Source · CQC inspection
Alnwick Infirmary
Provider Northumbria Healthcare NHS Foundation Trust
Type NHS Healthcare Organisation
Region North East
Last inspected 16 Oct 2019
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 (26)
Must-do action 1 of 26
Must do
Safe
The trust must ensure that mandatory training compliance meets the trust target.
Must-do action 2 of 26
Must do
Well-led
The trust must implement and monitor timescales for the investigation of incidents and monitor reporting behaviour within the trust.
Must-do action 3 of 26
Must do
Well-led
The trust must ensure that risks are consistently monitored, escalated and mitigated.
Must-do action 4 of 26
Must do
Well-led
The trust must ensure that SI/SLE action plans are completed in a timely way.
Must-do action 5 of 26
Must do
Well-led
The trust must ensure that the electronic track and trigger system is audited and that the timeliness of patient observations is improved.
Must-do action 6 of 26
Must do
Safe
The trust must ensure it has oversight of all patients requiring level 2 care and that these patients receive the level of nursing care they require.
Must-do action 7 of 26
Must do
Well-led
The trust must increase the sample size of mortality reviews and ensure learning is disseminated throughout the organisation.
Must-do action 8 of 26
Must do
Safe
The trust must ensure it has day to day oversight of the effectiveness of the medicines reconciliation process.
Must-do action 9 of 26
Must do
Well-led
The trust must ensure that complaints are investigated within timescales set by the trust.
Must-do action 10 of 26
Must do
Safe
The trust must ensure mechanisms are in place to monitor oxygen prescribing.
Must-do action 11 of 26
Must do
Safe
The trust must ensure that PGDs are reviewed and updated to provide continuity of safe care.
Must-do action 12 of 26
Must do
Well-led
The trust must ensure medical records meet national requirements.
Must-do action 13 of 26
Must do
Safe
The service must ensure that mandatory training compliance, including safeguarding training, Mental Capacity Act and Deprivation of Liberty Safeguards training, meets the trust target.
Must-do action 14 of 26
Must do
Safe
The service must ensure oxygen for patients is prescribed, in line with national guidance.
Must-do action 15 of 26
Must do
Well-led
The service must ensure that patient group directions do not exceed their respective expiry dates through adherence to trust policy and national guidelines.
Must-do action 16 of 26
Must do
Safe
The service must ensure that patient observations are completed in line with the electronic track and trigger system.
Must-do action 17 of 26
Must do
Safe
The department must ensure all staff are up to date with all mandatory training.
Must-do action 18 of 26
Must do
Safe
The department must ensure all clinical records are correctly labelled with patient identifiers and loose sheets are attached to the clinical record.
Must-do action 19 of 26
Must do
Safe
Staff must follow the trust policy for oxygen prescribing.
Must-do action 20 of 26
Must do
Well-led
The trust must ensure there is a robust process in place for reviewing PGDs to ensure they do not expire.
Must-do action 21 of 26
Must do
Well-led
The department must have a robust process in place to addressing RCEM audit results where audit standards are not met and be able to demonstrate actions to improve compliance and improvement in compliance over time.
Must-do action 22 of 26
Must do
Safe
The department must continue to monitor flow and work towards improving flow through the department especially at times of surge.
Must-do action 23 of 26
Must do
Safe
The service must ensure all staff complete mandatory training to meet the Trust compliance target of 95% for all modules.
Must-do action 24 of 26
Must do
Well-led
The service must ensure staff receive an appraisal and meet the trust compliance target of 95%.
Must-do action 25 of 26
Must do
Well-led
The service must ensure emergency resuscitation trolley equipment checks are carried out consistently.
Must-do action 26 of 26
Must do
Well-led
The service must ensure review dates for Patient Group Directions (PGDs) used by midwives are checked regularly in line with regulation and NICE guidance.
Should-do actions (24)
Should-do action 1 of 24
Should do
Well-led
The trust should continue to develop its capacity and sustainability in IT.
Should-do action 2 of 24
Should do
Responsive
The trust should develop and broaden it’s capacity within community services to support the flow through acute services.
Should-do action 3 of 24
Should do
Well-led
The trust should ensure all business unit strategies are up to date and progress is monitored adequately.
Should-do action 4 of 24
Should do
Well-led
The trust should review its mechanisms of assurance to ensure that programmes of work being delivered at business unit level have oversight at board level.
Should-do action 5 of 24
Should do
Well-led
The trust should ensure that quality improvement projects are sustainable and quantify the impact upon the trust.
Should-do action 6 of 24
Should do
Well-led
The service should ensure that all staff receive an appraisal.
Should-do action 7 of 24
Should do
Well-led
The service should ensure that risk registers are updated to evidence risk review and target dates.
Should-do action 8 of 24
Should do
Safe
The service should ensure that records are completed in line with trust policy ensuring all entries are signed, dated, errors clearly amended and patient identifiers used on every page.
Should-do action 9 of 24
Should do
Responsive
The service should ensure business unit management are sighted on and taking action on specialties experiencing a longer than average length of stay or higher than average risk of readmission.
Should-do action 10 of 24
Should do
Effective
The service should continue to monitor and explore the drivers behind readmission rates for non-elective admissions to improve performance compared to the national average.
Should-do action 11 of 24
Should do
Well-led
The service should review the process of clinical governance dissemination surrounding weekly ward level safety huddles to evidence information sharing.
Should-do action 12 of 24
Should do
Safe
The service should review the non-invasive ventilation (NIV) policy to reflect the initiation of NIV on base sites.
Should-do action 13 of 24
Should do
Safe
The department should ensure all staff have up to date safeguarding training.
Should-do action 14 of 24
Should do
Safe
All staff should ensure they are following the trust’s infection control policy of being bare below the elbows, including not wearing nail varnish.
Should-do action 15 of 24
Should do
Safe
All blood transfusion waste products including sharps should be stored securely and disposed of appropriately in a timely manner in line with transfusion guidance.
Should-do action 16 of 24
Should do
Caring
Staff should ensure the privacy and dignity of patients is maintained particularly in busy, thoroughfares.
Should-do action 17 of 24
Should do
Responsive
The trust should continue to work to improve time to initial assessment and ambulance handover times.
Should-do action 18 of 24
Should do
Safe
Staff should ensure information contained within patient records is consistent across both paper and electronic records.
Should-do action 19 of 24
Should do
Caring
Staff should ensure patient comfort rounds are documented and evidenced within patient records.
Should-do action 20 of 24
Should do
Well-led
The department should ensure that all staff, including administrative staff receive annual appraisals.
Should-do action 21 of 24
Should do
Effective
The department should ensure all staff are confident about mental capacity assessment and are aware of tools available to support them carrying out assessments.
Should-do action 22 of 24
Should do
Responsive
The department should work closely with the complaints department to ensure complaints are managed in line with the trust policy.
Should-do action 23 of 24
Should do
Well-led
The service should continue to monitor the sickness rate for nursing and midwifery staff in maternity and continue to follow the trustsickness policy to support and manage staff appropriately and meet the trust target of 4.0%.
Should-do action 24 of 24
Should do
Safe
The service should ensure all fluid balance charts are completed and totals are recorded.