Source · CQC inspection
Montagu Hospital, Mexborough
Provider Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Type NHS Healthcare Organisation
Region Yorkshire & Humberside
Last inspected 28 Mar 2024
Overall rating: Requires Improvement View full CQC report
Domain ratings
Safe
Requires Improvement
Effective
Good
Caring
Good
Responsive
Good
Well-led
Requires Improvement
Earlier inspection findings
Must-do actions (89)
Must-do action 1 of 89
Must do
Well-led
Thetrustmustensurestafffeelsupportedtospeakupbyseekingandactingonfeedbackfromrelevantpersonsorotherpersonsontheserviceprovidedinthecarryingonoftheregulatedactivity,forthepurposeofcontinuallyevaluatingandimprovingsuchservices.TheTrustBoardmusthaveeffectiveoversightofallFreedomtoSpeakUpactions.
Must-do action 2 of 89
Must do
Well-led
Thetrustmustensurethereareeffectivesystemsandprocessestoidentifywherequalityandsafetyarebeingcompromisedandtorespondappropriatelyandwithoutdelay.Itmustensureitimprovesitsclinicalauditprocessesandsystems.Itmustcontinuetoimprovegovernanceprocessesinparticularthesenioroversightofrisk,qualityofdataandthemanagementofrisk.Regulation17(1)(2)(a)
Must-do action 3 of 89
Must do
Effective
Thetrustmustensurestaffreceiveappropriatesupport,training,andappraisalasisnecessarytoenablethemto carryouttheroletheyareemployedtoperform.Regulation18(2)(a)
Must-do action 4 of 89
Must do
Safe
Thetrustmustensurestafffollowinfectioncontrolprinciplessuchashandhygieneandbarebelowtheelbows.Regulation12(2)(h)
Must-do action 5 of 89
Must do
Safe
Thetrustmustensureclinicalareasarekeptclean,cleaningrecordsareup-to-dateandstaffcleanequipmentafterpatientcontact,andlabelequipmenttoshowwhenitwaslastcleaned.Regulation15(1)(a)(e)
Must-do action 6 of 89
Must do
Safe
Thetrustmustensureitmeetstherequirementsofrelevantlegislationandtrustpolicysothatequipmentisproperly,used,maintained,andstored.Regulation15(1)(d)(e)
Must-do action 7 of 89
Must do
Safe
Thetrustmustensuretheservice’smedicalandnursingstaffmatchtheplannednumbers.Theymustalsoensuretheservicehasenoughmedicalstaffwithappropriateskillmixoneachshift.Regulation18(1)(2)(a)
Must-do action 8 of 89
Must do
Safe
Thetrustmustensurestafffollowtheproperandsafemanagementofmedicines,andtheserviceusessystemsandprocessestoprescribeandadministermedicinessafely.Regulation12(2)(g)
Must-do action 9 of 89
Must do
Safe
Thetrustmustensureitmaintainssecurelyanaccurate,complete,andcontemporaneousrecordinrespectofeachserviceuser,includingarecordofthecareandtreatmentprovidedtotheserviceuserandofdecisionstakeninrelationtothecareandtreatmentprovided.Thisshouldincludeallergystatusandtheissuingofawarningwristbandwhenallergieshavebeendisclosed,andcompleterecordingofpatientfluidandnutritioncharts.Regulation17(2)(c)
Must-do action 10 of 89
Must do
Safe
Thetrustmustensuretheservicehaseffectivesystemsandprocessestoassess,monitorandimprovethequalityandsafetyoftheservicesprovidedincarryingonoftheregulatedactivity.Whererisksareidentifiedthetrustmusthavemeasurestoreduceandremovetheriskswithinatimescalethatreflectthelevelofriskandtheimpactonpeopleusingtheservice.Regulation17(1)(2)(a)(b)
Must-do action 11 of 89
Must do
Effective
