Source · CQC inspection
Corbett Hospital
Provider The Dudley Group NHS Foundation Trust
Type NHS Healthcare Organisation
Region West Midlands
Last inspected 12 Jul 2019
Overall rating: Inadequate View full CQC report
Domain ratings
Safe
Inadequate
Effective
Good
Caring
Good
Responsive
Good
Well-led
Inadequate
Earlier inspection findings
Must-do actions (54)
Must-do action 1 of 54
Must do
Safe
The trust must ensure that there are robust escalation and full capacity protocols in place aimed at avoiding a crowded emergency department and that they are followed in times of high demand.
Must-do action 2 of 54
Must do
Safe
The trust must ensure that all patients in the emergency department are subject to the same safety checks.
Must-do action 3 of 54
Must do
Responsive
The trust must ensure that ambulance crews are able to handover the care of their patients as soon as they arrive at the emergency department.
Must-do action 4 of 54
Must do
Safe
The trust must ensure that all staff within the emergency department complete mandatory training and additional training for their role as per trust policy.
Must-do action 5 of 54
Must do
Safe
The trust must ensure that all staff in the emergency department are trained in and to the appropriate levels of safeguarding for adults and children.
Must-do action 6 of 54
Must do
Safe
The trust must ensure that patients being cared for on corridors are appropriately supervised at all times.
Must-do action 7 of 54
Must do
Safe
The trust must ensure that all required patients presenting to the emergency department receive a robust clinical assessment in line with national guidelines and standards within 15 minutes of arrival.
Must-do action 8 of 54
Must do
Safe
The trust must ensure that patients with deteriorating conditions are effectively identified and treated within the emergency department.
Must-do action 9 of 54
Must do
Safe
The trust must ensure the appropriate storage, checking and administration of medicines at all times within the emergency department.
Must-do action 10 of 54
Must do
Safe
The trust must ensure that all staff within the emergency department understand their responsibilities in supervising mental health patients and have the skills, training and competency to do so.
Must-do action 11 of 54
Must do
Safe
The trust must ensure that risks within the emergency department appropriately identified and managed.
Must-do action 12 of 54
Must do
Safe
The trust must ensure that specialist clinical expertise is secured to ensure expertise across the emergency department. The clinicians should provide the oversight of care provision, ensuring all patients receive care from senior clinicians that is safe, effective, timely and in line with best practice.
Must-do action 13 of 54
Must do
Safe
The trust must ensure that there is enough staff within the emergency department with the right qualification, skills, training and experience to keep people safe and to provide the right care and treatment.
Must-do action 14 of 54
Must do
Safe
The trust must ensure that it follow through with plans to train all recovery staff in Advanced Life Support training in line with guidance.
Must-do action 15 of 54
Must do
Safe
The provider must ensure that the premises used by the service are safe for their intended purpose, including ensuring the premises are safe for patients admitted with a mental health condition.
Must-do action 16 of 54
Must do
Safe
The provider must ensure there are sufficient numbers of suitably qualified, competent, skilled and experienced nursing staff available to provide care to children and young people.
Must-do action 17 of 54
Must do
Safe
The provider must review the counting of trainee nurse associates within the registered staff numbers on the neonatal unit.
Must-do action 18 of 54
Must do
Safe
The provider must ensure there are sufficient numbers of suitably qualified, competent, skilled and experienced medical staff available to provide care to children and young people.
Must-do action 19 of 54
Must do
Responsive
The providemust ensure that suitable transitional pathways from children’s services to adult services are in place to meet the needs and reflect the personal preferences of young people.
Must-do action 20 of 54
Must do
Responsive
The provider must ensure that care is planned and delivered in a way that meets the individual needs of all children, young people and those close to them, including those children and young people with a mental health condition. (Regulation 9(1)).
Must-do action 21 of 54
Must do
Well-led
The provider must ensure that systems are in place to make sure all complaints are investigated without delay and learning from complaints shared across the service.
Must-do action 22 of 54
Must do
Well-led
The provider must have systems and processes in place to monitor progress against plans, including a vision and strategy, to improve the quality and safety of services.
