Source · CQC inspection
Sir William Gowers Centre
Provider University College London Hospitals NHS Foundation Trust
Type NHS Healthcare Organisation
Region South East
Last inspected 11 Dec 2018
Overall rating: Good View full CQC report
Domain ratings
Safe
Requires Improvement
Effective
Good
Caring
Outstanding
Responsive
Outstanding
Well-led
Good
Earlier inspection findings
Must-do actions (5)
Must-do action 1 of 5
Must do
Safe
The trust must ensure that its restraint policy follows best practice guidance as set out in Positive and Proactive Care: Reducing the Need for Restrictive Interventions (Department of Health, 2014) and Violence and aggression: short-term management in mental health, health and community settings (National Institute for Health and Care Excellence, 2015). This includes ensuring that there is a rigorous process so that mechanical restraint such as mittens are only used in exceptional circumstances, and that ongoing monitoring of all restrictive interventions is in place.
Must-do action 2 of 5
Must do
Safe
The trust must ensure that there is a rapid tranquilisation policy which follows national guidance as set out in Violence and aggression: short-term management in mental health, health and community settings (National Institute for Health and Care Excellence, 2015). For example, ensuring that patients are monitored at the frequency recommended to ensure they are kept safe.
Must-do action 3 of 5
Must do
Caring
The trust must ensure people using services within the endoscopy unit are treated with dignity and respect. If any form of surveillance is used for any purpose, providers must ensure this is in the best interests of people using the service.
Must-do action 4 of 5
Must do
Safe
The trust must ensure that there are sufficient numbers of suitably qualified and experienced medical staff within the intensive therapy unit (ITU), in line with national standards.
Must-do action 5 of 5
Must do
Safe
The trust must ensure that all staff have child safeguarding training that is relevant and at a suitable level for their role.
Should-do actions (66)
Should-do action 1 of 66
Should do
Caring
The trust should ensure that the signs above the transitional assessment facility rooms which restrict patients’ liberty are removed without delay.
Should-do action 2 of 66
Should do
Effective
The trust should ensure that patients have their mental health needs assessed alongside their physical health needs.
Should-do action 3 of 66
Should do
Safe
The trust should improve the quality and consistency of patient documentation.
Should-do action 4 of 66
Should do
Responsive
The trust should take to action to address the backlog of GP discharge summaries.
Should-do action 5 of 66
Should do
Responsive
The trust should improve upon the Department of Health’s standard of 95% for time to treatment and decision to admit, transfer or discharge.
Should-do action 6 of 66
Should do
Well-led
The trust should review risks in the paediatric emergency department.
Should-do action 7 of 66
Should do
Safe
The trust should ensure resuscitation equipment is only accessible to authorised persons.
Should-do action 8 of 66
Should do
Safe
The trust should ensure staff follow the correct procedures for disposal of medicines.
Should-do action 9 of 66
Should do
Safe
The trust should ensure that emergency medicines are secure and tamper evident seals are used as per guideline.
Should-do action 10 of 66
Should do
Safe
The trust should ensure that all staff adhere to infection prevention and control measures, including the appropriate use of personal protective equipment, and ensuring that all areas are clean and dust free.
Should-do action 11 of 66
Should do
Safe
The trust should ensure that all staff have relevant safeguarding training.
Should-do action 12 of 66
Should do
Safe
The trust should ensure that staff adhere to information governance guidelines all the time and computer screens with confidential patient information are not left unattended.
Should-do action 13 of 66
Should do
Well-led
The trust should ensure they review all legal and practical issues before considering the use of the monitoring screens within the endoscopy unit.
Should-do action 14 of 66
Should do
Effective
The trust should ensure that fluid charts are completed in full for all relevant patients.
Should-do action 15 of 66
Should do
Well-led
The trust should ensure that business continuity plan is shared with all relevant staff.
Should-do action 16 of 66
Should do
Well-led
The trust should ensure that actions from risk assessments are implemented and monitored.
Should-do action 17 of 66
Should do
Responsive
The trust should ensure they meet the operational standard for patients receiving their first cancer treatment within 62 days of an urgent GP referral.
Should-do action 18 of 66
Should do
Responsive
The trust should continue to take action to address the high did not attend rate within the department.
Should-do action 19 of 66
Should do
Safe
The trust should ensure patient paper records are locked away securely for safety and privacy and data protection.
Should-do action 20 of 66
Should do
Responsive
The trust should ensure the GP and patient discharge letters are sent out on time to reduce and avoid any backlog.
Should-do action 21 of 66
Should do
Responsive
The trust should ensure the telephone call centre is accessible to patients trying to make or change an appointment.
Should-do action 22 of 66
Should do
Safe
The trust should ensure there is safe and adequate seating for all patients attending the fracture clinic.
Should-do action 23 of 66
Should do
Effective
The trust should monitor the effectiveness of the care and treatment being provided to patients and use the findings to improve them.
Should-do action 24 of 66
Should do
Caring
The trust should ensure there is a private area at reception for patients to be able to speak to the receptionists on arrival, if required.
Should-do action 25 of 66
Should do
Safe
The trust should review the cleaning provision of the service to ensure the environment and equipment are clean to prevent the risk of infection.
Should-do action 26 of 66
Should do
Safe
The trust should ensure that medicines are managed appropriately and medicine storage temperatures are monitored and recorded in line with trust requirements.