Thetrustmustimplementeffectivesystemsandprocessestoensureallnursingandmedicalstaffarecompliantwithmandatorytraining,includingbutnotlimitedto,safeguardingvulnerableadultsandchildren,toalevelappropriatefortheirrole.Regulation18(2)(a)
Must-do action 12 of 89
Must do
Safe
Thetrustmustensureithasenoughnursing,medicalandsupportstaffwiththerightqualifications,skills,training,andexperiencetokeeppatientssafefromavoidableharmandtoprovidetherightcareandtreatment.Regulation18(1)
Must-do action 13 of 89
Must do
Safe
Thetrustmustensuretheproperandsafemanagementofmedicines.Regulation12(2)(g)
Must-do action 14 of 89
Must do
Safe
Thetrustmustensuresubstanceshazardoustohealtharealwaysstoredsecurely,inaccordancewithControlofSubstancesHazardoustoHealthRegulations2002andtrustpolicy.Regulation15(1)(a)
Must-do action 15 of 89
Must do
Safe
Thetrustmustensurethereisaneffectiveprocessinplaceforensuringequipmentisindateandsafetychecked.Regulation15(1)(e)
Must-do action 16 of 89
Must do
Effective
Thetrustmustensureitimprovesappraisalratesinlinewithtrusttargets.Regulation18(2)(a)
Must-do action 17 of 89
Must do
Safe
Thetrustmustensurethereareeffectivesystemsandprocessestoidentifywherequalityandsafetyarebeingcompromisedandtorespondappropriatelyandwithoutdelay.Regulation17(1)(2)(a)
Must-do action 18 of 89
Must do
Effective
Thetrustmustensurethatallstaffparticularlymedicalstaffcompletemandatorytraininginlinewithtrustpolicy.Regulation18(2)(a)
Must-do action 19 of 89
Must do
Safe
Thetrustmustensurethatallstaffparticularlymedicalstaffcompletesafeguardingtrainingrelevanttotheirrole.Regulation18(2)(a)
Must-do action 20 of 89
Must do
Safe
ThetrustmustensurethatstaffadheretouniformandInfection,Prevention,andControlpoliciesinrelationtobarebelowtheelbows.Regulation12(2)(h)
Must-do action 21 of 89
Must do
Safe
Thetrustmustensureitmeetstherequirementsofrelevantlegislationandtrustpolicysothatequipmentisproperly,used,maintained,andstored.Regulation15(1)(d)(e)
Must-do action 22 of 89
Must do
Safe
Theservicemustensurepremisesandenvironmentaresafeandsecure.ThisincludesbutisnotlimitedtoensuringstoreroomdoorsarenotleftopenorunlockedandCOSHHcleaningchemicalsandoxygencylindersaresafelystored.Regulation12(1)(2)(d).
Must-do action 23 of 89
Must do
Safe
Theservicemustensurethatappropriatemalnutritionuniversalscreeningtool(MUST)riskassessmentsarecompletedandrecordedforpatientswhorequiredsupport.Regulation12(1)(2)(a)(b)
Must-do action 24 of 89
Must do
Safe
Thetrustmustensurethatallstaffunderstandthetrustsincidentreportingsystemandthatincidentsarereportedconsistentlyandappropriately.Regulation12(2)(b)
Must-do action 25 of 89
Must do
Safe
Thetrustmustensurerisksinservicesareappropriatelyrecorded,assessed,andregularlyreviewed.Regulation17(1)(2)(a)
Must-do action 26 of 89
Must do
Effective
Theservicemustimplementaneffectivesystemtomonitorandimprovecompliancewithmedicalappraisalsandrevalidation.Regulation17(1)(2)(a)
Must-do action 27 of 89
Must do
Safe
Theservicemustimplementaneffectiveprocesstomanage,monitorandrecordtheambienttemperatureofroomswhichstorefluidsandmedication.Regulation17(1)(2)(a)
Must-do action 28 of 89
Must do
Safe
