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Lister Hospital

Type NHS Healthcare Organisation Region East Last inspected 3 Nov 2023

Overall rating: Requires Improvement  View full CQC report

Domain ratings

Five CQC key questions
Safe
Requires Improvement
Effective
Requires Improvement
Caring
Good
Responsive
Requires Improvement
Well-led
Requires Improvement

Earlier inspection findings

pre-2024 framework · 17 must-do 27 should-do

Must-do actions (17)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 17
Must do
Safe
The service must have systems in place to ensure staff complete their mandatory training and that mandatory training is monitored to meet the trust’s target completion.
Regulation: Regulation 12(2)(c)
⚠ Staff did not always complete their mandatory training, and monitoring systems were not effective in ensuring target completion across services.
Must-do action 2 of 17
Must do
Safe
The trust must ensure that children receive an initial clinical assessment with 15 minutes.
Regulation: Regulation 12(2)(a)
⚠ Some children were not assessed within 15 minutes of arrival, exceeding recommended times.
Must-do action 3 of 17
Must do
Safe
The service must have systems in place to ensure staff complete their mandatory training and that mandatory training is monitored to meet the trust’s target completion.
Regulation: Regulation 12(2)(c)
⚠ Medical staff's mandatory training compliance was not assured, with some doctors not completing recent resuscitation training.
Must-do action 4 of 17
Must do
Safe
The trust must ensure that risks to patients are not increased by caring for them in crowded and unsuitable areas of the emergency department.
Regulation: Regulation 12(1)
⚠ Patients were cared for in crowded and unsuitable areas of the emergency department, increasing risks, and evacuation in case of fire would be difficult.
Must-do action 5 of 17
Must do
Safe
The service must have systems in place to ensure staff complete their mandatory training and that mandatory training is monitored to meet the trust’s target completion.
Regulation: Regulation 12(2)(c)
⚠ Not all staff were up to date with mandatory training, and training rates consistently fell below targets.
Must-do action 6 of 17
Must do
Well-led
The trust must ensure that auditing systems and processes enable staff to effectively monitor the safety and quality of the service provided.
Regulation: Regulation 17(2)
⚠ Auditing systems and processes did not effectively monitor safety and quality, making it unclear how improvements were tracked or if leaders had full oversight.
Must-do action 7 of 17
Must do
Responsive
The trust must ensure that information sharing and planning with social care providers is timely to ensure safe and timely discharge from the service.
Regulation: Regulation 12(2)
⚠ Information sharing and planning with social care providers was not timely, leading to delays in patient discharge.
Must-do action 8 of 17
Must do
Safe
The trust must ensure that investigations in incidents are completed in a timely manner to allow actions and learning to be shared with the relevant staff to prevent possible future occurrence.
Regulation: Regulation 12(2)
⚠ Incident investigations were not always completed thoroughly or in a timely manner, with a backlog of open incidents not closed within policy timeframes.
Must-do action 9 of 17
Must do
Safe
The service must have systems in place to ensure staff complete their mandatory training and that mandatory training is monitored to meet the trust’s target completion.
Regulation: Regulation 12(2)(c)
⚠ All staff groups were below the trust's mandatory training target of 90% compliance.
Must-do action 10 of 17
Must do
Safe
The service must ensure all single use consumables are in date.
Regulation: Regulation 12(2)(e)
⚠ Out-of-date single-use consumables were found in resuscitation trolleys.
Must-do action 11 of 17
Must do
Safe
The service must ensure all COSHH cupboards are locked and not accessible to the public or patients.
Regulation: Regulation 12(2)(d)
⚠ Unlocked cupboards containing controlled substances hazardous to health were found, posing a risk to patients and visitors.
Must-do action 12 of 17
Must do
Responsive
The service must continue working on reducing the waiting lists.
Regulation: Regulation 12
⚠ The overall waiting list for surgery had increased, with a rise in patients waiting for various surgical procedures.
Must-do action 13 of 17
Must do
Safe
The service must ensure there is an effective system for checking the airway trollies outside the theatre room and the plastic adult cardiac arrest trolleys in the day surgery unit.
Regulation: Regulation 17(2)(b)
⚠ Daily safety checks of specialist equipment, including paediatric airway trolleys and adult cardiac arrest trolleys, were not consistently completed.
Must-do action 14 of 17
Must do
Well-led
The service must ensure they have a comprehensive risk register where risks are identified, the service must introduce measures to reduce or remove the risk with in a time scale that reflects the level of risk and impact on people using the service.
Regulation: Regulation 17(2)(b)
⚠ The risk register lacked information on the impact of risks, measures to reduce them, review dates, and responsible persons.
Must-do action 15 of 17
Must do
Well-led
The service must ensure their policies are the most up to date version and reviewed within the timeframes stated within the policy.
Regulation: Regulation 17(2)(d)
⚠ Some policies were not the final version, contained comments, and had not been reviewed within the stated timeframes.
Must-do action 16 of 17
Must do
Safe
The service must ensure incidents are investigated without delay in line with trust policy.
Regulation: Regulation 17(1)(2)
⚠ Incidents were not always managed in a timely manner, with a backlog of overdue open maternity incidents awaiting review or grading.
Must-do action 17 of 17
Must do
Safe
The service must ensure all steps are taken to appropriately manage and maintain safe staffing in the maternity unit.
Regulation: Regulation 18(1)
⚠ The service did not always have enough nursing and midwifery staff to keep women and babies safe, with staffing levels not consistently matching planned numbers and a high vacancy rate for midwives.

