Source · CQC inspection
Devonshire Centre for Neuro-rehabilitation
Type NHS Healthcare Organisation
Region North West
Last inspected 21 Dec 2018
Overall rating: Good View full CQC report
Domain ratings
Safe
Good
Effective
Requires Improvement
Caring
Good
Responsive
Good
Well-led
Good
Earlier inspection findings
Must-do actions (12)
Must-do action 1 of 12
Must do
Well-led
The trust must ensure that it is fully compliant with the requirements laid out in legislation applicable to fit and proper persons: directors.
Must-do action 2 of 12
Must do
Effective
The trust must ensure that care and treatment meets all individual needs of patients including those with learning disabilities and mental capacity concerns.
Must-do action 3 of 12
Must do
Effective
The trust must ensure that best interests’ decision making is documented within patient records.
Must-do action 4 of 12
Must do
Well-led
The trust must ensure it has systems and processes in place to assess, monitor and mitigate the risks relating to the health, safety and welfare of service users. This includes legacy risks from the previous recording system.
Must-do action 5 of 12
Must do
Well-led
The trust must improve the quality and consistency of serious incident investigations.
Must-do action 6 of 12
Must do
Safe
The trust must improve performance in prescription of patients’ regular medications.
Must-do action 7 of 12
Must do
Effective
The trust must take appropriate actions to ensure patients restricted under the Deprivation of Liberty Safeguards receive an on-going review or assessment of their needs.
Must-do action 8 of 12
Must do
Safe
The trust must ensure that equipment is maintained in line with its policies and processes and manufacturers’ guidance.
Must-do action 9 of 12
Must do
Safe
The service must take appropriate actions so that sufficient numbers of trained nursing staff are in place at all times.
Must-do action 10 of 12
Must do
Effective
The service must take appropriate actions so that patients restricted under the Deprivation of Liberty Safeguards receive an on-going review or assessment of their needs.
Must-do action 11 of 12
Must do
Well-led
The trust must ensure that governance processes are sufficient to mitigate identified clinical risks.
Must-do action 12 of 12
Must do
Safe
The service must ensure that compliance with mandatory training is increased, including safeguarding training, particularly for medical staff.
Should-do actions (45)
Should-do action 1 of 45
Should do
Well-led
The trust should consider developing a documented talent map or succession plan.
Should-do action 2 of 45
Should do
Well-led
The trust should move at pace to implement the medium term financial strategy.
Should-do action 3 of 45
Should do
Responsive
The trust should consider involving patients in the development of the patient experience strategy.
Should-do action 4 of 45
Should do
Well-led
The trust should consider improving the quality of appraisals.
Should-do action 5 of 45
Should do
Well-led
The trust should consider embracing the spirit of duty of candour in all applicable incident investigations.
Should-do action 6 of 45
Should do
Well-led
The trust should consider board level clinical staff sign off of all clinical serious incidents.
Should-do action 7 of 45
Should do
Safe
The trust should consider auditing all areas for medicines reconciliation.
Should-do action 8 of 45
Should do
Well-led
The trust should strengthen performance management arrangements for the business units.
Should-do action 9 of 45
Should do
Well-led
The trust should consider improving governors' understanding of the trust’s strategic direction.
Should-do action 10 of 45
Should do
Safe
The trust should ensure the ambient temperature of the medicines storage room is monitored to make sure medicines are stored within their accepted temperature range.
Should-do action 11 of 45
Should do
Effective
The trust should take appropriate actions so that staff competency records are reviewed, maintained and kept up to date.
Should-do action 12 of 45
Should do
Safe
The serviceshould take appropriate actions so that sufficient numbers of trained nursing staff are in place at all times.
Should-do action 13 of 45
Should do
Effective
The serviceshould take appropriate actions so that acute non-invasive ventilation patients receive care and treatment in line with British Thoracic Society (BTS) Quality Standards.
Should-do action 14 of 45
Should do
Effective
The serviceshould take appropriate actions to improve staff mandatory training and appraisal process compliance.
Should-do action 15 of 45
Should do
Safe
The serviceshould take appropriate actions to improve staff compliance in fluid balance monitoring and the management of patients with sepsis.
