Source · CQC inspection
New Forest Birth Centre
Type NHS Healthcare Organisation
Region South East
Last inspected 17 Apr 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 (13)
Must-do action 1 of 13
Must do
Safe
Ensure that the environment and equipment are kept clean and fit for purpose. Infection control procedures are in place and adhered to in order to control and minimise the risks of cross infection.
Must-do action 2 of 13
Must do
Safe
Ensure emergency equipment are maintained safely and all necessary checks are completed to safeguard patients.
Must-do action 3 of 13
Must do
Safe
Ensure that arrangements are in place for the safe transfer of women within the maternity unit.
Must-do action 4 of 13
Must do
Safe
The provider must ensure premises are suitable for the service provided, including the layout and fit to deliver care and treatment must meet people’s needs.
Must-do action 5 of 13
Must do
Safe
The provider must ensure that security of the premises is managed effectively and have the appropriate level of security needed in relation to the services being delivered.
Must-do action 6 of 13
Must do
Safe
Ensure the outpatients service environment is kept clean and fit for purpose. Infection control procedures are in place and adhered to.
Must-do action 7 of 13
Must do
Safe
Ensure systems and procedures are in place to monitor and manage patient’s care and outcomes. Thus, avoiding delays in patient appointments which has resulted in patient harm.
Must-do action 8 of 13
Must do
Well-led
Ensure complete oversight of outpatients services across the trust sites for the management and leadership, governance, risk and consistency of services.
Must-do action 9 of 13
Must do
Well-led
Ensure there is a finalised strategy for outpatients services.
Must-do action 10 of 13
Must do
Safe
Ensure staff personal property is stored appropriately and securely when on duty.
Must-do action 11 of 13
Must do
Safe
Ensure patients are kept safe from harm such as by having working emergency call bells and observation of patients left in waiting areas.
Must-do action 12 of 13
Must do
Responsive
Ensure the physical capacity of the outpatient environments meet the needs of the number of patients waiting and being treated.
Must-do action 13 of 13
Must do
Well-led
Ensure records are stored securely.
Should-do actions (32)
Should-do action 1 of 32
Should do
Well-led
Work with staff for the promotion of equality and diversity in the trust’s day to day work and for supporting opportunities for career progression.
Should-do action 2 of 32
Should do
Well-led
Develop the board assurance framework process.
Should-do action 3 of 32
Should do
Responsive
Continue to improve the complaint response targets had not been met and there were delays responding to patients.
Should-do action 4 of 32
Should do
Safe
Review the condition of the estate where this did provide a good experience for patients.
Should-do action 5 of 32
Should do
Effective
Review process for all staff to complete annual appraisals.
Should-do action 6 of 32
Should do
Safe
Review process for medical staff to complete mandatory training
Should-do action 7 of 32
Should do
Responsive
Continue in the planning and monitoring at board level for the delays in patient care such as ophthalmology services.
Should-do action 8 of 32
Should do
Safe
The service should ensure that staff in the community have access to information to support and provide women with safe and effective care to meet their needs.
Should-do action 9 of 32
Should do
Safe
The service should ensure medicines are stored at the correct temperatures in the day care unit.
Should-do action 10 of 32
Should do
Safe
Ensure patient information is kept secure by not leaving patient notes unattended and computers unlocked when not in use.
Should-do action 11 of 32
Should do
Well-led
Ensure standard operating procedures are reviewed and updated as soon as possible.
Should-do action 12 of 32
Should do
Safe
Makesure mandatory training is completed by all staff. Makesure there is oversight of mandatory training compliance rate of the medical staff working in the outpatients services.
Should-do action 13 of 32
Should do
Effective
Makesure there is dedicated time for staff to complete training and receive yearly appraisals.
Should-do action 14 of 32
Should do
Safe
Ensure clinical areas are cleaned regularly in accordance with trust policies and procedures.
Should-do action 15 of 32
Should do
Responsive
Ensure there is sufficient capacity and flow within the department and across the trust to effectively manage patients requiring step-down care.
Should-do action 16 of 32
Should do
Caring
Ensure patient’s privacy is maintained at all times by reviewing the triage arrangements within the main waiting area.
Should-do action 17 of 32
Should do
Responsive
Ensure complaints are managed in accordance with the trust policy.
Should-do action 18 of 32
Should do
Safe
Makesure there is accurate recording of the completion of the relevant mandatory courses by all doctors.
Should-do action 19 of 32
Should do
Safe
Makethe frequency of change of curtains around the patient bed area is followed and staff made aware of this.
Should-do action 20 of 32
Should do
Caring
Makesure the arrangements in the neurological unit meet patient’s needs of privacy.
Should-do action 21 of 32
Should do
Safe
Continueto ensure improvement with the recording of venous thromboembolism (VTE) risk assessments as per the trust policy.
Should-do action 22 of 32
Should do
Safe
Ensure there is a specific checklist for the equipment on the major bleed trolley in endoscopy.
Should-do action 23 of 32
Should do
Safe
Ensure incident and learning from medicine administration is shared across the medical teams.
Should-do action 24 of 32
Should do
Effective
Ensure all clinical staff receive regular appraisal.
Should-do action 25 of 32
Should do
Safe
Ensure patient safety thermometer data is shared with patients and visitors.
Should-do action 26 of 32
Should do
Responsive
Continueto improve meeting timeframe for complaints as per the trust policy.
Should-do action 27 of 32
Should do
Safe
Develop their IT system enabling staff in the community to have access to information to support and provide women with safe and effective care to meet their needs.
Should-do action 28 of 32
Should do
Safe
Review midwife staffing to ensure women and babies receive timely support when needed.
Should-do action 29 of 32
Should do
Effective
Support all staff to complete yearly appraisal in line with the Trust policy.
Should-do action 30 of 32
Should do
Effective
Support staff to complete maternity specific training such as management of women in the birthing pool.
Should-do action 31 of 32
Should do
Responsive
Continueto improve how complaints are investigated within the timeframes detailed in their own complaints policy.
Should-do action 32 of 32
Should do
Safe
Allow patient safety thermometer data to be shared with women and visitors.