Source · CQC inspection
St Albans City Hospital
Type NHS Healthcare Organisation
Region East
Last inspected 17 Jun 2020
Overall rating: Requires Improvement View full CQC report
Domain ratings
Safe
Requires Improvement
Effective
Requires Improvement
Caring
Good
Responsive
Good
Well-led
Good
Earlier inspection findings
Must-do actions (6)
Must-do action 1 of 6
Must do
Safe
The trust must ensure medical staff are up to date with their mandatory training requirements.
Must-do action 2 of 6
Must do
Safe
The trust must ensure that daily safety checks of specialist equipment such as resuscitation equipment are completed.
Must-do action 3 of 6
Must do
Safe
The trust must ensure medical staff are up to date with safeguarding training.
Must-do action 4 of 6
Must do
Safe
The trust must ensure medical staff are up to date with adult basic life support training.
Must-do action 5 of 6
Must do
Safe
The trust must ensure that patient medical records are accurate, complete and contemporaneous including risk assessment and nutritional assessments.
Must-do action 6 of 6
Must do
Safe
The trust must ensure that risks are identified, reviewed and acted upon in a timely manner to mitigate risk.
Should-do actions (34)
Should-do action 1 of 34
Should do
Safe
The trust should ensure that all seating is fit for purpose (Regulation 12).
Should-do action 2 of 34
Should do
Safe
The trust should ensure all cleaning materials covered by COSHH are stored in line with legislation (Regulation 15).
Should-do action 3 of 34
Should do
Safe
The trust should ensure that records are always clear, up-to-date or easily available to all staff providing care (Regulation 17).
Should-do action 4 of 34
Should do
Safe
The trust should ensure that patients are weighed to facilitate medication dosing (Regulation 12).
Should-do action 5 of 34
Should do
Safe
The trust should ensure that all medicines are stored securely in line with legislation (Regulation 12).
Should-do action 6 of 34
Should do
Effective
The trust should ensure that pain scores are clearly recorded (Regulation 12).
Should-do action 7 of 34
Should do
Safe
The trust should ensure that patients received antibiotics for the treatment of suspected sepsis in a timely manner (Regulation 12).
Should-do action 8 of 34
Should do
Responsive
The trust should ensure they improve complaint response times for complex cases.(Regulation 16).
Should-do action 9 of 34
Should do
Well-led
The trust should ensure that IT systems are appropriate to service needs (Regulation 15).
Should-do action 10 of 34
Should do
Safe
The trust should improve compliance with mandatory, mental capacity and deprivation of liberty safeguard training amongst medical staff.(Regulation 12).
Should-do action 11 of 34
Should do
Safe
The trust should ensure all medical wards are cleaned regularly and to ensure cleaning schedules are in place.(Regulation 12).
Should-do action 12 of 34
Should do
Safe
The trust should ensure all cleaning materials covered by Control of Substances Hazardous to Health Regulations 2002 (COSHH, 2002) are stored appropriately.(Regulation 15).
Should-do action 13 of 34
Should do
Safe
The trust should ensure medicines are managed in line with guidelines. The trust should ensure that antibiotic prescriptions clearly record review dates and ensure that patients weights are clearly recorded.(Regulation 12).
Should-do action 14 of 34
Should do
Caring
The trust should ensure relevant information is communicated to patients around their care and treatment.(Regulation 9).
Should-do action 15 of 34
Should do
Effective
The trust should ensure that audit performance is in line with national targets.(Regulation 17).
Should-do action 16 of 34
Should do
Responsive
The trust should ensure they improve complaint response times for complex cases’(Regulation 16).
Should-do action 17 of 34
Should do
Well-led
The trust should ensure that IT systems are appropriate to service needs.(Regulation 15).
Should-do action 18 of 34
Should do
Safe
The trust should ensure that mandatory training compliance is above the trust target.(Regulation 12).
Should-do action 19 of 34
Should do
Safe
The trust should ensure theatre staff maintain hand hygiene at all times.(Regulation 12).
Should-do action 20 of 34
Should do
Safe
The trust should ensure patient resuscitation and treatment plan records are completed and information is easy to locate.(Regulation 17).
Should-do action 21 of 34
Should do
Responsive
The trust should continue to ensure people can access the service when they need it.(Regulation 17).
Should-do action 22 of 34
Should do
Responsive
The trust should ensure that complaint responses are timely in line with trust policy.(Regulation 16).
Should-do action 23 of 34
Should do
Well-led
The trust should ensure that IT systems are appropriate to service needs.(Regulation 15).
Should-do action 24 of 34
Should do
Safe
The trust should ensure that mandatory training compliance is in line with trust targets.(Regulation 12).
Should-do action 25 of 34
Should do
Well-led
The trust should ensure that all staff receive annual appraisals.(Regulation 12).
Should-do action 26 of 34
Should do
Well-led
The trust should ensure that audits are used to monitor compliance with policy and performance.(Regulation 17).
Should-do action 27 of 34
Should do
Responsive
The trust should ensure that patients receive treatment within one hour of arrival to the department, in line with national guidance.(Regulation 17).
Should-do action 28 of 34
Should do
Responsive
The trust should ensure they improve complaint response times for complex cases.(Regulation 16).
Should-do action 29 of 34
Should do
Safe
The trust should ensure that National Early Warning Scores are recorded for every admission.(Regulation 12).
Should-do action 30 of 34
Should do
Safe
The trust should ensure that substances subject to the Control of Substances Hazardous to Health Regulations 2002 (COSHH, 2002), are stored safely and line with service policy.(Regulation 15).
Should-do action 31 of 34
Should do
Safe
The trust should have systems and processes in place to ensure that staff are aware of any recent medicine related incidents and share learning from incidents.(Regulation 12).
Should-do action 32 of 34
Should do
Safe
The trust should ensure that all incidents are reported appropriately.(Regulation 17).
Should-do action 33 of 34
Should do
Well-led
The trust should ensure that plans for the ward are shared with the team and all services are included in the hospital vision.(Regulation 17).
Should-do action 34 of 34
Should do
Responsive
The trust should ensure they improve complaint response times for complex cases.(Regulation 16).