Source · CQC inspection
Diana Princess of Wales Hospital
Type NHS Healthcare Organisation
Region Yorkshire & Humberside
Last inspected 2 Dec 2022
Overall rating: Requires Improvement View full CQC report
Domain ratings
Safe
Requires Improvement
Effective
Requires Improvement
Caring
Good
Responsive
Requires Improvement
Well-led
Requires Improvement
Earlier inspection findings
Must-do actions (47)
Must-do action 1 of 47
Must do
Well-led
The service must ensure that effective and robust systems are in place to support the management of governance, risk and performance.
Must-do action 2 of 47
Must do
Safe
The service must ensure that all staff complete mandatory training to meet the trust’s set standard of 85%.
Must-do action 3 of 47
Must do
Well-led
The service must ensure that all staff have an up to date appraisal completed.
Must-do action 4 of 47
Must do
Safe
The service must continue to appropriately recruit medical staff to ensure that there are sufficiently suitably qualified, competent and experienced staff on duty to meet the needs of patients and to ensure there is a consistent and sustainable workforce available.
Must-do action 5 of 47
Must do
Safe
The service must continue to appropriately recruit staff (specifically registered sick children’s nurses (RSCN) and ensure that there are sufficiently suitably qualified, competent and experienced staff on duty to meet the needs of patients. The emergency department was not meeting the Intercollegiate Emergency Standard to have sufficient RSCNs to provide two per shift.
Must-do action 6 of 47
Must do
Responsive
The service must continue to address the challenges regarding overdue new and follow up appointments and ensure patients receive their appointment in a timely way across outpatient specialties.
Must-do action 7 of 47
Must do
Responsive
The service must ensure the 62-day cancer waiting times target for appointments is achieved
Must-do action 8 of 47
Must do
Safe
The trust must ensure that there is consistent measurement and monitoring of safety of all equipment and environments.
Must-do action 9 of 47
Must do
Well-led
The trust must ensure there are effective governance systems and processes to make sure criteria is consistently followed regarding equipment safety and quality assurance, including Ionising Radiation (Medical Exposure) Regulations (IR(ME)R).
Must-do action 10 of 47
Must do
Safe
The trust must ensure that there is safe storage of medicines in all areas.
Must-do action 11 of 47
Must do
Effective
The trust must ensure that there is consistent recording of patient consent for all procedures in line with trust policy and national body recommendations.
Must-do action 12 of 47
Must do
Safe
The service must ensure that persons providing care or treatment to service users have the qualifications, competence, skills, and experience to do so safely.
Must-do action 13 of 47
Must do
Safe
The service must ensure that medicine reconciliation is conducted in line with NICE Quality statement (QS) 120 and audited in line with trust policy.
Must-do action 14 of 47
Must do
Safe
The service must ensure that medicines are stored and administered safely as per manufacturing guidance.
Must-do action 15 of 47
Must do
Safe
The service must ensure that oxygen is prescribed as required by national guidelines.
Must-do action 16 of 47
Must do
Safe
The service must ensure that the assessment of risk, preventing, detecting, and controlling the spread of, infections, including those that are healthcare associated is managed in line with trust and national guidance
Must-do action 17 of 47
Must do
Safe
The service must ensure that all staff have safeguarding training at a level that is appropriate to their role in line with national guidance and trust policy.
Must-do action 18 of 47
Must do
Well-led
The trust must ensure that version-controlled documents are reviewed in line with trust policy and national guidance.
Must-do action 19 of 47
Must do
Safe
The service must ensure patient records are stored securely and confidential waste is stored securely and disposed of in line with national guidance and trust policy.
Must-do action 20 of 47
Must do
Safe
The service must ensure there are appropriate numbers suitably qualified, competent, and experienced medical staff to enable them to meet the needs of patients in their care.
Must-do action 21 of 47
Must do
Well-led
The service must ensure that persons employed receive such appropriate support, training, professional development, supervision and appraisal as is necessary to enable them to carry out the duties they are employed to perform and be enabled where appropriate to obtain further qualifications appropriate to the work they perform.