Should-do action 27 of 66
Should do
Safe
The trust should improve staff awareness of the escalation and management processes for when medication fridge temperatures fall outside the range stated in the trust policy for the safe storage of medicines.
Should-do action 28 of 66
Should do
Safe
The trust should ensure appropriate management of clinical equipment and emergency equipment.
Should-do action 29 of 66
Should do
Effective
The trust should ensure that audits on mental health are undertaken and that learning is shared across the service.
Should-do action 30 of 66
Should do
Responsive
The trust should improve the lifts signage and ensure it provides clear information for visitors on how to access the maternity wards.
Should-do action 31 of 66
Should do
Caring
The trust should review the current bereavement room provision for bereaved women in the service.
Should-do action 32 of 66
Should do
Well-led
The trust should take action to address the low staff morale in the service.
Should-do action 33 of 66
Should do
Well-led
The trust should review and put in place robust arrangements to support the right of staff to exercise a conscientious objection to participate in termination of pregnancy. These arrangements should be assessed for their effectiveness, monitored and kept under review to ensure a safe service is always available to patients who need it.
Should-do action 34 of 66
Should do
Effective
The trust should update its guidance for women requesting termination of pregnancy for fetal abnormality to enable staff to correctly apply current processes.
Should-do action 35 of 66
Should do
Effective
The trust should review the termination of pregnancy audit programme to enable changes in practice in response to the audits.
Should-do action 36 of 66
Should do
Safe
The trust should ensure compliance with mandatory training meets the required targets.
Should-do action 37 of 66
Should do
Effective
The trust should review its participation in external audits and benchmarking against other services.
Should-do action 38 of 66
Should do
Responsive
The trust should ensure they meet the operational standard for patients receiving their first cancer treatment within 62 days of an urgent GP referral.
Should-do action 39 of 66
Should do
Safe
The trust should ensure mandatory training, including safeguarding training, for medical staff meets the trust target of 90%.
Should-do action 40 of 66
Should do
Safe
The trust should ensure the storage of control drugs complies with their medicines storage policy or The Misuse of Drugs (Safe Custody) Regulations 1973.
Should-do action 41 of 66
Should do
Effective
The trust should ensure fluid balance management is recorded consistently.
Should-do action 42 of 66
Should do
Caring
The trust should ensure patients are offered pain relief when they need it.
Should-do action 43 of 66
Should do
Well-led
The trust should ensure that the processes for identifying and monitoring risk carry through to action to mitigate the risks as far as possible.
Should-do action 44 of 66
Should do
Safe
The trust should ensure that the storage of controlled drugs complies with the Misuse of Drugs (Safe Custody) Regulations (1973).
Should-do action 45 of 66
Should do
Safe
The trust should encourage better hand hygiene compliance including reviewing their measurement of this to ensure it captured practice more effectively.
Should-do action 46 of 66
Should do
Safe
The trust should ensure mandatory training, including safeguarding training, for medical staff meets the trust target of 90%.
Should-do action 47 of 66
Should do
Safe
The trust should ensure allied staffing levels, in particular pharmacy and therapy staff are in line with national standards.
Should-do action 48 of 66
Should do
Effective
The trust should review record keeping to ensure reassessments are completed where required.
Should-do action 49 of 66
Should do
Safe
The trust should review equipment checks to ensure they are properly checked against standards.
Should-do action 50 of 66
Should do
Safe
The trust should review storage facilities for medicines.
Should-do action 51 of 66
Should do
Effective
The trust should ensure it has a process in place to continually review nursing qualifications to ensure the unit meets recommended guidelines for post registration qualifications.
Should-do action 52 of 66
Should do
Safe
The trust should ensure mandatory training, including safeguarding training, for medical staff meets the trust target of 90%.
Should-do action 53 of 66
Should do
Safe
The service should ensure that all resuscitation equipment is checked on a regular basis.
Should-do action 54 of 66
Should do
Responsive
The service should ensure that instructions given to patients are clear and that correspondence regarding their appointments is received by the patient and their GP in a timely manner.
Should-do action 55 of 66
Should do
Caring
The service should ensure that reception staff behave in a polite and courteous manner to all patients and visitors.
Should-do action 56 of 66
Should do
Responsive
The service should ensure that there are minimal delays to clinics and patients are seen on time.
Should-do action 57 of 66
Should do
Safe
The trust should ensure infection control procedures are fit for purpose and result in a clean and hygienic environment.
Should-do action 58 of 66
Should do
Safe
The trust should ensure access to chemicals is restricted through secure storage.
Should-do action 59 of 66
Should do
Safe
The trust should ensure access to secure clinical areas is restricted.
Should-do action 60 of 66
Should do
Safe
The trust should ensure there are adequate means of staff and patients calling for help using call bells that are accessible.
Should-do action 61 of 66
Should do
Responsive
The trust should ensure patients and visitors have access to the complaints procedure.
Should-do action 62 of 66
Should do
Responsive
The trust should ensure signage on the premises reflect the names of clinics and services.
Should-do action 63 of 66
Should do
Well-led
The trust should ensure there is a system in place to identify and document risks specific to this site.
Should-do action 64 of 66
Should do
Effective
The trust should ensure all staff have access to a structured, well-defined system of supervisions and appraisals.
Should-do action 65 of 66
Should do
Safe
The trust should ensure medicines are stored safely within the appropriate temperature limits.
Should-do action 66 of 66
Should do
Safe
The trust should ensure mandatory training compliance targets are achieved for medical staff.