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

Overall rating: Good View full CQC report

Domain ratings

Five CQC key questions

Safe

Requires Improvement

Effective

Not Yet Rated

Caring

Not Yet Rated

Responsive

Not Yet Rated

Well-led

Good

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.