Source · CQC inspection
Wharfedale Hospital
Provider Leeds Teaching Hospitals NHS Trust
Type NHS Healthcare Organisation
Region Yorkshire & Humberside
Last inspected 27 Sep 2016
Overall rating: Good View full CQC report
Domain ratings
Safe
Good
Effective
Good
Caring
Good
Responsive
Good
Well-led
Good
Earlier inspection findings
Must-do actions (12)
Must-do action 1 of 12
Must do
Safe
The trust must ensure at all times there are sufficient numbers of suitably skilled, qualified and experienced staff in line with best practice and national guidance taking into account patients’ dependency levels.
Must-do action 2 of 12
Must do
Safe
The trust must ensure all staff have completed mandatory training and role specific training.
Must-do action 3 of 12
Must do
Safe
The trust must ensure staff have undertaken safeguarding training at the appropriate levels for their role.
Must-do action 4 of 12
Must do
Safe
The trust must review the admission of critical care patients to theatre recovery areas when critical care beds are not available to ensure staff are suitably skilled, qualified and experienced.
Must-do action 5 of 12
Must do
Safe
The trust must review how learning from Never Events is embedded within theatre practice.
Must-do action 6 of 12
Must do
Safe
The trust must review the appropriateness of out of hours’ operations taking place and take the necessary steps to ensure these are in compliance with national guidance.
Must-do action 7 of 12
Must do
Safe
The trust must review the storage arrangements for substances hazardous to health, including cleaning products and sharps disposal bins to ensure safety in line with current procedures.
Must-do action 8 of 12
Must do
Safe
The trust must review and address the implementation of the WHO Five Steps to Safer Surgery within theatres.
Must-do action 9 of 12
Must do
Safe
The trust must ensure that physiological observations and NEWS are calculated, monitored and that all patients at risk of deterioration are escalated in line with trust guidance.
Must-do action 10 of 12
Must do
Safe
The trust must ensure that all equipment used across core services is properly maintained and serviced.
Must-do action 11 of 12
Must do
Effective
The trust must ensure that staff maintain patient confidentiality at all times, including making sure that patient identifiable information is not left unattended.
Must-do action 12 of 12
Must do
Safe
The trust must ensure that infection prevention and control protocols are adhered to in theatres.
Should-do actions (7)
Should-do action 1 of 7
Should do
Effective
The trust should review and improve the consent process to ensure trust policies and best practice is consistently followed.
Should-do action 2 of 7
Should do
Responsive
The trust should review the availability of referral processes for formal patient psychological and emotional support following a critical illness.
Should-do action 3 of 7
Should do
Responsive
The trust should review the provision of post-discharge rehabilitation support to patients discharged from critical care.
Should-do action 4 of 7
Should do
Safe
The trust should ensure that appropriate staff have access to safeguarding supervision in line with best practice guidance.
Should-do action 5 of 7
Should do
Safe
The trust should continue to monitor the safe and correct identification of deceased patients before they are taken to the mortuary and take necessary action to ensure this is embedded in practice.
Should-do action 6 of 7
Should do
Responsive
The trust should continue to work towards improving the assessment to treatment times within the ED department. The trust should also continue to work towards improving ambulance handover times and reduce the number of handovers that take more than 30 minutes.
Should-do action 7 of 7
Should do
Safe
The trust should ensure that systems and processes are in place and followed for the safe storage, security, recording and administration of medicines including controlled drugs.