Source · CQC inspection

Broadgreen Hospital Site

Provider Royal Liverpool and Broadgreen University Hospitals NHS Trust Type NHS Healthcare Organisation Region North West Last inspected 30 Mar 2016

Overall rating: Good  View full CQC report

Domain ratings

Five CQC key questions
Safe
Good
Effective
Good
Caring
Good
Responsive
Good
Well-led
Good

Earlier inspection findings

pre-2024 framework · 5 must-do 18 should-do

Must-do actions (5)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 5
Must do
Safe
The trust must ensure that fridges used to store medications in all areas are kept at the required temperatures and checks are completed on these fridges as per the trust’s own policy.
Regulation: Regulation 12 HSCA (RA) Regulations 2014 Safe care and treatment
⚠ The provider did not do all that was reasonably practicable to mitigate risks. This is because: Checks on fridges used to store medications in all areas were not always completed as per the trust’s own policy. Where fridge temperature ranges were recorded outside the recommended minimum or maximum range, steps …
Must-do action 2 of 5
Must do
Safe
Where fridge temperature ranges are recorded outside the recommended minimum or maximum range, steps must be taken to identify if medicines stored in the fridges are fit for use.
Regulation: Regulation 12 HSCA (RA) Regulations 2014 Safe care and treatment
⚠ The provider did not do all that was reasonably practicable to mitigate risks. This is because: Checks on fridges used to store medications in all areas were not always completed as per the trust’s own policy. Where fridge temperature ranges were recorded outside the recommended minimum or maximum range, steps …
Must-do action 3 of 5
Must do
Safe
The trust must ensure that medicines, including controlled drugs and intra-venous (IV) fluids, are securely stored in line with legislation.
Regulation: Regulation 12 HSCA (RA) Regulations 2014 Safe care and treatment
⚠ The provider did not do all that was reasonably practicable to mitigate risks. This is because: Checks on fridges used to store medications in all areas were not always completed as per the trust’s own policy. Where fridge temperature ranges were recorded outside the recommended minimum or maximum range, steps …
Must-do action 4 of 5
Must do
Safe
The checking of medication, including controlled medication must be carried out consistently as per trust policy.
Regulation: Regulation 12 HSCA (RA) Regulations 2014 Safe care and treatment
⚠ The provider did not do all that was reasonably practicable to mitigate risks. This is because: Checks on fridges used to store medications in all areas were not always completed as per the trust’s own policy. Where fridge temperature ranges were recorded outside the recommended minimum or maximum range, steps …
Must-do action 5 of 5
Must do
Safe
The trust must ensure the expiration date of medicines is monitored. Drugs that are past their expiry date must be disposed of promptly.
Regulation: Regulation 12 HSCA (RA) Regulations 2014 Safe care and treatment
⚠ The provider did not do all that was reasonably practicable to mitigate risks. This is because: Checks on fridges used to store medications in all areas were not always completed as per the trust’s own policy. Where fridge temperature ranges were recorded outside the recommended minimum or maximum range, steps …

Should-do actions (18)

Recommended improvements to enhance service quality.

Should-do action 1 of 18
Should do
Well-led
The service should seek greater patient feedback is obtained so that more details on service delivery and quality of care can be obtained to drive improvement.
Should-do action 2 of 18
Should do
Caring
The service should continue to strive to improve communication between health professionals, families and patients.
Should-do action 3 of 18
Should do
Responsive
The service should continue to make sure that patients are discharged in a timely manner.
Should-do action 4 of 18
Should do
Caring
The service should continue to provide clear signage on the wards to help maintain patient privacy and dignity.
Should-do action 5 of 18
Should do
Effective
The service should improve compliance with mandatory training.
Should-do action 6 of 18
Should do
Safe
The service should review the practice of leaving record trolleys containing patient notes opened or larger records unsecured on the trolleys.
Should-do action 7 of 18
Should do
Effective
The service should review the Deprivation of Liberty Safeguards (DoLS) paperwork and the issue of nursing staff transcribing information from the medical notes as part of the assessment application process. The services should ensure information is correctly entered on the application forms and all the relevant information related to the patient has been captured.
Should-do action 8 of 18
Should do
Responsive
The trust should continue to review its management of patient flow and the issues of outliers to make sure patients are treated on wards suitable to meet their needs.
Should-do action 9 of 18
Should do
Effective
The trust should improve mandatory training rates and the levels of staff trained in resuscitating patients.
Should-do action 10 of 18
Should do
Safe
The trust should ensure that all intravenous fluids are stored securely at all times.
Should-do action 11 of 18
Should do
Safe
The checking and labelling of medication, including controlled medications should be carried out consistently as per trust policy.
Should-do action 12 of 18
Should do
Safe
The trust must ensure that all medications are within their expiry dates and any expired medications must be disposed of promptly and not stored with other medications which have not expired.
Should-do action 13 of 18
Should do
Responsive
The trust should manage serious complaints in a timelier manner.
Should-do action 14 of 18
Should do
Safe
Checking and maintenance of equipment should be robust and clear.
Should-do action 15 of 18
Should do
Well-led
The trust should ensure that action plans are in place where areas fall below required standards and they should be reviewed as agreed.
Should-do action 16 of 18
Should do
Effective
The trust should ensure staff complete mandatory training when required.
Should-do action 17 of 18
Should do
Responsive
The trust should monitor patient waiting times following arrival in outpatient departments.
Should-do action 18 of 18
Should do
Responsive
The trust should take steps to resolve issues for patients attempting to contact outpatients services by telephone.

Location details

CQC ID: RQ601
Local authority: Liverpool
Region: North West

Inspection report

Type: Comprehensive inspection
Date: 30 March 2016
Rating: Good
Actions: 5 must-do 18 should-do
AI-extracted 2 Jun 2026