Must-do action 23 of 54
Must do
Well-led
The provider must ensure it has systems and processes in place to collect, analyse and use information to improve quality and safety across the service.
Must-do action 24 of 54
Must do
Safe
The trust must ensure staff follow infection control procedures at all times.
Must-do action 25 of 54
Must do
Safe
The trust must ensure local rules in ophthalmology are kept up to date and regularly reviewed.
Must-do action 26 of 54
Must do
Safe
The trust must ensure clear plans are in place around deteriorating patients including the use of the sepsis screening tool.
Must-do action 27 of 54
Must do
Safe
The trust must ensure robust systems are in place around missing/patient notes, to include effectively monitoring the amounts and developing robust plans of action.
Must-do action 28 of 54
Must do
Well-led
The trust must ensure all risks are reviewed on the departmental risk register and that action is taken to move risks on.
Must-do action 29 of 54
Must do
Safe
The trust must ensure they review the suitability of premises outpatients and the ophthalmology department and review patient flow thought the departments.
Must-do action 30 of 54
Must do
Safe
The trust must ensure clear plans are in place around deteriorating patients; to include a review of the availability of resuscitation equipment, the storage of anaphylaxis kits, cascading learning from the revised cardiac arrest procedure and assessing the risk of clinical support workers working in clinics without the direct supervision of a registered nurse.
Must-do action 31 of 54
Must do
Safe
The trust must ensure systems are in place to improve the accessibility of patient notes, to include effectively monitoring the volume of missing notes and developing clear plans of action to reduce the use of temporary notes.
Must-do action 32 of 54
Must do
Safe
The trust must ensure Improve the storage of patient notes within the department in relation to confidentiality and information governance requirements and health and safety.
Must-do action 33 of 54
Must do
Well-led
The trust must ensure all risks are mitigated and reviewed on the departmental risk registers and that action is taken to move risks on.
Must-do action 34 of 54
Must do
Safe
The trust must ensure risks to patients in urology are effectively managed in relation to the use of trolleys with no sides for patients undergoing invasive procedures.
Must-do action 35 of 54
Must do
Safe
The trust must ensure they review the suitability of the outpatient premises in relation to patient flow thought the department.
Must-do action 36 of 54
Must do
Safe
The trust must ensure they improve mandatory staff training compliance
Must-do action 37 of 54
Must do
Safe
The trust must ensure they improve the uptake of safeguarding staff training
Must-do action 38 of 54
Must do
Safe
The trust must ensure they put in place a protocol for managing a deteriorating adult or child including training staff in paediatric life support
Must-do action 39 of 54
Must do
Safe
The trust must ensure they improve resuscitation adults staff training compliance
Must-do action 40 of 54
Must do
Safe
The trust must ensure they put in place an effective system for measuring the safety of imaging services
Must-do action 41 of 54
Must do
Safe
The trust must ensure they put in place a system of medical supervision of inpatients waiting on corridors for Imaging appointments.
Must-do action 42 of 54
Must do
Caring
The trust must ensure inpatients and ED patients waiting for imaging appointment’s on corridors are kept sufficiently warm
Must-do action 43 of 54
Must do
Caring
The trust must ensure inpatients and ED patients waiting for imaging appointment’s on corridors are able to be modestly covered
Must-do action 44 of 54
Must do
Effective
The trust must ensure they put in place guidelines for pain assessment in children
Must-do action 45 of 54
Must do
Responsive
The trust must ensure they take effective steps to meet the diagnostic standard and to catch up with paediatrics anesthetic, colonoscopy and cardiac waiting lists.
Must-do action 46 of 54
Must do
Well-led
The trust must ensure they review and improve the Imaging services measures of quality and patient outcomes
Must-do action 47 of 54
Must do
Well-led
The trust must ensure they put in place an effective management and governance structure in imaging services and monitor its performance
Must-do action 48 of 54
Must do
Safe
The trust must ensure confidential patient information is protected from casual view and hearing in imaging services.
