Source · CQC inspection

Bluebell Ward - The Meadows

Provider Stockport NHS Foundation Trust Type NHS Healthcare Organisation Region North West Last inspected 21 Dec 2018

Overall rating: Good  View full CQC report

Domain ratings

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

Earlier inspection findings

pre-2024 framework · 15 must-do 48 should-do

Must-do actions (15)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 15
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.
Regulation: Regulation 5 HSCA (RA) Regulations 2014 Fit and proper persons: directors
⚠ We were concerned regarding some of the systems and processes within the trust. These included the process for assessing whether directors were fit and proper.
Must-do action 2 of 15
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.
Regulation: Regulation 9 HSCA (RA) Regulations 2014 Person-centred care
⚠ Whilst care assessments generally considered the full range of people’s diverse needs, care provided did not consistently reflect the adjustments made particularly in relation to patients with learning disabilities.
Must-do action 3 of 15
Must do
Effective
The trust must ensure that best interests’ decision making is documented within patient records.
Regulation: Regulation 9 HSCA (RA) Regulations 2014 Person-centred care
⚠ In relation to Deprivation of Liberty Safeguards, records were reviewed did not consistently evidence that care was provided in line with patients’ ‘best interests’.
Must-do action 4 of 15
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.
Regulation: Regulation 17 HSCA (RA) Regulations 2014 Good governance
⚠ We were concerned regarding some of the systems and processes within the trust...parts of the governance and risk management systems.
Must-do action 5 of 15
Must do
Well-led
The trust must improve the quality and consistency of serious incident investigations.
Regulation: Regulation 17 HSCA (RA) Regulations 2014 Good governance
⚠ In six out of ten of the serious incidents we reviewed, we noted that there was inconsistency across the template that was used and the trust missed opportunities for learning.
Must-do action 6 of 15
Must do
Safe
The trust must improve performance in prescription of patients’ regular medications.
⚠ Medicines prescribing lacked sufficient pharmacy monitoring on site.
Must-do action 7 of 15
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.
Regulation: Regulation 9 HSCA (RA) Regulations 2014 Person-centred care
⚠ We did not see sufficient evidence in patient’s records to demonstrate that patients restricted under the Deprivation of Liberty Safeguards (DoLS) had an on-going review or assessment of their needs after the initial Deprivation of Liberty Safeguards application had been made.
Must-do action 8 of 15
Must do
Safe
The trust must ensure that equipment is maintained in line with its policies and processes and manufacturers’ guidance.
Regulation: Regulation 15 HSCA (RA) Regulations 2014 Premises and equipment
⚠ Across the trust we were not assured regarding the effectiveness of the system to ensure equipment was maintained and in service. We found out of date items during our core service inspections, which we escalated to the trust.
Must-do action 9 of 15
Must do
Safe
The service must take appropriate actions so that sufficient numbers of trained nursing staff are in place at all times.
Regulation: Regulation 18 HSCA (RA) Regulations 2014 Staffing
⚠ Across urgent and emergency care, maternity and medical services the trust did not have sufficient numbers of trained staff, including support staff.
Must-do action 10 of 15
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.
Regulation: Regulation 9 HSCA (RA) Regulations 2014 Person-centred care
⚠ We did not see sufficient evidence in patient’s records to demonstrate that patients restricted under the Deprivation of Liberty Safeguards (DoLS) had an on-going review or assessment of their needs after the initial Deprivation of Liberty Safeguards application had been made.
Must-do action 11 of 15
Must do
Well-led
The trust must ensure that governance processes are sufficient to mitigate identified clinical risks.
Regulation: Regulation 17 HSCA (RA) Regulations 2014 Good governance
⚠ We were concerned regarding some of the systems and processes within the trust...parts of the governance and risk management systems.
Must-do action 12 of 15
Must do
Safe
The service must ensure that compliance with mandatory training is increased, including safeguarding training, particularly for medical staff.
Regulation: Regulation 18 HSCA (RA) Regulations 2014 Staffing
⚠ The majority of nursing and medical staff had completed their mandatory training. However, the 90% training completion target had not been achieved for several training topics, including conflict resolution, information governance and essentials in end of life care.
Must-do action 13 of 15
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.
Regulation: Regulation 9 HSCA (RA) Regulations 2014 Person-centred care
⚠ We did not see sufficient evidence in patient’s records to demonstrate that patients restricted under the Deprivation of Liberty Safeguards (DoLS) had an on-going review or assessment of their needs after the initial Deprivation of Liberty Safeguards application had been made.
Must-do action 14 of 15
Must do
Well-led
The trust must ensure that governance processes are sufficient to mitigate identified clinical risk.
Regulation: Regulation 17 HSCA (RA) Regulations 2014 Good governance
⚠ In maternity there was improvement in the effective and well-led domains. However, we had concerns regarding patient safety for different reasons than those outlined in our last inspection.
Must-do action 15 of 15
Must do
Safe
The service must ensure that compliance with mandatory training is increased, including safeguarding training, particularly for medical staff.
Regulation: Regulation 18 HSCA (RA) Regulations 2014 Staffing
⚠ The trust had improved their mandatory training levels since our last inspection. However, there was still further work to do. Data received from the trust indicated that training compliance rates for nursing staff did not meet the trust’s target in six areas. For medical staff they did not meet the …

Should-do actions (48)

Recommended improvements to enhance service quality.