Thetrustmustensurethatpersonsprovidingcareortreatmenttoserviceusershavethequalifications,competence,skills,andexperiencetodososafely.Regulation12(1)(2)(c)
Must-do action 29 of 89
Must do
Safe
Thetrustmustensurethatcommunitystaffaresuitablytrainedforhomebirthemergencies.Regulation12(1)(2)(c)
Must-do action 30 of 89
Must do
Safe
Thetrustmustensurethatstaffreceivepracticaltrainingsessionsintheuseofhoistsandwrittenguidanceonhoistuseinclinicalareas.Regulation12(1)(2)(b)
Must-do action 31 of 89
Must do
Safe
Thetrustmustensurethatthestorageofcontrolofsubstanceshazardoustohealth(COSSH)productsissecure.Regulation15(1)(a)
Must-do action 32 of 89
Must do
Safe
Thetrustmustensuretheproperandsafemanagementofmedicines.Regulation12(1)(2)(g)
Must-do action 33 of 89
Must do
Safe
Thetrustmustensureambientroomtemperaturesaremonitoredandrecordedinallroom’smedicinesarestored.Regulation12(1)(2)(g)
Must-do action 34 of 89
Must do
Safe
Thetrustmustensurethatdailychecksofemergencyboxesforhypoglycaemia,cordprolapse,sepsisandpre-eclampsiatakeplaceaspolicy.Regulation12(1)(2)(g)
Must-do action 35 of 89
Must do
Safe
Thetrustmustensurethatthemissingemergencymedicinefromeachboxisreplaced.Regulation12(1)(2)(g)
Must-do action 36 of 89
Must do
Safe
Thetrustmustensurethatsharpsbinsaredatedandsignedonopening.Regulation12(1)(2)(g)
Must-do action 37 of 89
Must do
Safe
Thetrustmustensurethatoxygenisprescribedbyaspecialistpractitionerafteraclinicalreviewanddocumentedontheprescriptionchart.Regulation12(1)(2)(g)
Must-do action 38 of 89
Must do
Safe
ThetrustmustensurethatoxygenandEntonoxcylindersarestoredsecurely.Regulation12(1)(2)(g)
Must-do action 39 of 89
Must do
Safe
Thetrustmustensurethattamperproofsealsandmedicineslistsarepresentinalltheseparateboxesusedforspecificconditions.Regulation12(1)(2)(g)
Must-do action 40 of 89
Must do
Safe
Thetrustmustensurethatmedicinesarestoredinsecureenvironmentsandthatallentry/exitandcupboarddoorsarelocked.Regulation12(1)(2)(g)
Must-do action 41 of 89
Must do
Safe
Thetrustmustassess,monitor,andmitigatetherisksrelatingtothehealth,safetyandwelfareofserviceusersandotherswhomaybeatriskwhicharisefromthecarryingonoftheregulatedactivity.Regulation17(1)(2)(b)
Must-do action 42 of 89
Must do
Safe
Thetrustmustensuretheyhaveenoughstaffwiththerightqualifications,skills,training,andexperiencetokeepwomensafefromavoidableharmandtoprovidetherightcareandtreatment.Regulation18(12)(a)
Must-do action 43 of 89
Must do
Effective
Thetrustmustensurestaffreceiveappropriatesupport,training,andappraisalasisnecessarytoenablethemto carryouttheroletheyareemployedtoperform.Regulation18(2)(a)
Must-do action 44 of 89
Must do
Safe
Thetrustmustensureitmeetstherequirementsofrelevantlegislationandtrustpolicysothatequipmentisproperlyused,maintained,andstored.Regulation15(1)(d)(e)
Must-do action 45 of 89
Must do
Safe
Thetrustmustensureclinicalareasarekeptclean,cleaningrecordsareup-to-dateandstaffcleanequipmentafterpatientcontact,andlabelequipmenttoshowwhenitwaslastcleaned.Regulation15(1)(a)(e)
Must-do action 46 of 89
Must do
Safe
Thetrustmustensurestafffollowtheproperandsafemanagementofmedicines,andtheserviceusessystemsandprocessestoprescribeandadministermedicinessafely.Regulation12(2)(g)
Must-do action 47 of 89
Must do
Safe