Should-do action 16 of 45
Should do
Responsive
The serviceshould take appropriate actions to reduce patient moves to other beds and wards during the night.
Should-do action 17 of 45
Should do
Responsive
The serviceshould take appropriate actions to improve the average length of patient stay for non-elective patients in geriatric medicine and cardiology specialties.
Should-do action 18 of 45
Should do
Safe
The serviceshould take appropriate actions so that records are maintained for medicines returned to pharmacy for disposal.
Should-do action 19 of 45
Should do
Safe
The serviceshould ensure there is sufficient pharmacy oversight of prescribing on site, including lithium blood level monitoring, timing of administration for pre-food medications and allergy recording on hard copy medication records.
Should-do action 20 of 45
Should do
Safe
The serviceshould ensure that sufficient clinical handwashing facilities are accessible to staff in patient care areas.
Should-do action 21 of 45
Should do
Well-led
The serviceshould ensure that there is senior nurse representation at department of medicine for older people quality board meetings.
Should-do action 22 of 45
Should do
Safe
The serviceshould consider reviewing the security arrangements at Kingsgate House.
Should-do action 23 of 45
Should do
Effective
The serviceshould ensure that the crisis response team carry out the expected nursing assessments based on the acuity and referral criteria of the patient.
Should-do action 24 of 45
Should do
Well-led
The serviceshould ensure the crisis response team review their terms of reference and key performance indicators.
Should-do action 25 of 45
Should do
Responsive
The serviceshould improve arrangements for meeting individual patient needs and access to information.
Should-do action 26 of 45
Should do
Responsive
The serviceshould consider reviewing targets for referral to treatment times.
Should-do action 27 of 45
Should do
Safe
The serviceshould take appropriate actionsostaff can access all mandatory training.
Should-do action 28 of 45
Should do
Safe
The serviceshould secure patient records at all times.
Should-do action 29 of 45
Should do
Safe
The serviceshould secure the doors leading to the ward area at all times.
Should-do action 30 of 45
Should do
Responsive
The serviceshould consider introducing regular engagement with patients and their families to identify areas requiring improvement that will improve care and experience.
Should-do action 31 of 45
Should do
Effective
The serviceshould take appropriate actionsopatients have access to psychiatric support.
Should-do action 32 of 45
Should do
Caring
The serviceshould take action sothat patients have regular access to an activity co-ordinator.
Should-do action 33 of 45
Should do
Well-led
The serviceshould provide appraisals to all members of staff.
Should-do action 34 of 45
Should do
Safe
The serviceshould consider installing neonatal resuscitation equipment in all birthing areas to prevent separation of mum and baby in an emergency.
Should-do action 35 of 45
Should do
Safe
The serviceshould continue to work towards staffing the unit to full establishment for the safety of women and babies, to improve the access and flow for women and to optimise their choices of place of birth.
Should-do action 36 of 45
Should do
Caring
The serviceshould consider redesign of the birthing room where the toilet is behind a curtain.
Should-do action 37 of 45
Should do
Effective
The serviceshould ensure patient records evidence capacity and delirium assessments.
Should-do action 38 of 45
Should do
Safe
The serviceshould ensure a review of the staffing model in the paediatric department is completed to ensure staffing complies with the Royal College of Paediatrics and Children’s Health standards.
Should-do action 39 of 45
Should do
Responsive
The serviceshould ensure that patients receive care in a timely way and work towards improving performance against national standards such as the time from arrival to treatment and median total time in the department.
Should-do action 40 of 45
Should do
Responsive
The serviceshould ensure that all patients receive an initial assessment within 15 minutes of arrival, in line with the Royal College of Emergency Medicine standards.
Should-do action 41 of 45
Should do
Responsive
The serviceshould ensure that plans for a new room for mental health assessments are completed.
Should-do action 42 of 45
Should do
Effective
The serviceshould ensure staff follow national guidance and patient pathways to ensure patients receive treatment that meets best practice.
Should-do action 43 of 45
Should do
Safe
The serviceshould continue to develop the number of substantive medical staff.
Should-do action 44 of 45
Should do
Caring
The serviceshould ensure that privacy and dignity of patients is always maintained.
Should-do action 45 of 45
Should do
Well-led
The serviceshould take action to promote a positive culture within the emergency department.