Must-do action 22 of 47
Must do
Safe
The trust must ensure control of substances hazardous to health (COSHH) cupboards are locked and not accessible to patients in theatres or on wards
Must-do action 23 of 47
Must do
Safe
The trust must ensure environmental issues in theatres do not pose risks to patient safety
Must-do action 24 of 47
Must do
Safe
The trust must ensure the WHO checklist is completely embedded within theatres and ensure staff complete the theatre register and patient marking verification
Must-do action 25 of 47
Must do
Well-led
Divisional and theatre leads must monitor the risks of theatre staff omitting or not documenting the WHO checklist stages in practice
Must-do action 26 of 47
Must do
Safe
The trust must ensure service staff have access to specialist equipment such as hoists to accurately weigh patients.
Must-do action 27 of 47
Must do
Safe
The trust must be assured medicine reconciliation is being conducted in line with the national institute for health and care excellence (NICE) quality standard (QS120) and audited as per trust’s own policy
Must-do action 28 of 47
Must do
Well-led
The trust must ensure root causes and conclusion findings identified from never event and serious incident investigations are actioned
Must-do action 29 of 47
Must do
Safe
The trust must ensure that all staff who require level 3 safeguarding adults training are compliant
Must-do action 30 of 47
Must do
Safe
The trust must assess risks associated with the ineffectiveness of the baby-tagging alarm system and put suitable controls in place, to further mitigate the risk of abduction.
Must-do action 31 of 47
Must do
Safe
The trust must ensure there is a robust consumable stock management system in please to reduce the risk to patients from staff using expired items, expired medicines and inappropriate equipment.
Must-do action 32 of 47
Must do
Safe
The trust must ensure that they have enough maternity staff with the right qualifications, skills, training and experience to keep women safe from avoidable harm and to provide the right care and treatment.
Must-do action 33 of 47
Must do
Safe
The trust must ensure bank and agency staff receive a full, formal induction so they are assured bank and agency staff are familiar with equipment, policies and emergency escalation procedures.
Must-do action 34 of 47
Must do
Well-led
The trust must ensure that all staff receive an annual appraisal.
Must-do action 35 of 47
Must do
Safe
The trust must ensure patient records are stored securely.
Must-do action 36 of 47
Must do
Well-led
The trust must ensure all identified risks affecting the service in line with trust policy are escalated to the risk register.
Must-do action 37 of 47
Must do
Safe
The service must ensure equipment used to deliver end of life and palliative care are used in accordance with trust policy and national best practice.
Must-do action 38 of 47
Must do
Safe
The service must ensure that there are sufficient staff with the right qualifications, skills and training to keep people safe from harm.
Must-do action 39 of 47
Must do
Safe
The service must ensure that patient records are completed consistently and appropriately and are easily accessible when needed.
Must-do action 40 of 47
Must do
Responsive
The service must ensure there is a formalised referral processes to the EoL teams with effective cross site cover.
Must-do action 41 of 47
Must do
Effective
The service must ensure there is a consistent approach to the monitoring of pain relief and the reassessment of pain.
Must-do action 42 of 47
Must do
Safe
The service must ensure the design and maintenance of the mortuary environment meets met the national standards. They must ensure all areas of the mortuary are clean and that equipment is fit for purpose and that waste is disposed of safely.
Must-do action 43 of 47
Must do
Well-led
The service must have an effective system which accurately identifies and tracks end of life and palliative care patients.
Must-do action 44 of 47
Must do
Effective
The service must ensure clinical care and treatment are delivered in accordance with national guidance and best practice.
Must-do action 45 of 47
Must do
Effective
The service must ensure that robust systems are in place to monitor the effectiveness of care and treatment delivered to achieve good outcomes for patients.
Must-do action 46 of 47
Must do
Well-led
The service must ensure robust governance processes are in place to lead, manage, risk assess and sustain effective services.
Must-do action 47 of 47
Must do
Well-led
The service must collect reliable data to understand performance, make decisions and improvements.