Thetrustmustensuretheservicehasenoughmedicalstaff,andalwayshasagoodskillmixofmedicalstaffoneachshift.Regulation18(1)(2)(a)
Must-do action 48 of 89
Must do
Safe
Thetrustmustensurestafffollowinfectioncontrolprinciplessuchashandhygieneandbarebelowtheelbows.Regulation12(2)(h)
Must-do action 49 of 89
Must do
Safe
Thetrustmustensurestaffcomplete,record,andmonitordailychecklistsforalladultandchildemergencyresuscitationtrolleyequipmentacrossthedepartmentsoitissafetouse.Regulation12(2)(e)
Must-do action 50 of 89
Must do
Safe
Thetrustmustensurethementalhealthassessmentroomhasenvironmentalriskassessmentscompletedandsignsinformingpatientsandthepublicclosed-circuittelevision(CCTV)isinuse.Regulation15(1)(b)
Must-do action 51 of 89
Must do
Safe
Thetrustmustensuretheservicehaseffectivesystemsandprocessestoassess,monitorandimprovethequalityandsafetyoftheservicesprovidedincarryingonoftheregulatedactivity.Whererisksareidentifiedthetrustmusthavemeasurestoreduceandremovetheriskswithinatimescalethatreflectthelevelofriskandtheimpactonpeopleusingtheservice.Regulation17(1)(2)(a)(b)
Must-do action 52 of 89
Must do
Effective
Thetrustmustimplementeffectivesystemsandprocessestoensureallnursingandmedicalstaffarecompliantwithmandatorytraining.Regulation18(2)(a)
Must-do action 53 of 89
Must do
Safe
Thetrustmustensureithasenoughnursing,medicalandsupportstaffwiththerightqualifications,skills,training,andexperiencetokeeppatientssafefromavoidableharmandtoprovidetherightcareandtreatment.(Regulation18(1))
Must-do action 54 of 89
Must do
Safe
Thetrustmustensuretheproperandsafemanagementofmedicines.Regulation12(2)(g)
Must-do action 55 of 89
Must do
Safe
Theservicemustimplementaneffectiveprocesstomanage,monitorandrecordtheambienttemperatureofroomswhichstoremedication.Regulation17(1)(2)(a)
Must-do action 56 of 89
Must do
Safe
Thetrustmustensuresubstanceshazardoustohealtharealwaysstoredsecurely,inaccordancewithControlofSubstancesHazardoustoHealthRegulations2002andtrustpolicy.Regulation15(1)(a)
Must-do action 57 of 89
Must do
Safe
Thetrustmustensurethereisaneffectiveprocessinplaceforensuringequipmentisindateandsafetychecked.Regulation15(1)(e)
Must-do action 58 of 89
Must do
Effective
Thetrustmustensureitimprovesappraisalratesinlinewithtrusttargets.Regulation18(2)(a)
Must-do action 59 of 89
Must do
Effective
Thetrustmustensurethatallstaffparticularlymedicalstaffcompletemandatorytraininginlinewithtrustpolicy.Regulation18(2)(a)
Must-do action 60 of 89
Must do
Safe
Thetrustmustensurethatallstaffparticularlymedicalstaffcompletesafeguardingtrainingrelevanttotheirrole.Regulation18(2)(a)
Must-do action 61 of 89
Must do
Safe
ThetrustmustensurethatstaffadheretouniformandInfection,Prevention,andControlpoliciesinrelationtobarebelowtheelbows.Regulation12(2)(h)
Must-do action 62 of 89
Must do
Safe
Thetrustmustensureitmeetstherequirementsofrelevantlegislationandtrustpolicysothatequipmentisproperly,used,maintained,andstored.Regulation15(1)(d)(e)
Must-do action 63 of 89
Must do
Safe
Theservicemustensurepremisesandenvironmentaresafeandsecure.ThisincludesbutisnotlimitedtoensuringstoreroomdoorsarenotleftopenorunlockedandCOSHHcleaningchemicalsaresafelystored.Regulation12(1)(2)(d).
