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Royal South Hants Hospital

Provider University Hospital Southampton NHS Foundation Trust Type NHS Healthcare Organisation Region South East Last inspected 6 Dec 2018

Overall rating: Requires Improvement  View full CQC report

Domain ratings

Five CQC key questions
Safe
Requires Improvement
Effective
Not Yet Rated
Caring
Good
Responsive
Requires Improvement
Well-led
Requires Improvement

Earlier inspection findings

pre-2024 framework · 13 must-do 29 should-do

Must-do actions (13)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 13
Must do
Safe
Ensurethattheenvironmentandequipmentarekeptcleanandfitforpurpose.Infectioncontrolproceduresarein placeandadheredtoinordertocontrolandminimisetherisksofcrossinfection.Regulation12(2)(h)
Regulation: Regulation12(2)(h)
⚠ The standard of cleanliness was variable particularly in areas such as the birthing pool on the Labour Ward, Burley and Lyndhurst wards. Infection control procedures were not consistently followed to ensure risks of cross infection was minimised. Loose tiles in the birthing pool area on the Labour Ward may pose …
Must-do action 2 of 13
Must do
Safe
Ensureemergencyequipmentaremaintainedsafelyandallnecessarychecksarecompletedtosafeguardpatients. Regulation15(1)(e)
Regulation: Regulation15(1)(e)
⚠ Emergency equipment was not maintained safely, as all the necessary checks were not completed in line with the trust policy and procedures. This posed risk of equipment may not be available when required in an emergency.
Must-do action 3 of 13
Must do
Safe
Ensurethatarrangementsareinplaceforthesafetransferofwomenwithinthematernityunit.Regulation15(1)(f)
Regulation: Regulation15(1)(f)
⚠ The maternity service had two passenger lifts as one of them was being refurbished. Arrangements for transfers of women were of concerns as the lift may be in use by visitors and not available in an emergency. There was no facility for overriding it and there was no dedicated patient’s …
Must-do action 4 of 13
Must do
Safe
Theprovidermustensurepremisesaresuitablefortheserviceprovided,includingthelayoutandfittodelivercare andtreatmentmustmeetpeople’sneeds.Regulation15(1)(c)
Regulation: Regulation15(1)(c)
⚠ The shower facilities on antenatal and post-natal wards were in poor state of repair and did not meet the needs of women. Some parts of the environment were draughty and cold as windows needed replacing.
Must-do action 5 of 13
Must do
Safe
Theprovidermustensurethatsecurityofthepremisesismanagedeffectivelyandhavetheappropriatelevelof securityneededinrelationtotheservicesbeingdelivered.Regulation15(1)(b).
Regulation: Regulation15(1)(b)
⚠ There were weaknesses in the security of the service at Princess Anne hospital which posed risks of unauthorised access to women and babies.
Must-do action 6 of 13
Must do
Safe
Ensuretheoutpatientserviceenvironmentiskeptcleanandfitforpurpose.Infectioncontrolproceduresareinplace andadheredto.Regulation12(2)(h)
Regulation: Regulation12(2)(h)
⚠ The service did not effectively control all infection risks. Premises were not always clean which could increase the spread of infection. There was no consistent approach to infection control and prevention in the outpatient departments.
Must-do action 7 of 13
Must do
Safe
Ensuresystemsandproceduresareinplacetomonitorandmanagepatient’scareandoutcomes.Thus,avoiding delaysinpatientappointmentswhichhasresultedinpatientharm.Regulation17
Regulation: Regulation17
⚠ Systems and procedures to monitor and manage risks to patients had failed which had led to patient harm.
Must-do action 8 of 13
Must do
Well-led
Ensurecompleteoversightofoutpatientservicesacrossthetrustsitesforthemanagementandleadership, governance,riskandconsistencyofservices.Regulation17
Regulation: Regulation17
⚠ Whilst there was management of outpatients in clinical speciality care groups, there was not a complete oversight of outpatients services for the trust for governance, risk and consistency of services.
Must-do action 9 of 13
Must do
Well-led
Ensurethereisafinalisedstrategyforoutpatientservices.Regulation17
Regulation: Regulation17
⚠ A strategy for improving outpatients was still in the planning stages.
Must-do action 10 of 13
Must do
Safe
Ensurestaffpersonalpropertyisstoredappropriatelyandsecurelywhenonduty.Regulation15
Regulation: Regulation15
⚠ Staff personal property not being held appropriately or securely.
Must-do action 11 of 13
Must do
Safe
Ensurepatientsarekeptsafefromharmsuchasbyhavingworkingemergencycallbellsandobservationofpatients leftinwaitingareas.Regulation15
Regulation: Regulation15
⚠ Broken emergency call bells and patients left unattended in waiting areas.
Must-do action 12 of 13
Must do
Safe
Ensurethephysicalcapacityoftheoutpatientenvironmentsmeettheneedsofthenumberofpatientswaitingand beingtreated.Regulation15
Regulation: Regulation15
⚠ Outpatient departments that could not cope with the volume of patients attending clinics.
Must-do action 13 of 13
Must do
Well-led
Ensurerecordsarestoredsecurely.Regulation17
Regulation: Regulation17
⚠ The service had some nursing and medical paper records that were not stored securely.

