Source · CQC inspection
The Queen Victoria Hospital (East Grinstead)
Type NHS Healthcare Organisation
Region South East
Last inspected 23 May 2019
Overall rating: Good View full CQC report
Domain ratings
Safe
Good
Effective
Good
Caring
Outstanding
Responsive
Good
Well-led
Good
Earlier inspection findings
Should-do actions (18)
Should-do action 1 of 18
Should do
Safe
The service should reduce their reliance and usage of agency nursing staff to meet with the Guidelines for the Provision of Intensive Care Services 2015, which recommends a maximum of 20% usage of agency staff on any one shift.
Should-do action 2 of 18
Should do
Safe
The service should ensure medical staffing meets with the Guidelines for the Provision of Intensive Care Services 2015 by having intensive care consultant cover seven days a week.
Should-do action 3 of 18
Should do
Safe
The trust should consider revising their burns admission criteria to ensure the service is consistent in only accepting patients with co-morbidities and total body surface area affected by burns that they can safely support on the Queen Victoria Hospitals site.
Should-do action 4 of 18
Should do
Responsive
The trust should continue working to improve referral to treatment times for surgical patients.
Should-do action 5 of 18
Should do
Responsive
The trust should review the toilet facilities in the Rowntree Theatre Unit and consider whether the current facilities meet the needs of all patients attending the unit.
Should-do action 6 of 18
Should do
Safe
The trust should ensure that resuscitation equipment is checked in line with trust policy.
Should-do action 7 of 18
Should do
Responsive
The trust should ensure complaints are responded to within the time frames set out in their policy.
Should-do action 8 of 18
Should do
Well-led
The trust should work to improve mandatory training rates for medical and dental staff to meet the trust target of 95%.
Should-do action 9 of 18
Should do
Well-led
The trust should develop and document their strategic direction and corresponding financial strategy.
Should-do action 10 of 18
Should do
Well-led
The trust should ensure it has robust systems and processes to identify, govern and implement its cost improvement programme.
Should-do action 11 of 18
Should do
Well-led
The trust should ensure that it has the right resources and capacity across its leadership teams and finance and performance committee to develop a new financial strategy and operate under new financial pressures.
Should-do action 12 of 18
Should do
Well-led
The trust should consider implementing a structured process for undertaking post implementation reviews of larger business cases.
Should-do action 13 of 18
Should do
Well-led
The trust should ensure process and policies, particularly those relevant to the formal disciplinary process, are applied equally no matter a staff members race or other characteristic protected under the Equality Act.
Should-do action 14 of 18
Should do
Well-led
The trust should ensure data quality across services including at all hubsites.
Should-do action 15 of 18
Should do
Safe
The trust should ensure products subject to Controlof Substances Hazardous to Health (COSHH) regulations are stored securely at all times. The trust should consider carrying out audits or checks to gain ongoing assurances around the storage of COSHH products.
Should-do action 16 of 18
Should do
Well-led
The service should continue to improve mandatory training completion, so they meet their target and ensure all staff are always receiving training.
Should-do action 17 of 18
Should do
Effective
The service should participate in national audits to monitor and improve patient care.
Should-do action 18 of 18
Should do
Well-led
The trust should ensure they improve Mental Capacity Act training compliance to meet trust target.