Must-do action 64 of 89
Must do
Safe
Thetrustmustensurethatallstaffunderstandthetrustsincidentreportingsystemandthatincidentsarereportedconsistentlyandappropriately.Regulation12(2)(b)
Must-do action 65 of 89
Must do
Safe
Thetrustmustensurerisksinservicesareappropriatelyrecorded,assessed,andregularlyreviewed.Regulation17(1)(2)(a)
Must-do action 66 of 89
Must do
Effective
Theservicemustimplementaneffectivesystemtomonitorandimprovecompliancewithmedicalappraisalsandrevalidation.Regulation17(1)(2)(a)
Must-do action 67 of 89
Must do
Safe
Theservicemustimplementaneffectiveprocesstomanage,monitorandrecordtheambienttemperatureofroomswhichstorefluidsandmedication.Regulation17(1)(2)(a)
Must-do action 68 of 89
Must do
Safe
Thetrustmustensurethatpersonsprovidingcareortreatmenttoserviceusershavethequalifications,competence,skills,andexperiencetodososafely.Regulation12(1)(2)(c)
Must-do action 69 of 89
Must do
Safe
Thetrustmustensurethatpatientsareprioritisedbasedonriskorconditionwhenbeingseeninthematernitydayassessmentunitsothatpatientswhopresentwiththehighestrisksareseenfirst.Regulation12(1)(2)(a)(b)
Must-do action 70 of 89
Must do
Safe
Thetrustmustensuretheyhaveenoughstaffwiththerightqualifications,skills,training,andexperiencetokeepwomensafefromavoidableharmandtoprovidetherightcareandtreatment.Regulation18(12)(a)
Must-do action 71 of 89
Must do
Safe
Thetrustmustensurethatstaffreceivepracticaltrainingsessionsintheuseofhoistsandwrittenguidanceonhoistuseinclinicalareas.Regulation12(1)(2)(b)
Must-do action 72 of 89
Must do
Safe
Thetrustmustensurethatthereisoutofhoursseniorsupportinplaceforcommunitymidwivesandcommunitystaffaresuitablytrainedforhomebirthemergencies.Regulation12(1)(2)(b)
Must-do action 73 of 89
Must do
Safe
Thetrustmustassess,monitor,andmitigatetherisksrelatingtothehealth,safetyandwelfareofserviceusersandotherswhomaybeatriskwhicharisefromthecarryingonoftheregulatedactivity.Regulation17(1)(2)(b)
Must-do action 74 of 89
Must do
Effective
Thetrustmustensureallnursingstaffcompletemandatoryandsafeguardingtrainingmodulesrelevanttotheirroleaspertrustpolicytomeettarget.ThismustincludetrainingintheMentalCapacityActorDeprivationofLibertySafeguards.Regulation18(1)(2)(a)
Must-do action 75 of 89
Must do
Safe
Thetrustmustensurestaffkeepalldailycleaningrecordsand(fireanddefibrillator)safetychecksuptodate.Regulation12(2)(b)
Must-do action 76 of 89
Must do
Effective
Thetrustmustimplementeffectivesystemsandprocessestoensureallnursingandmedicalstaffarecompliantwithmandatorytraining,includingbutnotlimitedto,safeguardingvulnerableadultsandchildren,toalevelappropriatefortheirrole.Regulation18(2)(a)
Must-do action 77 of 89
Must do
Safe
Thetrustmustensureithasenoughnursing,medicalandsupportstaffwiththerightqualifications,skills,training,andexperiencetokeeppatientssafefromavoidableharmandtoprovidetherightcareandtreatment.Regulation18(1)
Must-do action 78 of 89
Must do
Safe
Thetrustmustensuretheproperandsafemanagementofmedicines.Regulation12(2)(g)
Must-do action 79 of 89
Must do
Safe
Thetrustmustensuresubstanceshazardoustohealtharealwaysstoredsecurely,inaccordancewithControlofSubstancesHazardoustoHealthRegulations2002andtrustpolicy.Regulation15(1)(a)
Must-do action 80 of 89
Must do
Safe
Thetrustmustensurethereisaneffectiveprocessinplaceforensuringequipmentisindateandsafetychecked.Regulation15(1)(e)
Must-do action 81 of 89
Must do
Effective
Thetrustmustensureitimprovesappraisalratesinlinewithtrusttargets.Regulation18(2)(a)
Must-do action 82 of 89
Must do
Safe
ThetrustmustensurethatstaffadheretoInfection,Prevention,andControlpoliciesinrelationtocleanliness.Regulation12(2)(h)
Must-do action 83 of 89
Must do
Safe
Thetrustmustensureitmeetstherequirementsofrelevantlegislationandtrustpolicysothatequipmentisproperly,used,maintained,andstored.Regulation15(1)(d)(e)
Must-do action 84 of 89
Must do
Safe
Theservicemustensurepremisesandenvironmentaresafeandsecure.ThisincludesCOSHHcleaningchemicalsbeingsafelystored.Regulation12(1)(2)(d).
