Source · CQC inspection
Royal Liverpool Site
Provider Royal Liverpool and Broadgreen University Hospitals NHS Trust
Type NHS Healthcare Organisation
Region North West
Last inspected 17 Jan 2019
Overall rating: Requires Improvement View full CQC report
Domain ratings
Safe
Requires Improvement
Effective
Requires Improvement
Caring
Good
Responsive
Requires Improvement
Well-led
Good
Earlier inspection findings
Must-do actions (15)
Must-do action 1 of 15
Must do
Well-led
The trust must ensure that all incident systems and processes are effective and fully implemented.
Must-do action 2 of 15
Must do
Well-led
The trust must ensure that all incidents that meet the criteria for duty of candour have this applied in line with legislation.
Must-do action 3 of 15
Must do
Well-led
The trust must ensure that all information that is used for monitoring performance is accurate and up to date.
Must-do action 4 of 15
Must do
Effective
The trust must ensure that all application for Deprivation of Liberty safeguards are made in line with trust policy and legislation.
Must-do action 5 of 15
Must do
Safe
The hospital must ensure there are sufficient numbers of qualified, competent and skilled staff in the emergency department to maintain a safe level of care, taking into account best practice and national guidelines in relation to the number of registered nurses on each shift, paediatric nursing provision and paediatric basic life support. Regulations 18(1)
Must-do action 6 of 15
Must do
Safe
The hospital must ensure there is effective assessment of patient’s pressure risk and undertake all that is reasonably possible to mitigate any such risk. Regulations 12(1)(2)(a)(b)
Must-do action 7 of 15
Must do
Safe
The hospital must ensure the proper and safe management of medicines and use of premises including secure storage in line with current legislation. Regulations 12(1)(2)
Must-do action 8 of 15
Must do
Safe
The hospital must ensure that substances that are hazardous to health are locked away safely, particularly on gerontology wards were patients have a cognitive impairment. Regulation 12(2)(b).
Must-do action 9 of 15
Must do
Safe
The hospital must ensure that risk assessments for patients, such as falls, pressure ulcers and patient observations are completed and updated in a timely manner. Regulation 12(2)(a).
Must-do action 10 of 15
Must do
Safe
The hospital must ensure that there are sufficient numbers of staff with the correct level of training to recover patients in endoscopy, particularly when they have had a local or general anaesthetic. Regulation 18(1).
Must-do action 11 of 15
Must do
Safe
The hospital must ensure that patient records are kept securely at all times so that patient confidentiality is maintained. Regulation 17(2)(c).
Must-do action 12 of 15
Must do
Effective
The trust must ensure that mental capacity assessments are fully completed when required, particularly before applying for a Deprivation of Liberty safeguard for patients. Regulation 11.
Must-do action 13 of 15
Must do
Safe
The service must ensure that controlled drugs are stored securely in line with trust policy, national guidance and legislation. Regulation 12(2)(g).
Must-do action 14 of 15
Must do
Safe
The service must ensure that patients who are prescribed antibiotics have a review date and end date recorded. Regulation 12(2)(g).
Must-do action 15 of 15
Must do
Responsive
The service must continue to take action to address the waiting times for paediatric dentistry. Regulation 9(1)(b)
Should-do actions (27)
Should-do action 1 of 27
Should do
Well-led
The trust should ensure take measures to put in place an achievable financial strategy.
Should-do action 2 of 27
Should do
Well-led
The trust should ensure that complaints processes are effectively managed.
Should-do action 3 of 27
Should do
Well-led
The trust should ensure that risks are fully mitigated and systems understood by staff.
Should-do action 4 of 27
Should do
Effective
The hospital should take measures to promote health, prevent and identify illness in its early stages.
Should-do action 5 of 27
Should do
Safe
The hospital should adopt control measure to make sure the risk to patients without call bells in the walk-in-minors area is as low as is reasonable possible.
Should-do action 6 of 27
Should do
Safe
The hospital should ensure that premises are clean, secure and properly maintained, the appropriate standard of hygiene should also be maintained.
Should-do action 7 of 27
Should do
Responsive
The hospital should design care and treatment with a view to achieving service users preferences and meeting the individual needs of patients, such as those living with dementia.
Should-do action 8 of 27
Should do
Responsive
The hospital should ensure the privacy of its patients including those in the emergency triage area.
Should-do action 9 of 27
Should do
Safe
The hospital should ensure that staff are ‘bare below the elbow’ when delivering patient care to make sure that the risk of infection being spread is reduced as much as possible.
Should-do action 10 of 27
Should do
Safe
The hospital should ensure that oxygen cylinders are stored in line with best practice guidance and trust policy.
Should-do action 11 of 27
Should do
Safe
The hospital should ensure that call bells are immediately available to all patients so that they are able to call for assistance when needed.
Should-do action 12 of 27
Should do
Well-led
The hospital should ensure that initial reviews for all serious incidents are completed in a timely manner, in line with trust policy and national guidance.
Should-do action 13 of 27
Should do
Well-led
The services should ensure that all areas of performance are identified and that improvements are made in a timely manner.
Should-do action 14 of 27
Should do
Well-led
The services should ensure that actions are implemented on the risk management system so that risks are further reduced or eliminated.
Should-do action 15 of 27
Should do
Responsive
The hospital should consider ways to improve patient flow, making sure that patients are managed in areas that meet their needs.
Should-do action 16 of 27
Should do
Safe
The hospital should consider ways in which to make sure that all agency nursing staff receive local inductions and that evidence for this is kept.
Should-do action 17 of 27
Should do
Safe
The service should ensure that action plans are in place to improve compliance for mandatory training, for medical staff.
Should-do action 18 of 27
Should do
Safe
The service should ensure that patients own medications are checked on admission as part of the medicines reconciliation process and in line with the trusts medicines optimisation strategy.
Should-do action 19 of 27
Should do
Safe
The service should ensure that all serviceable equipment has a legible, recorded asset number on it.
Should-do action 20 of 27
Should do
Responsive
The service should ensure policies and procedures include all areas used to hold patients for a prolonged period of time whilst waiting for beds.
Should-do action 21 of 27
Should do
Safe
The services should review staff awareness of the incident reporting procedure.
Should-do action 22 of 27
Should do
Safe
The services should review mandatory training rates for medical staff.
Should-do action 23 of 27
Should do
Safe
Service leads should implement a system to monitor safety performance across community services.
Should-do action 24 of 27
Should do
Effective
Service leads should continue to develop more accurate and through means of monitoring and measuring effectiveness in terms of patient outcomes and performance indicators.
Should-do action 25 of 27
Should do
Effective
Service leads should continue with plans to formalise clinical supervision for staff within the community respiratory and heart failure teams.
Should-do action 26 of 27
Should do
Safe
The services should provide additional training so that staff are aware of how to access all the patient information they need to plan care.
Should-do action 27 of 27
Should do
Well-led
Service leads should consider how governance systems can be improved to better support community services.