Source · CQC inspection

Evesham Community Hospital

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

Overall rating: Requires Improvement View full CQC report

Domain ratings

Five CQC key questions

Safe

Requires Improvement

Effective

Good

Caring

Good

Responsive

Requires Improvement

Well-led

Requires Improvement

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.