Source · CQC inspection
Weston Park Hospital
Provider Sheffield Teaching Hospitals NHS Foundation Trust
Type NHS Healthcare Organisation
Region Yorkshire & Humberside
Last inspected 14 Nov 2018
Overall rating: Requires Improvement View full CQC report
Domain ratings
Safe
Good
Effective
Requires Improvement
Caring
Outstanding
Responsive
Outstanding
Well-led
Requires Improvement
Earlier inspection findings
Must-do actions (14)
Must-do action 1 of 14
Must do
Well-led
The trust must ensure that all board members have been subject to all the appropriate fit and proper person checks and that these are recorded. In addition, the trust should comply with its own FPPR policy by ensuring that there is evidence of the qualitative assessment and values-based assessment directors had undergone as part of the recruitment process.
Must-do action 2 of 14
Must do
Well-led
The trust must ensure that there is effective oversight by the board of significant operational risks and how these are being managed.
Must-do action 3 of 14
Must do
Safe
The trust must ensure that there are named doctors for safeguarding in place and that the safeguarding policy for children is in date and reflects national guidelines.
Must-do action 4 of 14
Must do
Safe
The trust must continue to ensure that its plans to manage the patient pathways in the outpatients follow up backlog are effectively, promptly and clinically assessed to ensure that no harm comes to patients.
Must-do action 5 of 14
Must do
Effective
The trust must ensure the Mental Capacity Act and Deprivation of Liberty Safeguards are applied consistently and staff are aware of the relevant forms to complete and where to store and record this within the patient records.
Must-do action 6 of 14
Must do
Safe
The trust must ensure the provision of 24-hour consultant medical cover within the emergency department as part of being a major trauma centre so that major trauma guidance is followed, and standards are achieved consistently.
Must-do action 7 of 14
Must do
Safe
The trust must ensure action is taken to achieve the recognised standard of 15-minute arrival by ambulance to handover to the emergency department and to ensure breaches of the ambulance arrival standard are minimal.
Must-do action 8 of 14
Must do
Safe
The trust must ensure standards of hygiene are maintained consistently in the emergency department, supported by correct handwashing in frequency and technique, equipment always being cleaned between patients and the availability of supplies and equipment to support appropriate cleaning of the department.
Must-do action 9 of 14
Must do
Safe
The trust must ensure emergency department staff follow policy and best practice guidance for the prescription of oxygen therapy and the completion of patient records related to oxygen therapy.
Must-do action 10 of 14
Must do
Effective
The trust must have systems and processes in place to ensure best interest decisions and capacity assessments are recorded in patients’ notes.
Must-do action 11 of 14
Must do
Effective
The trust must have systems and processes in place, so all staff are aware of the escalation procedures if a patient appeals against their Mental Health Act section and requests an independent mental health advocate.
Must-do action 12 of 14
Must do
Well-led
The trust must further develop systems and process to ensure effective engagement and clinical support for junior doctors at Weston Park.
Must-do action 13 of 14
Must do
Well-led
The trust must have clear systems and processes in place to identify, manage, mitigate and escalate risk.
Must-do action 14 of 14
Must do
Safe
The trust must ensure all staff at Northern General Hospital and Weston Park are compliant with medical device training.
Should-do actions (27)
Should-do action 1 of 27
Should do
Responsive
The trust should ensure the emergency department takes further action to achieve the Department of Health’s standard for emergency departments that 95% of patients to be admitted, transferred or discharged within four hours of arrival in accident and emergency.
Should-do action 2 of 27
Should do
Effective
The trust should ensure the emergency department has clearly sighted actions in place to improve door to antibiotic time for sepsis patients.
Should-do action 3 of 27
Should do
Safe
The trust should ensure the emergency department has clearly sighted actions in place to fully implement electronic patient record keeping without the need to maintain paper records for use in the department.
Should-do action 4 of 27
Should do
Well-led
The trust should ensure all clinical staff are fully conversant with the emergency department risk register and the trust board are appropriately sighted on the risks classed as ‘extreme’ by the emergency department.
Should-do action 5 of 27
Should do
Well-led
The trust should ensure the friends and family test and other means of patient and public engagement are further developed.
Should-do action 6 of 27
Should do
Safe
The trust should ensure the planned completion rate for mandatory training of 90% is achieved overall staff groups.
Should-do action 7 of 27
Should do
Effective
The trust should ensure the emergency department has clearly sighted actions in place to respond to the findings of both national RCEM audits and its programme of local audits.
Should-do action 8 of 27
Should do
Responsive
The trust should ensure health promotion information and materials are available in areas of the emergency department which are accessible to patients.
Should-do action 9 of 27
Should do
Caring
The trust should ensure drinks and snacks which represent healthy lifestyle choices and promote healthier options for patients and visitors are available in the emergency department waiting areas.
Should-do action 10 of 27
Should do
Safe
The trust should ensure the doors on ward E1 and E2 at Royal Hallamshire Hospital are fitted with appropriate locking mechanisms to help to keep patients and staff safe.
Should-do action 11 of 27
Should do
Effective
The trust should increase the availability of Mental Health Act specific training around detention under the Act to more staff.
Should-do action 12 of 27
Should do
Responsive
The trust should improve the experience for patients who need extra support, such as those living with dementia.
Should-do action 13 of 27
Should do
Safe
The trust should ensure secure access to medication at Northern General Hospital.
Should-do action 14 of 27
Should do
Caring
The trust should ensure the privacy of all patients is respected.
Should-do action 15 of 27
Should do
Safe
The trust should ensure stock is rotated.
Should-do action 16 of 27
Should do
Safe
The trust should ensure bowls are washed and dried at Northern General Hospital as according to best practice for infection prevention.
Should-do action 17 of 27
Should do
Safe
The trust should ensure carpets are removed from clinical areas at Royal Hallamshire hospital.
Should-do action 18 of 27
Should do
Safe
The trust should continue to reduce the movement of staff to clinical areas outside of their speciality at Royal Hallamshire Hospital.
Should-do action 19 of 27
Should do
Safe
The trust should ensure all treatment rooms at Royal Hallamshire hospital have lockable doors that are not propped open.
Should-do action 20 of 27
Should do
Effective
The trust should ensure they use available data to evidence positive, or implement actions to improve, patient outcomes.
Should-do action 21 of 27
Should do
Safe
The trust should ensure all staff meet the trust’s own target for mandatory training compliance.
Should-do action 22 of 27
Should do
Safe
The trust should ensure staff at Northern General Hospital and Weston Park are able to access pressure relieving mattresses in a timely manner, to enable them to safely care for patients at risk of pressure damage.
Should-do action 23 of 27
Should do
Caring
The trust should improve the mortuary facilities to prevent deceased patients being taken outside the building and through a public area.
Should-do action 24 of 27
Should do
Safe
The trust should ensure the frequency of environmental and infection prevention and control audits conducted on the Macmillan palliative care unit matches the frequency identified by the trust.
Should-do action 25 of 27
Should do
Effective
The trust should ensure patients’ care at Weston Park is planned in line with the trust’s end of life care guidelines.
Should-do action 26 of 27
Should do
Effective
The trust should ensure it has robust document control processes in place at Weston Park to prevent the use of out of date guidance.
Should-do action 27 of 27
Should do
Responsive
The trust should consider further improvements at Weston Park to support individual patients, for example those living with dementia.