Source · CQC inspection
Papworth Hospital
Provider Royal Papworth Hospital NHS Foundation Trust
Type NHS Healthcare Organisation
Region East
Last inspected 2 Dec 2014
Overall rating: Good View full CQC report
Domain ratings
Safe
Good
Effective
Outstanding
Caring
Outstanding
Responsive
Good
Well-led
Good
Earlier inspection findings
Must-do actions (7)
Must-do action 1 of 7
Must do
Safe
Stop the practice of routinely preparing the one medicine (GTN) in advance of its immediate use in catheter labs, in contravention of the Nursing and Midwifery Council’s standards.
Must-do action 2 of 7
Must do
Safe
Ensure that incidents are reported in a timely manner and that learning from incidents takes place.
Must-do action 3 of 7
Must do
Safe
Ensure that all fire exits are clear.
Must-do action 4 of 7
Must do
Safe
Have an effective system in place to ensure that drugs stored in resuscitation trolleys are in date.
Must-do action 5 of 7
Must do
Responsive
Address the breach of single-sex accommodation on Duchess ward.
Must-do action 6 of 7
Must do
Well-led
Improve the way in which risk is managed and reported.
Must-do action 7 of 7
Must do
Responsive
Develop and implement a strategy for patients with a diagnosis of dementia.
Should-do actions (20)
Should-do action 1 of 20
Should do
Safe
Review the routing of outpatients through inpatient wards.
Should-do action 2 of 20
Should do
Safe
Address the lack of pre-operative MRSA screening in the catherisation laboratory.
Should-do action 3 of 20
Should do
Well-led
Review the management of risk within individual wards and departments.
Should-do action 4 of 20
Should do
Safe
Ensure the reporting of incidents in a timely manner.
Should-do action 5 of 20
Should do
Well-led
Develop cross-directorate learning from incidents.
Should-do action 6 of 20
Should do
Safe
Review risk assessments for the location of resuscitation trolleys and fire safety exits.
Should-do action 7 of 20
Should do
Safe
Improve the audit process for the maintenance of drugs required for the resuscitation trolleys.
Should-do action 8 of 20
Should do
Effective
Review the staffing levels for allied health professionals, particularly occupational therapy, to ensure that they are available as part of the multidisciplinary team.
Should-do action 9 of 20
Should do
Responsive
Review capacity issues in some of the services, particularly in bronchiectasis services.
Should-do action 10 of 20
Should do
Safe
Address the lack of clarity in selection criteria or pathways for patients admitted to the Progressive Care Unit.
Should-do action 11 of 20
Should do
Safe
Review the use of regular acuity assessments of patients in the unit.
Should-do action 12 of 20
Should do
Effective
Consider the use of competency frameworks in the Progressive Care Unit.
Should-do action 13 of 20
Should do
Responsive
Consider the options available to address the referral-to-treatment time for cardiothoracic surgery.
Should-do action 14 of 20
Should do
Responsive
Review and address the reasons for the significant number of cancelled operations and high theatre use.
Should-do action 15 of 20
Should do
Responsive
Consider the provision of a dedicated emergency theatre.
Should-do action 16 of 20
Should do
Responsive
Review the availability of facilities for relatives in the Critical Care Area.
Should-do action 17 of 20
Should do
Safe
Review the medical staffing. In terms of the consultant/patient ratio, with up to 33 patients on the unit and one or two consultant intensivists on duty, this falls below the best current evidence ratios as set out in the Intensive Care Society standards.
Should-do action 18 of 20
Should do
Well-led
Explore ways to share and highlight the expertise of the end of life team and encourage earlier referral and more open conversations as part of the patient’s journey, with greater cross-service working.
Should-do action 19 of 20
Should do
Well-led
Improve the contingency plans to respond to the introduction of the new electronic record system at the nearby acute centre that was providing the hospital with pathology services.
Should-do action 20 of 20
Should do
Responsive
Assess the suitability of the environment to maintain the expansion of outpatients services.