Should-do actions (29)
Should-do action 1 of 29
Should do
Effective
The service should ensure that medical staff compliance with Mental Capacity Act training meets the trust target.
Should-do action 2 of 29
Should do
Effective
The service should ensure that nutrition and hydration audits are completed on a consistent basis.
Should-do action 3 of 29
Should do
Safe
The service should ensure that all patients deemed to be at risk of falling have a risk assessment completed upon initial assessment.
Should-do action 4 of 29
Should do
Safe
The service should ensure that a record of patients’ prescribed medications is completed upon initial assessment within the department.
Should-do action 5 of 29
Should do
Well-led
The trust should consider ways to improve visibility of the senior leadership team.
Should-do action 6 of 29
Should do
Well-led
The trust should ensure all key policies and guidance documents are up to date.
Should-do action 7 of 29
Should do
Well-led
The trust should ensure that initiatives to address trust wide shortages of radiologists continue to develop.
Should-do action 8 of 29
Should do
Safe
The trust should ensure temperatures are measured in environments where contrast agents are stored to ensure manufacturers’ guidance is followed.
Should-do action 9 of 29
Should do
Responsive
The trust should ensure that initiatives to reduce waiting lists and backlogs for reporting continue.
Should-do action 10 of 29
Should do
Safe
The trust should ensure Safeguarding leads complete Safeguarding Children Level 3 training.
Should-do action 11 of 29
Should do
Well-led
The trust should ensure service level agreements with external providers for radiation protection and telereporting accurately reflect safe practice, RPS training, and quality assurance requirements.
Should-do action 12 of 29
Should do
Safe
The Trust should ensure protocols for ultrasound and x-ray equipment are adapted for each piece of equipment, so staff are aware of specific requirements of the equipment they use.
Should-do action 13 of 29
Should do
Safe
The trust should ensure that oxygen cylinders are stored securely in line with trust policy
Should-do action 14 of 29
Should do
Safe
The trust should ensure that fire doors are closed at all times in line with trust policy
Should-do action 15 of 29
Should do
Safe
The trust should ensure the division’s overall mandatory training and role specific training compliance meets trust targets, particularly for medical staff.
Should-do action 16 of 29
Should do
Safe
The trust should ensure staff wear personal protective equipment correctly and follow infection prevention control (IPC) principles.
Should-do action 17 of 29
Should do
Safe
The trust should have accurate, and current records of patients’ weights to ensure safe prescribing.
Should-do action 18 of 29
Should do
Safe
The trust should ensure medicines with changes in expiry dates as per manufacturers’ instructions, are correctly managed.
Should-do action 19 of 29
Should do
Safe
The trust should complete and sign controlled drugs books in theatres in line with national policy.
Should-do action 20 of 29
Should do
Well-led
The trust should ensure all key policies and guidance documents are up to date.
Should-do action 21 of 29
Should do
Effective
The trust should consider ways to increase ultrasonography provision, to ensure standards set by RCOG, NICE and Saving Babies Lives are met.
Should-do action 22 of 29
Should do
Responsive
The trust should risk assess the need for triage and consider ways to expedite its implementation.
Should-do action 23 of 29
Should do
Well-led
The trust should consider ways to improve visibility of the senior leadership team.
Should-do action 24 of 29
Should do
Effective
The service should ensure all medical staff receive training to ensure they have the skills and knowledge to recognise and identify those patients approaching EoL.
Should-do action 25 of 29
Should do
Safe
The service should ensure all staff follow trust policy with regard to infection prevention and control.
Should-do action 26 of 29
Should do
Safe
The service should ensure that patient’s medical records are stored securely and appropriately archived.
Should-do action 27 of 29
Should do
Safe
The service should ensure that prescription charts are always completed when oxygen is prescribed.
Should-do action 28 of 29
Should do
Caring
The service should ensure there are formalised referral processes to the chaplaincy teams.
Should-do action 29 of 29
Should do
Caring
The service should ensure that bereavement staff are invited to relevant end of life team meetings.