Must-do action 85 of 89
Must do
Safe
Thetrustmustensurerisksinservicesareappropriatelyrecorded,assessed,andregularlyreviewed.Regulation17(1)(2)(a)
Must-do action 86 of 89
Must do
Safe
Theservicemustimplementaneffectiveprocesstomanage,monitorandrecordtheambienttemperatureofroomswhichstorefluidsandmedication.Regulation17(1)(2)(a)
Must-do action 87 of 89
Must do
Safe
Thetrustmustensurethatallstaffknowtheemergencyproceduresthatareinplaceforpatientswhomaydeteriorate.Regulation12(1)(2)(b)
Must-do action 88 of 89
Must do
Safe
Thetrustmustensurethatthereisaresuscitationtrolleyavailabletostaffincaseofemergency.Regulation15(1)(f)
Must-do action 89 of 89
Must do
Effective
Thetrustmustensurethatallclinicalguidanceiscurrent.
Should-do actions (73)
Should-do action 1 of 73
Should do
Responsive
Thetrustshouldensureitcontinuestooperateeffectivesystemstorespondtocomplaintsandtakeappropriateactionwithoutdelaytoanyfailuresidentifiedbyacomplaintortheinvestigationofacomplaint.
Should-do action 2 of 73
Should do
Effective
ThetrustshouldensureitcontinuestorollouttheOliverMcGowanstatutorylearningdisabilityandautismtrainingorequivalent.
Should-do action 3 of 73
Should do
Well-led
ThetrustshouldensureitcontinuestoimprovediversityandequalityatBoardlevel.
Should-do action 4 of 73
Should do
Responsive
ThetrustshouldensureitcontinuestocompletetheworkneededtomeettherequirementsfortheAccessibleInformationStandards.
Should-do action 5 of 73
Should do
Well-led
ThetrustshouldconsiderareviewofthetimescalesforDisclosureandBarring(DBS)re-checksforexecutiveandnon-executivedirectorstobeundertakensoonerthanevery10years.
Should-do action 6 of 73
Should do
Caring
Thetrustshouldensurestaffalwaysmaintainpatient’sprivacy,dignity,andconfidentialityparticularlyinpublicareas.
Should-do action 7 of 73
Should do
Well-led
Thetrustshouldensureithaseffectiveprocessestoengagewithstaffparticularlymedicalstaffactivelyandopenly.
Should-do action 8 of 73
Should do
Effective
Thetrustshouldconsiderastandardoperatingprocedure(SOP)forpatientsontheambulatorypathwaywithclearguidancetofollow.
Should-do action 9 of 73
Should do
Effective
Thetrustshouldensurestafffullyandaccuratelycompletepatients’fluidbalancecharts.
Should-do action 10 of 73
Should do
Safe
Thetrustshouldensureitalwayskeeprecordssecure.
Should-do action 11 of 73
Should do
Well-led
Thetrustshouldconsiderwaystoimprovetheprovisionofwardmeetingstosharelearningfromincidents.
Should-do action 12 of 73
Should do
Well-led
Thetrustshouldhaveaneffectiveprocesstoreviewperformanceandmanagerisksateachhospitalsite.
Should-do action 13 of 73
Should do
Well-led
Thetrustshouldhaveaneffectiveprocesstoreviewperformanceandmanagerisksateachhospitalsite.
Should-do action 14 of 73
Should do
Safe
Thetrustshouldensurethatmedicineauditsarecompletedwithintimescalesinlinewithtrustpolicy.
Should-do action 15 of 73
Should do
Effective
Thetrustshouldensurethatcapacityassessmentsandbestinterestdecisionsarefollowedandrecordedinlinewithlegislation.
Should-do action 16 of 73
Should do
Responsive
Thetrustshouldcontinuetoensurethatcomplaintsarerespondedtoinlinewithtimescalessetoutinthetrustpolicy.
Should-do action 17 of 73
Should do
Safe
Thetrustshouldensurethatrefrigeratorchecksareconsistentlyundertakeninlinewithtrustpolicy.
Should-do action 18 of 73
Should do
Safe
Thetrustshouldensurethatlegionellaactionplansfortheantenatalclinicareinplaceandupdatedsoanyactionsidentifiedarerespondedtoquickly.
Should-do action 19 of 73
Should do
Safe
Thetrustshouldensurethatlegionellatestingrecordsconfirmactionstakenshouldlegionellabepresent.
Should-do action 20 of 73
Should do
Safe
Thetrustshouldensurethatallequipmentisservicedwithinitsnextservicedate.
