Source · CQC inspection
Sunderland Royal Hospital
Provider City Hospitals Sunderland NHS Foundation Trust
Type NHS Healthcare Organisation
Region North East
Last inspected 17 Apr 2018
Overall rating: Good View full CQC report
Domain ratings
Safe
Requires Improvement
Effective
Good
Caring
Good
Responsive
Good
Well-led
Good
Earlier inspection findings
Must-do actions (8)
Must-do action 1 of 8
Must do
Safe
Ensure that staff adhere to the hand hygiene policies and procedures are adhered to by all staff at all times
Must-do action 2 of 8
Must do
Responsive
Have a proactive approach about how to improve the unplanned re-attendance rate of patients other than mental health patients.
Must-do action 3 of 8
Must do
Safe
Ensure there are sufficient qualified, skilled and experienced nursing and medical staff on medical wards. This is to include provision of staff out of hours, bank holidays and at weekends.
Must-do action 4 of 8
Must do
Safe
Ensure consistency of staffing across wards through the introduction of an acuity tool to determine accurate staffing levels.
Must-do action 5 of 8
Must do
Safe
The service must ensure safe staffing levels in order to deliver safe harm free care for patients.
Must-do action 6 of 8
Must do
Safe
Ensure controlled drugs are checked and monitored in line with NICE guidelines
Must-do action 7 of 8
Must do
Well-led
Ensure lessons learned from Never Events are shared across the whole surgical division and not just within the surgical speciality where the incident occurred.
Must-do action 8 of 8
Must do
Safe
Ensure the safe storage of dirty linen on wards to reduce the risk of infection
Should-do actions (14)
Should-do action 1 of 14
Should do
Safe
Record daily checks on resuscitation equipment and supplies to ensure there is evidence of checks being carried out.
Should-do action 2 of 14
Should do
Safe
Work towards improving compliance to mandatory training.
Should-do action 3 of 14
Should do
Safe
Ensure all eligible staff have signed patient group directives (PGDs).
Should-do action 4 of 14
Should do
Safe
Ensure all staff have undergone the most appropriate level of life support training for their grade as per the Royal College of Emergency Medicine.
Should-do action 5 of 14
Should do
Effective
Have robust processes in place to demonstrate compliance with RCEM clinical audit requirements and show improvements in compliance when standards are not being met.
Should-do action 6 of 14
Should do
Caring
Consider providing staff with additional training about working with people with mental health conditions to ensure such patients are treated with dignity and respect at all times.
Should-do action 7 of 14
Should do
Safe
Ensure consistent practice and compliance across wards with trust policies regarding the management of medicines.
Should-do action 8 of 14
Should do
Safe
Ensure mandatory training compliance rates meet trust targets.
Should-do action 9 of 14
Should do
Effective
Ensure the input from a consultant cardiologist identified in the heart failure audit meets national targets.
Should-do action 10 of 14
Should do
Safe
Investigate the causes of the failure to meet the aspirational standards for vision assessment, blood pressure assessment, assessment for the presence or absence of delirium and the proportion of patients with a call bell in reach identified in the national audit of inpatient falls.
Should-do action 11 of 14
Should do
Responsive
Ensure the division meets the trust target for the investigation and closure of complaints.
Should-do action 12 of 14
Should do
Safe
The service should continue to work towards the national guidelines of 1:28 midwifery staffing ratio.
Should-do action 13 of 14
Should do
Effective
The service should ensure that all clinical guidelines that are past their review date have been reviewed and if approved issued with a revised review date.
Should-do action 14 of 14
Should do
Effective
The trust should continue to reduce the percentage incidence of Apgar scores of less than seven at five minutes to bring it into line with or below the England average.