Source · CQC inspection
Andover War Memorial Hospital
Provider Hampshire Hospitals NHS Foundation Trust
Type NHS Healthcare Organisation
Region South East
Last inspected 7 Apr 2020
Overall rating: Good View full CQC report
Domain ratings
Safe
Good
Effective
Good
Caring
Good
Responsive
Good
Well-led
Requires Improvement
Earlier inspection findings
Must-do actions (1)
Must-do action 1 of 1
Must do
Safe
The trust must have clear processes for checking expiration dates, storing medication and recording fridge temperatures.
Should-do actions (30)
Should-do action 1 of 30
Should do
Safe
The trust should ensure all qualified nursing staff complete medicine management training.
Should-do action 2 of 30
Should do
Safe
The trust should ensure all medical staff complete safeguarding children training
Should-do action 3 of 30
Should do
Effective
The service should provide all necessary support for its staff to improve compliance for MCA/DoLS training for medical and nursing staff.
Should-do action 4 of 30
Should do
Safe
The service should continue to review nursing staffing in the medical care wards and focus on recruitment and retention to ensure safe staffing levels can be consistently achieved across all wards.
Should-do action 5 of 30
Should do
Caring
Staff should document patients personal, cultural, social and religious needs and how they may relate to their care needs as part of assessment processes.
Should-do action 6 of 30
Should do
Effective
The service should continue to work to improve its performance in national clinical audits.
Should-do action 7 of 30
Should do
Safe
The service should ensure there is pharmacy oversight and support towards and departments.
Should-do action 8 of 30
Should do
Well-led
The service should continue to embed diversity groups within the trust.
Should-do action 9 of 30
Should do
Responsive
The service should achieve its referral to treatment target for urology, ear nose and throat and ophthalmology.
Should-do action 10 of 30
Should do
Safe
The service should ensure patients have their risk of developing a venous thromboembolism reassessed within 24 hours of admission.
Should-do action 11 of 30
Should do
Effective
The service should ensure appraisal compliance meets the trust target.
Should-do action 12 of 30
Should do
Well-led
The service should consider training in quality improvement methods to support the service to enhance the service provided.
Should-do action 13 of 30
Should do
Well-led
Senior managers should consider how to strengthen governance process and the mechanisms for identifying and understanding of risk.
Should-do action 14 of 30
Should do
Well-led
Senior managers should consider how the day surgery unit can monitor and benchmark performance.
Should-do action 15 of 30
Should do
Safe
The service should ensure there is effective governance and analyse of the risk for the anaesthetic medicines within the unit.
Should-do action 16 of 30
Should do
Safe
The service should consider consistency with the World Health Organisation Safer Surgery Checklist.
Should-do action 17 of 30
Should do
Well-led
The service should consider a vision or strategy for the development of the service.
Should-do action 18 of 30
Should do
Well-led
The service should continue to improve senior oversight and visibility within the unit.
Should-do action 19 of 30
Should do
Safe
The service should follow processes and procedures in line with the trust’s medicines management policy
Should-do action 20 of 30
Should do
Well-led
The provider should review staff’s access to up to date policies and procedures.
Should-do action 21 of 30
Should do
Effective
The provider should act to meet the trust target of 90% for appraisals in all staff groups.
Should-do action 22 of 30
Should do
Effective
The provider should act to improve the completion of patients’ food and fluid records and review their dietary care plans to meet the patients’ needs safely.
Should-do action 23 of 30
Should do
Safe
The provider should act and review the process for fasting pre-operatively in line with guidelines.
Should-do action 24 of 30
Should do
Effective
Ensure qualified nurses complete training in the Mental Capacity Act.
Should-do action 25 of 30
Should do
Safe
Ensure that there is an accurate process to record medicine related stationary and that this is monitored, including storing, recording and auditing the use of FP10 forms.
Should-do action 26 of 30
Should do
Effective
Continue to review and improve care pathways to ensure patient care meet the standards set by the Royal College of Emergency Medicine.
Should-do action 27 of 30
Should do
Responsive
Continue to work with the rest of the hospital teams to meet the nationally agreed wait times for patients attending the emergency department.
Should-do action 28 of 30
Should do
Safe
Ensure that patient directive paperwork on the trust intranet is the most recent and in date version.
Should-do action 29 of 30
Should do
Safe
Ensure staff record if patients are at risk of developing blood clots in all notes.
Should-do action 30 of 30
Should do
Safe
Review processes for monitoring the use of PGDs.