Should-do actions (29)

Recommended improvements to enhance service quality.

Should-do action 1 of 29
Should do
Well-led
Workwithstaffforthepromotionofequalityanddiversityinthetrust’sdaytodayworkandforsupporting opportunitiesforcareerprogression.
Should-do action 2 of 29
Should do
Well-led
Developtheboardassuranceframeworkprocess.
Should-do action 3 of 29
Should do
Safe
Reviewtheconditionoftheestatewherethisdidprovideagoodexperienceforpatients.
Should-do action 4 of 29
Should do
Well-led
Continueintheplanningandmonitoringatboardlevelforthedelaysinpatientcaresuchasophthalmologyservices.
Should-do action 5 of 29
Should do
Safe
Makesurepatientinformationiskeptsecurebynotleavingpatientnotesunattendedandcomputersunlockedwhen notinuse.
Should-do action 6 of 29
Should do
Safe
Makesuremandatorytrainingiscompletedbyallstaff.Makesurethereisoversightofmandatorytrainingcompliance rateofthemedicalstaffworkingintheoutpatientservices.
Should-do action 7 of 29
Should do
Effective
Makesurethereisdedicatedtimeforstafftocompletetrainingandreceiveyearlyappraisals.
Should-do action 8 of 29
Should do
Well-led
Makesurestandardoperatingproceduresarereviewedandupdatedassoonaspossible.
Should-do action 9 of 29
Should do
Safe
DeveloptheirITsystemenablingstaffinthecommunitytohaveaccesstoinformationtosupportandprovidewomen withsafeandeffectivecaretomeettheirneeds.
Should-do action 10 of 29
Should do
Safe
Havesystemsinplaceformedicinestobestoredatthecorrecttemperaturesinthedaycareunit.
Should-do action 11 of 29
Should do
Effective
HavearrangementsinplacetosupportstaffandachievetheTrust’stargetforyearlystaffappraisals.
Should-do action 12 of 29
Should do
Responsive
Investigatecomplaintswithinthetimeframesasdetailedintheirowncomplaints’policy.
Should-do action 13 of 29
Should do
Safe
Ensureallstaffcompletetheirmandatorytraininginlinewithtrustandstatutoryrequirements.
Should-do action 14 of 29
Should do
Safe
Ensureclinicalareasarecleanedregularlyinaccordancewithtrustpoliciesandprocedures.
Should-do action 15 of 29
Should do
Responsive
Ensurethereissufficientcapacityandflowwithinthedepartmentandacrossthetrusttoeffectivelymanagepatients requiringstep-downcare.
Should-do action 16 of 29
Should do
Caring
Ensurepatient’sprivacyismaintainedatalltimesbyreviewingthetriagearrangementswithinthemainwaitingarea.
Should-do action 17 of 29
Should do
Responsive
Ensurecomplaintsaremanagedinaccordancewiththetrustpolicy.
Should-do action 18 of 29
Should do
Safe
Makesurethereisaccuraterecordingofthecompletionoftherelevantmandatorycoursesbyalldoctors.
Should-do action 19 of 29
Should do
Safe
Makethefrequencyofchangeofcurtainsaroundthepatientbedareaisfollowedandstaffmadeawareofthis.
Should-do action 20 of 29
Should do
Caring
Makesurethearrangementsintheneurologicalunitmeetpatient’sneedsofprivacy.
Should-do action 21 of 29
Should do
Safe
Continuetoensureimprovementwiththerecordingofvenousthromboembolism(VTE)riskassessmentsasperthe trustpolicy.
Should-do action 22 of 29
Should do
Safe
Ensurethereisaspecificchecklistfortheequipmentonthemajorbleedtrolleyinendoscopy.
Should-do action 23 of 29
Should do
Safe
Ensureincidentandlearningfrommedicineadministrationissharedacrossthemedicalteams.
Should-do action 24 of 29
Should do
Effective
Ensureallclinicalstaffreceiveregularappraisal.
Should-do action 25 of 29
Should do
Well-led
Ensurepatientsafetythermometerdataissharedwithpatientsandvisitors.
Should-do action 26 of 29
Should do
Responsive
Continuetoimprovemeetingtimeframeforcomplaintsasperthetrustpolicy.
Should-do action 27 of 29
Should do
Safe
Reviewmidwifestaffingtoensurewomenandbabiesreceivetimelysupportwhenneeded.
Should-do action 28 of 29
Should do
Safe
Supportstafftocompletematernityspecifictrainingsuchasmanagementofwomeninthebirthingpool.
Should-do action 29 of 29
Should do
Well-led
Allowpatientsafetythermometerdatatobesharedwithwomenandvisitors.

Location details

CQC ID: RHM02
Local authority: Southampton
Region: South East

Inspection report

Type: Comprehensive inspection
Date: 6 December 2018
Rating: Good
Actions: 13 must-do 29 should-do
AI-extracted 3 Jun 2026