Source · CQC inspection
Windsor Dialysis Unit
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
Responsive
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
Makesureemergencyexitsandemergencyequipmentarenotobstructedbyconsumablesandotherequipment.
Should-do action 11 of 42
Should do
Safe
Makesurethestorageofequipmentontheresuscitationtrolleysarestandardisedthroughoutthehospital.
Should-do action 12 of 42
Should do
Safe
Lockallcleaningcupboardswhenunoccupied.
Should-do action 13 of 42
Should do
Safe
Removealltriphazardsespeciallyontheelderlycarewards.
Should-do action 14 of 42
Should do
Safe
Makesureallchairsarecoveredinawipeablematerial.
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
Makesuremedicalgasesarestoredaccordingtonationalguidance.
Should-do action 18 of 42
Should do
Effective
Makesuresepsispoliciesandproceduresarefollowedonelderlycarewards.
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
The services should develop a procedure to safely store empty oxygen cylinders prior to them being collected.
Should-do action 41 of 42
Should do
Well-led
Team leaders should be supported and encouraged to attend senior team meetings at the Royal Berkshire Hospital to build relationship and share learning. The trust told us that minutes of meetings were shared with the staff.
Should-do action 42 of 42
Should do
Effective
The trust should continue to work through their action plan on achieving JAG accreditation for the Endoscopy service.