Source · CQC inspection
Ipswich Hospital
Provider Ipswich Hospital NHS Trust
Type NHS Healthcare Organisation
Region East
Last inspected 13 Oct 2017
Overall rating: Good View full CQC report
Domain ratings
Safe
Requires Improvement
Effective
Good
Caring
Good
Responsive
Good
Well-led
Good
Earlier inspection findings
Must-do actions (11)
Must-do action 1 of 11
Must do
Safe
The trust must ensure that staff are up to date with mandatory training in accordance to their roles, specifically basic, intermediate and advanced life support.
Must-do action 2 of 11
Must do
Safe
The trust must ensure that all staff are up to date with safeguarding training to a level in accordance with their roles and that safeguarding documentation/flowcharts makes reference to the different aspects of potential abuse.
Must-do action 3 of 11
Must do
Safe
The trust must ensure that there are effective processes in place for equipment maintenance and servicing. Oversight of the action plans for Electrical and Biomedical Engineering (EBME) department should continue to ensure the environment is fit for purpose.
Must-do action 4 of 11
Must do
Well-led
The trust must ensure that the recently established senior management oversight of the discharge lounge continues.
Must-do action 5 of 11
Must do
Safe
The trust must undertake a formalised assessment process to ensure that the area in majors used for mental health assessments is safe and suitable for use.
Must-do action 6 of 11
Must do
Safe
The trust must ensure that staff are competent and documentation is accurate in relation to the modified early warning score (MEWS) within the emergency department.
Must-do action 7 of 11
Must do
Safe
The trust must ensure there are effective processes in place to manage the electrical safety testing for all electrical equipment.
Must-do action 8 of 11
Must do
Safe
The trust must ensure there are processes in place to manage effective equipment checks for example all resuscitation equipment is checked daily.
Must-do action 9 of 11
Must do
Safe
The trust must ensure that staff complete the required mandatory training.
Must-do action 10 of 11
Must do
Safe
The trust must ensure that all relevant staff are up to date with safeguarding children level three training.
Must-do action 11 of 11
Must do
Safe
The trust must ensure that the first hour of care documentation is completed by medical staff for all babies admitted to the neonatal unit.
Should-do actions (22)
Should-do action 1 of 22
Should do
Safe
The trust should ensure that additional steps are taken to improve staff knowledge, understanding and ownership around safeguarding.
Should-do action 2 of 22
Should do
Safe
The trust should ensure that additional steps are taken to improve staff knowledge, understanding of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) applications.
Should-do action 3 of 22
Should do
Well-led
The trust should ensure that continued steps are taken to improve staff communications within the Electrical and Biomedical Engineering (EBME) department.
Should-do action 4 of 22
Should do
Effective
The trust should ensure the opportunity is provided for junior doctors to attend mortality and morbidity meetings as a learning opportunity.
Should-do action 5 of 22
Should do
Safe
The trust should consider the security of medical records in unlocked trolleys to reduce the potential risk of confidential information breach.
Should-do action 6 of 22
Should do
Safe
The trust should ensure records of venous thromboembolism (VTE) assessments are consistency completed both electronically and in hard copy paper records.
Should-do action 7 of 22
Should do
Safe
The trust should ensure that effective systems are in place for checking of fridge temperatures and areas where medications are stored. Appropriate actions should be recorded when breaches are found.
Should-do action 8 of 22
Should do
Effective
The trust should review fasting times for children undergoing day surgery.
Should-do action 9 of 22
Should do
Effective
The trust should reduce readmission rates for children and young people with long-term conditions and following elective admission.
Should-do action 10 of 22
Should do
Responsive
The trust should ensure that transitional arrangements for adolescents are established in all areas.
Should-do action 11 of 22
Should do
Effective
The trust should ensure that all staff are confident in assessing Gillick competence (a term used in medical law to decide whether a child (under 16 years of age) is able to consent to his or her own medical treatment, without the need for parental permission or knowledge).
Should-do action 12 of 22
Should do
Well-led
The trust should ensure that effective processes are in place to ensure timely review of all policies and guidelines.
Should-do action 13 of 22
Should do
Safe
The trust should ensure that the actions identified in the recent infection prevention and control audit for the mortuary are completed and that refurbishment of the mortuary environment is undertaken as planned.
Should-do action 14 of 22
Should do
Responsive
The trust should ensure there is a system in place to coordinate care with other providers for patients in the last year of life.
Should-do action 15 of 22
Should do
Responsive
The trust should ensure there is a system in place for monitoring whether patients receiving end of life care achieve their preferred place of care and preferred place of death.
Should-do action 16 of 22
Should do
Effective
The trust should ensure that consultant staffing in the specialist palliative care team is in line with national guidance.
Should-do action 17 of 22
Should do
Responsive
The trust should ensure that face-to-face specialist palliative care support is available to patients seven days a week and that there is a system in place for measuring the responsiveness of the service.
Should-do action 18 of 22
Should do
Effective
The trust should ensure an effective process to review and improved documented assessment of the patient’s mental capacity especially in relation to DNACPR.
Should-do action 19 of 22
Should do
Well-led
The trust should ensure there is clear oversight of incidents and risks relating to end of life care across the trust.
Should-do action 20 of 22
Should do
Responsive
The trust should ensure that death certificates and cremation forms are completed in a timely way.
Should-do action 21 of 22
Should do
Responsive
The trust should ensure the views of bereaved relatives are formally captured and acted upon.
Should-do action 22 of 22
Should do
Well-led
The trust should ensure that risk management process is embedded in community settings.