Should-do action 1 of 48
Should do
Well-led
The trust should consider developing a documented talent map or succession plan.
Should-do action 2 of 48
Should do
Well-led
The trust should move at pace to implement the medium term financial strategy.
Should-do action 3 of 48
Should do
Responsive
The trust should consider involving patients in the development of the patient experience strategy.
Should-do action 4 of 48
Should do
Well-led
The trust should consider improving the quality of appraisals.
Should-do action 5 of 48
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 48
Should do
Well-led
The trust should consider board level clinical staff sign off of all clinical serious incidents.
Should-do action 7 of 48
Should do
Safe
The trust should consider auditing all areas for medicines reconciliation.
Should-do action 8 of 48
Should do
Well-led
The trust should strengthen performance management arrangements for the business units.
Should-do action 9 of 48
Should do
Well-led
The trust should consider improving governors' understanding of the trust’s strategic direction.
Should-do action 10 of 48
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 48
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 48
Should do
Safe
The services should take appropriate actions so that sufficient numbers of trained nursing staff are in place at all times.
Should-do action 13 of 48
Should do
Effective
The services should 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 48
Should do
Effective
The services should take appropriate actions to improve staff mandatory training and appraisal process compliance.
Should-do action 15 of 48
Should do
Safe
The services should take appropriate actions to improve staff compliance in fluid balance monitoring and the management of patients with sepsis.
Should-do action 16 of 48
Should do
Responsive
The services should take appropriate actions to reduce patient moves to other beds and wards during the night.
Should-do action 17 of 48
Should do
Responsive
The services should 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 48
Should do
Safe
The services should take appropriate actions so that records are maintained for medicines returned to pharmacy for disposal.
Should-do action 19 of 48
Should do
Safe
The services should 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 48
Should do
Safe
The services should monitor room temperature where medicines are stored.
Should-do action 21 of 48
Should do
Safe
The services should ensure that sufficient clinical handwashing facilities are accessible to staff in patient care areas.
Should-do action 22 of 48
Should do
Well-led
The services should ensure that there is senior nurse representation at department of medicine for older people quality board meetings.
Should-do action 23 of 48
Should do
Safe
The services should consider reviewing the security arrangements at Kingsgate House.
Should-do action 24 of 48
Should do
Effective
The services should 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 25 of 48
Should do
Well-led
The services should ensure the crisis response team review their terms of reference and key performance indicators.
Should-do action 26 of 48
Should do
Responsive
The services should improve arrangements for meeting individual patient needs and access to information.
Should-do action 27 of 48
Should do
Responsive
The services should consider reviewing targets for referral to treatment times.
Should-do action 28 of 48
Should do
Effective
The trust should take appropriate actions so that best interest meeting decisions are documented in a standardised and consistent manner.
Should-do action 29 of 48
Should do
Safe
The trust should take appropriate actions so staff can access all mandatory training.
Should-do action 30 of 48
Should do
Safe
The trust should secure patient records at all times.
Should-do action 31 of 48
Should do
Safe
The trust should secure the doors leading to the ward area at all times.
Should-do action 32 of 48
Should do
Responsive
The trust should consider introducing regular engagement with patients and their families to identify areas requiring improvement that will improve care and experience.
Should-do action 33 of 48
Should do
Safe
The trust should take appropriate action to improve the systems and processes in place so equipment that is not maintained is not accessible for use.
Should-do action 34 of 48
Should do
Effective
The trust should take appropriate actions so patients have access to psychiatric support.
Should-do action 35 of 48
Should do
Caring
The trust should take action so that patients have regular access to an activity co-ordinator.
Should-do action 36 of 48
Should do
Effective
The trust should provide appraisals to all members of staff.
Should-do action 37 of 48
Should do
Safe
The trust should consider installing neonatal resuscitation equipment in all birthing areas to prevent separation of mum and baby in an emergency.
Should-do action 38 of 48
Should do
Safe
The trust should 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 39 of 48
Should do
Caring
The trust should consider redesign of the birthing room where the toilet is behind a curtain.
Should-do action 40 of 48
Should do
Effective
The services should ensure patient records evidence capacity and delirium assessments.
Should-do action 41 of 48
Should do
Safe
The services should 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 42 of 48
Should do
Responsive
The services should 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 43 of 48
Should do
Responsive
The services should 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 44 of 48
Should do
Responsive
The services should ensure that plans for a new room for mental health assessments are completed.
Should-do action 45 of 48
Should do
Effective
The services should ensure staff follow national guidance and patient pathways to ensure patients receive treatment that meets best practice.
Should-do action 46 of 48
Should do
Safe
The services should continue to develop the number of substantive medical staff.
Should-do action 47 of 48
Should do
Caring
The services should ensure that privacy and dignity of patients is always maintained.
Should-do action 48 of 48
Should do
Well-led
The services should take action to promote a positive culture within the emergency department.

Location details

CQC ID: RWJ88
Local authority: Stockport
Region: North West

Inspection report

Type: Location
Date: 21 December 2018
Rating: Requires improvement
Actions: 15 must-do 48 should-do
AI-extracted 2 Jun 2026