Should-do actions (27)

Recommended improvements to enhance service quality.

Should-do action 1 of 27
Should do
Well-led
The trust should ensure that governance systems continue to improve.
Regulation: Regulation 17
Should-do action 2 of 27
Should do
Well-led
The trust should ensure that they have a clear equality, diversity and inclusion strategy and action plan
Regulation: Regulation 17
Should-do action 3 of 27
Should do
Responsive
The trust should ensure that they improve the whole-hospital approach to access and flow.
Regulation: Regulation 17
Should-do action 4 of 27
Should do
Responsive
The trust should ensure that on-call medical teams are able to respond quickly to urgent and emergency referrals.
Regulation: Regulation 18
Should-do action 5 of 27
Should do
Well-led
The trust should ensure that senior staff meet regularly to discuss operational performance.
Regulation: Regulation 17
Should-do action 6 of 27
Should do
Well-led
The trust should ensure that Internal Professional Standards (agreed and unambiguous principles and times around specialty engagement) are implemented.
Regulation: Regulation 17
Should-do action 7 of 27
Should do
Safe
The trust should ensure that staff comply with Control of Substances Hazardous to Health regulations.
Regulation: Regulation 12
Should-do action 8 of 27
Should do
Safe
The trust should consider ways to enable visiting psychiatrists to use ED prescribing systems.
Regulation: Regulation 12
Should-do action 9 of 27
Should do
Effective
The trust should ensure that all staff are familiar with the new electronic sepsis screening tool.
Regulation: Regulation 17
Should-do action 10 of 27
Should do
Effective
The trust should ensure that pain scores are recorded and re-assessed.
Regulation: Regulation 12
Should-do action 11 of 27
Should do
Well-led
The trust should ensure that accurate records of staff appraisals are maintained.
Regulation: Regulation 18
Should-do action 12 of 27
Should do
Responsive
The trust should ensure that it continues to implement a full capacity plan and staff are provided with clear guidance for the action to be taken when there are delays for patients to be admitted to a ward.
Regulation: Regulation 17
Should-do action 13 of 27
Should do
Well-led
The trust should ensure that relevant information and learning is shared to the appropriate staff and ensure it is understood.
Regulation: Regulation 17
Should-do action 14 of 27
Should do
Safe
The trust should ensure that they are able to demonstrate that all equipment and premises are properly maintained.
Regulation: Regulation 12
Should-do action 15 of 27
Should do
Safe
Staff should ensure that allergies documented on patient wristbands match those documented on the EPMA system.
Regulation: Regulation 12
Should-do action 16 of 27
Should do
Caring
The service should consider allowing a safe space for families to use whilst visiting and to use for having difficult conversations.
Regulation: Regulation 15
Should-do action 17 of 27
Should do
Safe
The service should ensure that all patients with dementia have their needs assessed and recorded as per policy to allow safe care in the absence of regular staff and the premises are suitable to meet these needs.
Regulation: Regulation 12
Should-do action 18 of 27
Should do
Responsive
The service should ensure that patients referred to specialist doctors from the emergency department are seen in a timely manner.
Regulation: Regulation 12
Should-do action 19 of 27
Should do
Effective
The service should ensure that mental capacity assessments are decision specific to the patient by demonstrating specifically how they were unable to consent.
Regulation: Regulation 11
Should-do action 20 of 27
Should do
Well-led
The service should ensure lessons learnt from incidents are shared with the whole team.
Regulation: Regulation 17
Should-do action 21 of 27
Should do
Well-led
The service should continue working on recruitment and retention of staff.
Regulation: Regulation 18
Should-do action 22 of 27
Should do
Responsive
The service should continue working on optimising hospital flow and taking any necessary steps which are in their control to improve flow.
Regulation: Regulation 12
Should-do action 23 of 27
Should do
Safe
The service should have systems in place to ensure medicines are stored according to manufacturer’s guidance.
Regulation: Regulation 12
Should-do action 24 of 27
Should do
Safe
The service should continue to improve the compliance of mandatory, maternity specific and safeguarding training.
Regulation: Regulation 12
Should-do action 25 of 27
Should do
Well-led
The service should have systems in place to for all staff to receive an annual appraisal.
Regulation: Regulation 18
Should-do action 26 of 27
Should do
Safe
The service should have systems in place to continue to improve the compliance of safety check of specialist equipment.
Regulation: Regulation 15
Should-do action 27 of 27
Should do
Well-led
The service should continue to work on the culture and staff morale within the service.
Regulation: Regulation 17

Location details

CQC ID: RWH01
Local authority: Hertfordshire
Region: East

Inspection report

Type: Location
Date: 3 November 2023
Rating: Requires Improvement
Actions: 17 must-do 27 should-do
AI-extracted 3 Jun 2026

Related PFD reports

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2015-0315 — Lorraine Bird (Aug 2015)