Must-do action 49 of 54
Must do
Well-led
The trust must ensure they review and improve the diagnostic imaging services measures of quality and patient outcomes.
Must-do action 50 of 54
Must do
Well-led
The trust must ensure they put in place an effective management and governance structure in diagnostic imaging services and monitor its performance.
Must-do action 51 of 54
Must do
Safe
The trust must ensure they improve mandatory staff training compliance.
Must-do action 52 of 54
Must do
Safe
The trust must ensure they put in place a protocol for managing a deteriorating adult or child including training staff in paediatric life support.
Must-do action 53 of 54
Must do
Safe
The trust must ensure they improve resuscitation for adults’ staff training compliance.
Must-do action 54 of 54
Must do
Safe
The trust must ensure they put in place an effective system for measuring the safety of diagnostic imaging services.
Should-do actions (52)
Should-do action 1 of 52
Should do
Safe
The trust should ensure that at night, senior doctors in the emergency department have sufficient time to treat children as well as patients in the resuscitation room.
Should-do action 2 of 52
Should do
Safe
The trust should ensure that infection control policies and practice are implemented and followed throughout the emergency department.
Should-do action 3 of 52
Should do
Caring
The trust should ensure that patients’ privacy is respected in the waiting and reception areas of the emergency department.
Should-do action 4 of 52
Should do
Effective
The trust should ensure effective monitoring and audit of treatment and interventions used for mental health patients within the emergency department.
Should-do action 5 of 52
Should do
Responsive
The trust should ensure that leaflets are information are available in other languages than English within the emergency department.
Should-do action 6 of 52
Should do
Safe
The trust should ensure that paediatric staff are alerted to unwell children on their way to the department.
Should-do action 7 of 52
Should do
Safe
The trust should ensure medical are up to date with mandatory training; including mental health and safeguarding training.
Should-do action 8 of 52
Should do
Safe
The trust should ensure substance managed under Control of Substances Hazardous to Health (COSHH) regulations are stored safely.
Should-do action 9 of 52
Should do
Effective
The trust should ensure patients attending the surgical ambulatory assessment unit are triaged within trust targets; and this is formally monitored.
Should-do action 10 of 52
Should do
Safe
The trust should ensure records are updated with 24-hour venous thromboembolism (VTE) assessment outcomes.
Should-do action 11 of 52
Should do
Safe
The trust should ensure all staff have access to learning following never events and serious incidents.
Should-do action 12 of 52
Should do
Effective
The trust should ensure staff follow a standardised approach to reducing unnecessary fasting prior to surgery. Enable a way for this to be audited consistently by local managers.
Should-do action 13 of 52
Should do
Caring
The trust should ensure staff are trained in autism and where necessary access materials to support awareness and to aid individualised treatment and care.
Should-do action 14 of 52
Should do
Safe
The trust should ensure that it follow through with plans to replace all the wooden cabinets with metal cabinets which are used to store flammable liquids in line with guidance.
Should-do action 15 of 52
Should do
Effective
The trust should ensure that it carries out observational audits of the World Health Organisation (WHO) checklist.
Should-do action 16 of 52
Should do
Safe
The trust should ensure that all staff at Corbett Hospital are aware of the major incident plan and that there is a copy of the plan on the unit.
Should-do action 17 of 52
Should do
Safe
The trust should ensure all staff maintain to completed documentation around CTG monitoring, including ‘fresh eyes’ to ensure its consistent throughout the service.
Should-do action 18 of 52
Should do
Safe
The trust should ensure all records are kept up to date and completed accurately.
Should-do action 19 of 52
Should do
Safe
The trust should ensure all staff adhere to Infection Prevention and control policy.
Should-do action 20 of 52
Should do
Responsive
The service should ensure complaints are managed in line with the trusts complaints policy.
Should-do action 21 of 52
Should do
Effective
The trust should ensure the clinical audit programme for maternity services is fully embedded within the service.
Should-do action 22 of 52
Should do
Well-led
The service should ensure governance arrangements within maternity should ensure they have a full overview of the service.
Should-do action 23 of 52
Should do
Safe
The service should ensure hand hygiene audits are large enough sample to provide assurance.
