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Frenchay Hospital

Provider North Bristol NHS Trust Type NHS Healthcare Organisation Region South West Last inspected 8 Dec 2015

Overall rating: Requires Improvement  View full CQC report

Domain ratings

Five CQC key questions
Safe
Requires Improvement
Effective
Not Yet Rated
Caring
Good
Responsive
Requires Improvement
Well-led
Good

Earlier inspection findings

pre-2024 framework · 5 must-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 all staff at the Head Injury Therapy Unit understand the incident reporting policy and report all incidents.
Regulation: Regulation 10 HSCA 2008 (Regulated Activities) Regulations 2010 Assessing and monitoring the quality of service providers
⚠ The registered person had not protected service users, and others who may be at risk, against the risk of inappropriate or unsafe treatment, by means of effective operation of systems designed to enable the registered person to identify, assess and manage risks relating to the health, welfare and safety of …
Must-do action 2 of 5
Must do
Safe
The trust must ensure that equipment and supplies are monitored and serviced appropriately to ensure that patients are not at risk of receiving treatment and care using defective or out-of-date equipment.
Regulation: Regulation 16 HSCA 2008 (Regulated Activities) Regulations 2010 Safety, availability and suitability of equipment
⚠ 16(1) The registered person had not made suitable arrangements to protect patients and others who may be at risk from the use of unsafe equipment by ensuring that equipment provided was: (a) properly maintained and suitable for its purpose This is because equipment was not serviced appropriately, taps were not …
Must-do action 3 of 5
Must do
Safe
The trust must ensure that infection control procedures are followed and monitored in the Head Injury Therapy Unit so that patients are not put at risk.
Regulation: Regulation 16 HSCA 2008 (Regulated Activities) Regulations 2010 Safety, availability and suitability of equipment
⚠ 16(1) The registered person had not made suitable arrangements to protect patients and others who may be at risk from the use of unsafe equipment by ensuring that equipment provided was: (a) properly maintained and suitable for its purpose This is because equipment was not serviced appropriately, taps were not …
Must-do action 4 of 5
Must do
Safe
Ensure that the rooms remain free from clutter.
Regulation: Regulation 15 HSCA 2008 (Regulated Activities) Regulations 2010 Safety and suitability of premises
⚠ The registered person has not ensured that people are protected against the risks associated with unsafe or unsuitable premises by means of proper operation of the premises. This is due the the use of rooms no longer fit for purpose, being cluttered with filing cabinets and equipment and in need …
Must-do action 5 of 5
Must do
Safe
The registered person had not protected service users against the risks associated with the unsafe use and management of medicines.
Regulation: Regulation 13 HSCA 2008 (Regulated Activities) Regulations 2010 Management of medicines
⚠ This is because the oxygen cylinder on site was out of date. Regulation 13.

Location details

CQC ID: RVJ20
Local authority: South Gloucestershire
Region: South West

Inspection report

Type: Quality Report
Date: 8 December 2015
Rating: Requires improvement
Actions: 5 must-do
AI-extracted 3 Jun 2026