Should-do action 21 of 73
Should do
Safe
Thetrustshouldensurethatallresuscitationchecklistsincludethenameofthelocationandtypeofequipmentnamed.
Should-do action 22 of 73
Should do
Well-led
Thetrustshouldensureseniormidwivesandmanagersarevisibleontheclinicalareas.
Should-do action 23 of 73
Should do
Well-led
Thetrustshouldensurethatallstaffgroupsareawareofthefreedomtospeakupguardiansandwhotheyareacrossthetrustsites.
Should-do action 24 of 73
Should do
Safe
Thetrustshouldensureastandardoperatingprocedureisavailableforstafftorefertowhenfentanylisdrawnupbystaff.
Should-do action 25 of 73
Should do
Effective
Thetrustshouldcontinuetoensureallstaffcompletemandatorytraininginlinewithtrustpolicy.
Should-do action 26 of 73
Should do
Safe
Thetrustshouldcontinuetoensurethatallstaffcompletesafeguardingtrainingrelevanttotheirrole.
Should-do action 27 of 73
Should do
Effective
Thetrustshouldensurethatallpoliciesarereviewedwithinthereviewperiodsetoutinthepolicy.
Should-do action 28 of 73
Should do
Well-led
Thetrustshouldensureithaseffectiveprocessestoengagewithstaffparticularlymedicalstaffactivelyandopenly.
Should-do action 29 of 73
Should do
Caring
Thetrustshouldensurestaffalwaysmaintainpatient’sprivacy,dignity,andconfidentialityparticularlyinpublicareas.
Should-do action 30 of 73
Should do
Effective
Thetrustshouldensurestafffullyandaccuratelycompletepatients’fluidbalancecharts.
Should-do action 31 of 73
Should do
Safe
Thetrustshouldensureitalwayskeeprecordssecure.
Should-do action 32 of 73
Should do
Well-led
Thetrustshouldconsiderwaystoimprovetheprovisionofwardmeetingstosharelearningfromincidents.
Should-do action 33 of 73
Should do
Well-led
Thetrustshouldhaveaneffectiveprocesstoreviewperformanceandmanagerisksateachhospitalsite.
Should-do action 34 of 73
Should do
Well-led
Thetrustshouldhaveaneffectiveprocesstoreviewperformanceandmanagerisksateachhospitalsite.
Should-do action 35 of 73
Should do
Safe
Thetrustshouldensurethatmedicineauditsarecompletedwithintimescalesinlinewithtrustpolicy.
Should-do action 36 of 73
Should do
Effective
Thetrustshouldensurethatcapacityassessmentsandbestinterestdecisionsarefollowedandrecordedinlinewithlegislation.
Should-do action 37 of 73
Should do
Responsive
Thetrustshouldcontinuetoensurethatcomplaintsarerespondedtoinlinewithtimescalessetoutinthetrustpolicy.
Should-do action 38 of 73
Should do
Safe
Thetrustshouldensurethatrefrigeratorchecksareconsistentlyundertakeninlinewithtrustpolicy.
Should-do action 39 of 73
Should do
Safe
Thetrustshouldensurethatlegionellatestingrecordsconfirmwhatactionsweretakenwhenlegionellawaspresent.
Should-do action 40 of 73
Should do
Safe
Thetrustshouldconsiderstoringtheresuscitairewhichiscurrentlystoredinthebereavementroominanothercupboardoutsideofthisroom.
Should-do action 41 of 73
Should do
Safe
Thetrustshouldensurethebirthingpoolsevacuationnetsareservicedinlinewithmanufacturer’sinstructions.
Should-do action 42 of 73
Should do
Safe
Thetrustshouldensurethatallequipmentisservicedwithinitsnextservicedate.
Should-do action 43 of 73
Should do
Safe
Thetrustshouldensurethatclearguidanceisinplacetoensurepigeonsdonotenterbirthingrooms.
Should-do action 44 of 73
Should do
Safe
ThetrustshouldensurethatIamcleanstickersaredated.
Should-do action 45 of 73
Should do
Effective
Thetrustshouldensurewrittenrevalidationguidanceisinplaceforstafftofollow.
Should-do action 46 of 73
Should do
Safe
ThetrustshouldensureastandardoperatingprocedureisdevelopedforthemanagementofFentanyluseasbolusdoses.