Should-do action 24 of 52
Should do
Safe
The service should ensure venous thromboembolism (VTE) assessments are completed on all patients.
Should-do action 25 of 52
Should do
Safe
The service should ensure SHDU has a resuscitation trolley based on the unit.
Should-do action 26 of 52
Should do
Effective
The service should ensure it meets the Guidelines for the Provision of Intensive Care Services (GPICS) for dietician’s staff.
Should-do action 27 of 52
Should do
Effective
The service should ensure medical staff mental health law meets the trust’s target.
Should-do action 28 of 52
Should do
Effective
The service should ensure it complies NICE requirements QS158 for rehabilitation after critical care illness for adults.
Should-do action 29 of 52
Should do
Responsive
The service should ensure complaints are managed in line with the trust’s complaints policy.
Should-do action 30 of 52
Should do
Responsive
The service should ensure patients are discharged in less than eight hours.
Should-do action 31 of 52
Should do
Caring
The trust should ensure that children, young people and their families are involved in making decisions about care.
Should-do action 32 of 52
Should do
Responsive
The trust should review how it obtains feedback from children, young people and those close to them to improve and shapes services.
Should-do action 33 of 52
Should do
Effective
The trust should ensure they increase the numbers/availability of radiographers competent to interpret and clinically report on diagnostic images as recommended by the CQC July 2018 national report on reducing wait times for imaging results.
Should-do action 34 of 52
Should do
Safe
The trust should ensure they make available information to patients and visitors on safeguarding children and vulnerable adults from abuse
Should-do action 35 of 52
Should do
Caring
The trust should ensure they provide drinking water for patients with imaging services areas.
Should-do action 36 of 52
Should do
Effective
The trust should ensure they make staff aware of guidelines in place for use of pain score for patients with dementia.
Should-do action 37 of 52
Should do
Responsive
The trust should ensure they encourage use of the telephone interpreters service over the use of staff and relatives.
Should-do action 38 of 52
Should do
Safe
The trust should ensure that risk assessments are completed around only being one resuscitation trolley in the outpatients’ department and be certain all staff know who will fetch the trolley in an emergency and that scenario training is completed to include reception staff.
Should-do action 39 of 52
Should do
Safe
The trust should ensure notes are legible and do not contain loose pages.
Should-do action 40 of 52
Should do
Safe
The trust should ensure relevant staff can access all medications easily in the ophthalmology department.
Should-do action 41 of 52
Should do
Well-led
The trust should ensure learning from morbidity and mortality meetings are shared to aid learning.
Should-do action 42 of 52
Should do
Effective
The trust should ensure they consider a programme of audit around compliance in areas such as national institute for health and care excellence (NICE) guidelines and consent.
Should-do action 43 of 52
Should do
Responsive
The trust should ensure they continue to reduce outstanding follow up appointments.
Should-do action 44 of 52
Should do
Safe
The trust should ensure annual refresher training for patient group directives (PGD’s).
Should-do action 45 of 52
Should do
Responsive
The trust should ensure they consider ways of improving communication with the rapid access team.
Should-do action 46 of 52
Should do
Safe
The trust should ensure they review storage space in the department and complete risk assessments in relation to staff handling the records.
Should-do action 47 of 52
Should do
Well-led
The trust should ensure all risks are recorded on the departmental risk register.
Should-do action 48 of 52
Should do
Responsive
The trust should ensure they continue to reduce outstanding follow up appointments.
Should-do action 49 of 52
Should do
Well-led
The trust should ensure review processes for staff engagement and involvement in decisions affecting their roles.
Should-do action 50 of 52
Should do
Safe
The trust should ensure they have enough suitable qualified staff to ensure compliance with recommendations from national bodies such as The Association of Palliative Medicine for Great Britain and Ireland and the National Council for Palliative Care.
Should-do action 51 of 52
Should do
Responsive
The trust should ensure they continue its efforts to provide a seven-day service.
Should-do action 52 of 52
Should do
Safe
The trust should ensure they have enough medical staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment.