Source · CQC inspection
West Berkshire Community Hospital
Provider Royal Berkshire NHS Foundation Trust
Type NHS Healthcare Organisation
Region South East
Last inspected 7 Jan 2020
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 (2)
Must-do action 1 of 2
Must do
Safe
Ensure mandatory, safeguarding and Mental Capacity Act and Deprivation of Liberty training is completed by all staff.
Must-do action 2 of 2
Must do
Caring
Ensure mixed sex accommodation are managed effectively, in line with national guidance.
Should-do actions (42)
Should-do action 1 of 42
Should do
Well-led
ContinueworkingtowardshavingatrustboardthatreflectedtheBAMErepresentationwithintheoverallworkforce
Should-do action 2 of 42
Should do
Well-led
Continuetodevelopandimplementformalsuccessionplanningprocessesusedalongsidetheappraisalsystem.
Should-do action 3 of 42
Should do
Safe
Implementactionstoincreasestaff’sconfidencetoreportviolenceandaggressionincidentsandmonitortheimpacttheseactionsarehavingonreducingtheincidenceofviolenceandaggressiontowardsstaff.
Should-do action 4 of 42
Should do
Well-led
Reviewengagementwithgovernorstomanagetheirexpectationsoftheroleandtheiractiveparticipationwithinthetrust.
Should-do action 5 of 42
Should do
Well-led
Takeactiontomeetthedatasecurityandprotectionstandardsandmonitoron-goingcompliancewiththese standards.
Should-do action 6 of 42
Should do
Well-led
Improvethequalityofdataandinformationavailableforinternalandexternalusetoensureitprovidesassuranceofperformanceandcompliance.
Should-do action 7 of 42
Should do
Effective
ContinuetoimprovecompliancewithSepsissixinalareasofthetrust.
Should-do action 8 of 42
Should do
Well-led
Continuetopromotethetrust’squalityimprovementtooltofacilitateaconsistentapproachtoallquality improvementprojectsandprogrammes.
Should-do action 9 of 42
Should do
Safe
Makesureinfectionandpreventioncontrolpracticesareembeddedintheservice,especiallyinregardoftransporting humanwasteanddirtylinen.
Should-do action 10 of 42
Should do
Safe
Replaceallchairsthatarenotcoveredinawipeablematerial.
Should-do action 11 of 42
Should do
Safe
Makesureemergencyexitsandemergencyequipmentarenotobstructedbyconsumablesandotherequipment.
Should-do action 12 of 42
Should do
Safe
Standardisedthestorageofequipmentontheresuscitationtrolleysthroughoutthehospital.
Should-do action 13 of 42
Should do
Safe
Lockallcleaningcupboardswhenunoccupied.
Should-do action 14 of 42
Should do
Safe
Removealltriphazardsespeciallyontheelderlycarewards.
Should-do action 15 of 42
Should do
Safe
Makesurethecheckingofmedicinesfollowedthetrust’spoliciesandprocedures.
Should-do action 16 of 42
Should do
Safe
Staffinthedialysisunitsshouldbeupdatedonthepolicyandproceduresforthesafemanagementofpatients’own controlleddrugs.
Should-do action 17 of 42
Should do
Safe
Storeallmedicalgasesaccordingtonationalguidance.
Should-do action 18 of 42
Should do
Effective
Monitorcompliancewithsepsispoliciesandproceduresontheelderlycarewards.
Should-do action 19 of 42
Should do
Responsive
ConsiderrecordingandmonitoringoutofhoursbedmovesasrecommendedbytheRoyalCollegeofPhysicians.
Should-do action 20 of 42
Should do
Effective
Theprovidershouldensurethatconsentfortheuseoffallsalaermsareincludedwithintheconsentpolicy.Wherea patientlackscapacitytoconsent,abestinterestdecisionshouldberecorded.
Should-do action 21 of 42
Should do
Effective
ContinuetoworkthroughtheiractionplantowardsachievingJAGaccreditationfortheendoscopyservices.
Should-do action 22 of 42
Should do
Well-led
TeamleadersshouldbesupportedandencouragedtoattendseniorteammeetingsattheRoyalBerkshireHospitalto buildrelationshipandsharelearning.Thetrusttoldusthatminutesofmeetingsweresharedwiththestaff.
Should-do action 23 of 42
Should do
Safe
Employsufficientmaternitystafftoensurethattheservicemeetsthetrust'sownassessedrequirementsas submittedintheMaternityBirthratePlusandreport2018.
Should-do action 24 of 42
Should do
Responsive
Providetimelyaccesstotheatresinallcaseswheneverrequired.
Should-do action 25 of 42
Should do
Safe
Regularlymaintainthematernityblockandaddressissueswiththefabricofthebuilding.
Should-do action 26 of 42
Should do
Safe
Alwayslockcupboardshousingelectricalmainsswitches.
Should-do action 27 of 42
Should do
Well-led
Theriskregistershouldclearlydocumentactionsthathavebeentakentomitigaterisksandtimescalesforwhen identifiedactionsshouldbecompleted.
Should-do action 28 of 42
Should do
Responsive
Thetrustshouldworktoreducethenumberofoccasionsthemidwiferyledunitissuspendedforfourhoursormore.
Should-do action 29 of 42
Should do
Effective
Careandtreatmentoutcomesmeasuredbykeyperformanceindicators(KPI)shouldmeetthetrust’sminimum standards.
Should-do action 30 of 42
Should do
Well-led
IssueswithITsystemsprovidingoutcomedataandthoserelatingtoremoteworkingshouldberesolved.
Should-do action 31 of 42
Should do
Safe
Improvethesafeguardingtrainingcomplianceratesformedicalstaff.
Should-do action 32 of 42
Should do
Safe
Considerremovingtapefromwastebinstoaideffectivecleaning.
Should-do action 33 of 42
Should do
Safe
Considerrepairingripsintheflooring.
Should-do action 34 of 42
Should do
Safe
Considernotusingelectricalsocketslocatedhighuponwalls.
Should-do action 35 of 42
Should do
Safe
Expediteplanstoimprovethesecurestorageofpatientrecordswithintheclinicpreparationarea.
Should-do action 36 of 42
Should do
Caring
Considerre-decoratingthe‘quietroom’andprovidinginformationforpatientstotakeaway.
Should-do action 37 of 42
Should do
Safe
Developeffectivestoragesolutionswithinthewardandclinicenvironmentandtoremoveadditionalequipmentfrom clinicalareas.
Should-do action 38 of 42
Should do
Responsive
Displayinformationonhowtomakeacomplaintinpublicareas.
Should-do action 39 of 42
Should do
Well-led
Continuetoengagewithstafftogetfeedbackontheserviceanditsmanagement.
Should-do action 40 of 42
Should do
Safe
Theserviceshoulddevelopaproceduretosafelystoreemptyoxygencylinderspriortothembeingcollected.
Should-do action 41 of 42
Should do
Well-led
TeamleadersshouldbesupportedandencouragedtoattendseniorteammeetingsattheRoyalBerkshireHospitalto buildrelationshipandsharelearning.Thetrusttoldusthatminutesofmeetingsweresharedwiththestaff.
Should-do action 42 of 42
Should do
Effective
ThetrustshouldcontinuetoworkthroughtheiractionplanonachievingJAGaccreditationfortheEndoscopyservice.