Should-do action 47 of 73
Should do
Safe
Thetrustshouldensurestaffreportincidentsfollowingtheiroccurrence.
Should-do action 48 of 73
Should do
Caring
Thetrustshouldensurethatconfidentialityismaintainedwhenconversingwithwomenandtheirfamilies.
Should-do action 49 of 73
Should do
Well-led
Thetrustshouldensurethatseniormidwivesandmanagersarevisibleontheclinicalareas.
Should-do action 50 of 73
Should do
Well-led
ThetrustshouldensurethatK2technologyisupdatedwithnationalupdatesassoonastheyarereleased.
Should-do action 51 of 73
Should do
Safe
Thetrustshouldcontinuetoensurethatallstaffcompletesafeguardingtrainingrelevanttotheirrole.
Should-do action 52 of 73
Should do
Effective
Thetrustshouldensurethatallpoliciesarereviewedwithinthereviewperiodsetoutinthepolicy.
Should-do action 53 of 73
Should do
Effective
Thetrustshouldensurethatallpoliciesarereviewedwithinthereviewperiodsetoutinthepolicy.
Should-do action 54 of 73
Should do
Safe
ThetrustshouldensuretheMIUambulance/resuscitationroomisprotectedfromfloodriskanddoesnotpreventpatientswhoneedemergencycarefromaccessingtreatmentonsite.
Should-do action 55 of 73
Should do
Safe
Thetrustshouldensurethereardoormagneticlocksareinstalledpromptlytoensuresafetyofpeoplewhousetheserviceandstaff.
Should-do action 56 of 73
Should do
Responsive
ThetrustshouldensureUTCsignageinsideandoutsidethebuildingiscorrectanduptodate.
Should-do action 57 of 73
Should do
Effective
Thetrustshouldensurestafffullyandaccuratelycompletepatients’fluidbalancecharts.
Should-do action 58 of 73
Should do
Safe
Thetrustshouldensureitalwayskeeprecordssecure.
Should-do action 59 of 73
Should do
Well-led
Thetrustshouldconsiderwaystoimprovetheprovisionofwardmeetingstosharelearningfromincidents.
Should-do action 60 of 73
Should do
Well-led
Thetrustshouldhaveaneffectiveprocesstoreviewperformanceandmanagerisksateachhospitalsite.
Should-do action 61 of 73
Should do
Well-led
Thetrustshouldhaveaneffectiveprocesstoreviewperformanceandmanagerisksateachhospitalsite.
Should-do action 62 of 73
Should do
Safe
Thetrustshouldensurethatrefrigeratorchecksareconsistentlyundertakeninlinewithtrustpolicy.
Should-do action 63 of 73
Should do
Safe
Thetrustshouldcontinuetoensurethatallstaffcompletesafeguardingtrainingrelevanttotheirrole.
Should-do action 64 of 73
Should do
Effective
Thetrustshouldensurethatallpoliciesarereviewedwithinthereviewperiodsetoutinthepolicy.
Should-do action 65 of 73
Should do
Effective
Thetrustshouldensurethatallpoliciesarereviewedwithinthereviewperiodsetoutinthepolicy.
Should-do action 66 of 73
Should do
Effective
Thetrustshouldcontinuetoensureallstaffcompletemandatorytraininginlinewithtrustpolicy.
Should-do action 67 of 73
Should do
Safe
Thetrustshouldcontinuetoensurethatallstaffcompletesafeguardingtrainingrelevanttotheirrole.
Should-do action 68 of 73
Should do
Effective
Thetrustshouldensurethatallpoliciesarereviewedwithinthereviewperiodsetoutinthepolicy.
Should-do action 69 of 73
Should do
Safe
Thetrustshouldensureallequipmentissafetytestedinlinewithguidance.
Should-do action 70 of 73
Should do
Effective
Thetrustshouldensurethereiswateravailabletopatientsinthewaitingareas.
Should-do action 71 of 73
Should do
Safe
ThetrustshouldensurethereishandgelavailablepriortoenteringthedepartmentatRetfordHospital.
Should-do action 72 of 73
Should do
Safe
Thetrustshouldensurethatchaperonetrainedstaffareavailableforpatientswhorequireachaperone.
Should-do action 73 of 73
Should do
Safe
Thetrustshouldensurethereareclearandavailablecleaningrecordsinplace.