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Evesham Community Hospital

Provider Worcestershire Acute Hospitals NHS Trust Type NHS Healthcare Organisation Region West Midlands Last inspected 20 Sep 2019

Location rating: Requires Improvement  View location on CQC

Location ratings by domain

Five CQC key questions

Ratings held for this CQC location under the inspection framework, last inspected 20 September 2019. Ratings extracted from individual reports are shown separately below.

Safe
Requires Improvement
Effective
Good
Caring
Good
Responsive
Requires Improvement
Well-led
Requires Improvement

Most recent report indexed for actions

The date and rating here are from an individual report, not necessarily the location's latest assessment. Report ratings are extracted with AI; verify the original PDF.

Type: Location
Date: 20 September 2019
Rating extracted from this report: Requires improvement
Actions indexed: 4 must-do 3 should-do

Read this inspection PDF

AI-extracted 3 Jun 2026

Earlier inspection findings

pre-2024 framework · 4 must-do 3 should-do

Must-do actions (4)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 4
Must do
Safe
Ensure staff adhere to surgical safety checks prior to, during and following surgical procedures.
Regulation: Regulation 12(1)(2)a)
⚠ Safety checks in theatre were not always followed, increasing the risk of patient harm. We found variable compliance with the WHO checklist. There were also changes to the theatre list during the list, some inadequacies and inaccuracies in the content of an operating list and failure to adhere to national …
Must-do action 2 of 4
Must do
Safe
Improve the content of operating list information, to ensure that all pertinent information is recorded.
Regulation: Regulation 12(1)(2)(a)
⚠ There were some inadequacies and inaccuracies in the content of an operating list.
Must-do action 3 of 4
Must do
Safe
Ensure all staff adhere to infection prevention and control best practice.
Regulation: Regulation 12(1)(2)(h)
⚠ Infection risk was not always controlled well. We observed poor compliance with infection prevention and control measures in theatres on the first day of our inspection.
Must-do action 4 of 4
Must do
Safe
Ensure surgical staff complete mandatory training.
Regulation: Regulation 18(2)
⚠ The percentage of medical staff completing mandatory training was lower than trust targets, and safeguarding training completion rates for medical staff did not meet the trust target of 90%.

Should-do actions (3)

Recommended improvements to enhance service quality.

Should-do action 1 of 3
Should do
Responsive
Continue with plans to improve performance in line with national referral to treatment times.
Should-do action 2 of 3
Should do
Safe
Review the use of the procedures room in the clinical intervention unit and ensure all invasive procedures are completed in a suitable environment.
Should-do action 3 of 3
Should do
Well-led
Review governance processes at Evesham Community hospital; systematically review risks to the service and ensure the risk register includes the risks, actions to control risks and a timescale for review/resolution.