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West Berkshire Community Hospital

Provider Royal Berkshire NHS Foundation Trust Type NHS Healthcare Organisation Region South East Last inspected 7 Jan 2020

Location rating: Good  View location on CQC

Location ratings by domain

Five CQC key questions

Ratings held for this CQC location under the inspection framework, last inspected 7 January 2020. Ratings extracted from individual reports are shown separately below.

Safe
Good
Effective
Good
Caring
Good
Responsive
Good
Well-led
Good

Most recent report indexed for actions

The date and rating here are from an individual report, not necessarily the location's latest assessment. Report ratings are extracted with AI; verify the original PDF.

Type: Location
Date: 7 January 2020
Rating extracted from this report: Good
Actions indexed: 2 must-do 42 should-do

Read this inspection PDF

AI-extracted 3 Jun 2026

Earlier inspection findings

pre-2024 framework · 2 must-do 42 should-do

Must-do actions (2)

Legal requirements based on regulation breaches identified during inspection.

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.
Regulation: Regulation 12 (Safe care and treatment)
⚠ Not all staff had completed the required mandatory or safeguarding training and the trust’s mandatory and safeguarding training targets were not met. Not all staff had completed the required Mental Capacity Act and Deprivation of Liberty safeguards training.
Must-do action 2 of 2
Must do
Caring
Ensure mixed sex accommodation are managed effectively, in line with national guidance.
Regulation: Regulation 10 (Dignity and respect)
⚠ Mixed sex accommodation was not effectively managed or in line with national guidance.

Should-do actions (42)

Recommended improvements to enhance service quality.

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.