Home / Sources / CQC / Penrith Community Hospital
Source · CQC inspection

Penrith Community Hospital

Provider North Cumbria Integrated Care NHS Foundation Trust Type NHS Healthcare Organisation Region North West Last inspected 22 Sep 2023

Location rating: Good  View location on CQC

Location ratings by domain

Five CQC key questions

Ratings held for this CQC location under the inspection framework, last inspected 22 September 2023. Ratings extracted from individual reports are shown separately below.

Safe
Requires Improvement
Effective
Not Yet Rated
Caring
Not Yet Rated
Responsive
Not Yet Rated
Well-led
Good

Most recent report indexed for actions

The date and rating here are from an individual report, not necessarily the location's latest assessment. Report ratings are extracted with AI; verify the original PDF.

Type: Location
Date: 22 September 2023
Rating extracted from this report: Good
Actions indexed: 3 must-do 4 should-do

Read this inspection PDF

AI-extracted 2 Jun 2026

Earlier inspection findings

pre-2024 framework · 3 must-do 4 should-do

Must-do actions (3)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 3
Must do
Safe
The servicemusthavesystemsandprocessesareinplacetoensuretheproperandsafemanagementofmedicines,includingsystemstoreviewthetrainingandcompetencyofstaffresponsibleforthemanagementandadministrationofmedication.
Regulation: Regulation12(2)(g)
⚠ The service used systems and processes to safely prescribe, administer, record and store medicines, however there were no competency checks in place. We did not receive compliance figures for staff, so we were not assured training and competency was in line with trust targets.
Must-do action 2 of 3
Must do
Safe
The servicemustensureenoughstaffhaveappropriatelifesupportandresuscitationtraining.
Regulation: Regulation18(2)(a)
⚠ Not all staff had completed appropriate advanced life support, neonatal advanced life support, immediate life support (55%), and newborn life support (56%) training for midwives. This was a risk because there were not always enough staff suitably trained to respond to emergency life support situations.
Must-do action 3 of 3
Must do
Well-led
The servicemustensurestaffreceivesuchappropriatesupport,training,professionaldevelopment,supervisionandappraisalasisnecessarytoenablethemtocarryoutthedutiestheyareemployedtoperform.
Regulation: Regulation18(2)(a)
⚠ Managers did not always appraise staff’s work performance or hold supervision meetings with them to provide support and development. Average compliance for completing appraisals across all staff groups for maternity services in the trust was 65%, which did not meet the trust target of 90%. Compliance for midwifery staff at …

Should-do actions (4)

Recommended improvements to enhance service quality.

Should-do action 1 of 4
Should do
Safe
The serviceshouldcontinuetoaddressstaffingandrecruitmentchallengestoensurethatsufficientnumbersofsuitablyqualified,competent,skilledandexperiencedstaffaredeployedinmaternityservices.
Should-do action 2 of 4
Should do
Safe
The serviceshouldensureappropriateactionistakenanddocumentedinresponsetoitsowninfectionpreventionandcontrolaudits.
Should-do action 3 of 4
Should do
Safe
The serviceshouldidentify,assess,scoreandmitigateligaturerisksinthemidwiferyledunitandthisshouldbesharedwithstaffwhoworkthere.
Should-do action 4 of 4
Should do
Safe
The serviceshouldcompleterecordsauditstoensurepatientrecordsarecompletedinlinewithguidance.