referrals for treatment pathways.
Regulation: Regulation 17
Should-do action 15 of 19
Should do
Safe
The service should continue to increase awareness and understanding of the application of relevant radiation regulations.
Should-do action 16 of 19
Should do
Effective
The service should continue with plans to build capacity within the radiologist workforce.
Should-do action 17 of 19
Should do
Safe
The service should consider how to improve safety culture within the service.
Should-do action 18 of 19
Should do
Well-led
The service should continue to build on existing working relationships with external providers to maintain joint oversight and governance of patient pathways where applicable.
Should-do action 19 of 19
Should do
Safe
The service should train all eligible staff in resuscitation training as soon as possible.
Regulation: Regulation 18(2)(a)

Location details

CQC ID: REN20
Local authority: Wirral
Region: North West

Inspection report

Type: Location
Date: 16 April 2019
Rating: Good
Actions: 14 must-do 19 should-do
AI-extracted 3 Jun 2026

Related PFD reports

2024-0050 — Marjorie McEvoy (Feb 2024)