Source · CQC inspection
Kidderminster Hospital and Treatment Centre
Provider Worcestershire Acute Hospitals NHS Trust
Type NHS Healthcare Organisation
Region West Midlands
Last inspected 10 Feb 2025
Overall rating: Good View full CQC report
Domain ratings
Safe
Good
Effective
Good
Caring
Good
Responsive
Requires Improvement
Well-led
Good
Current CQC assessment
Good
The service is performing well and meeting our expectations.
Ratings by service
Services for children & young people
Good
Earlier inspection findings
Must-do actions (39)
Must-do action 1 of 39
Must do
Safe
The trust must ensure staff receive mandatory training in accordance with trust policies.
Must-do action 2 of 39
Must do
Safe
The trust must ensure patients have their clinical needs assessed and care delivered in accordance with national best practice standards, and within nationally defined timescales.
Must-do action 3 of 39
Must do
Safe
The trust must ensure the environment is suitable and fit for purpose.
Must-do action 4 of 39
Must do
Safe
The trust must ensure speciality doctors review their patients within defined timescales to reduce the occurrence of breaches associated with delayed speciality reviews.
Must-do action 5 of 39
Must do
Safe
The trust must ensure there are sufficient medical staff working in the ED to meet patient needs.
Must-do action 6 of 39
Must do
Safe
The trust must ensure that all medical staff complete the required mandatory training including safeguarding children and adults training to a level appropriate for their role.
Must-do action 7 of 39
Must do
Safe
The trust must ensure that the Sepsis Six bundle is completed within recommended timescales for all relevant patients.
Must-do action 8 of 39
Must do
Safe
The trust must ensure that all assigned mortality reviews are completed within the 30-day target.
Must-do action 9 of 39
Must do
Safe
Ensure all surgical staff complete mandatory training including safeguarding training.
Must-do action 10 of 39
Must do
Safe
Ensure surgery is only undertaken when compliance with World Health Organisation ‘Five steps to safer surgery’ including brief and debrief and peri-operative safety checks are completed.
Must-do action 11 of 39
Must do
Responsive
Improve the performance for cancer patients receiving their first treatment within 62 days of an urgent GP referral, to be in line with national averages and operational standards.
Must-do action 12 of 39
Must do
Responsive
Improve performance against 18-week referral to treatment times, with the aim of meeting operational standards.
Must-do action 13 of 39
Must do
Safe
Ensure staff are compliant with trust targets for safeguarding training.
Must-do action 14 of 39
Must do
Safe
Ensure that all staff receive and complete their required mandatory training and safeguarding and MCA/DoLS training compliance for medical staff is in line with trust targets.
Must-do action 15 of 39
Must do
Safe
The trust must ensure that ambulance handovers are timely and effective and that all patients are assessed in a timely manner. The trust must ensure that patients receive medical and speciality reviews in a timely manner.
Must-do action 16 of 39
Must do
Safe
The trust must ensure that consultant cover in the department meets national guidelines and there are always adequate numbers of suitably qualified nurses.
Must-do action 17 of 39
Must do
Safe
The service must ensure that immediate life support and paediatric immediate life support training compliance is in line with trust targets.
Must-do action 18 of 39
Must do
Safe
The service must ensure that staff are compliant with hand hygiene and personal protective equipment guidelines.
Must-do action 19 of 39
Must do
Safe
The service must ensure that patients are assessed and treated in appropriate environments.
Must-do action 20 of 39
Must do
Well-led
The service must report all instances where it is not possible to separate male and female patients in the emergency decision unit as a mixed sex breach, in line with regulations.
Must-do action 21 of 39
Must do
Well-led
The service must ensure that information technology systems which record private and confidential patient information are not visible to patients, visitors and unauthorised personnel.
Must-do action 22 of 39
Must do
Safe
The service must ensure a formal competency framework for looking after children is rolled out and completed by all nurses working in the department.
Must-do action 23 of 39
Must do
Safe
The service must ensure doctors working in the ED complete their Mental Capacity Act training at a level appropriate to their role.
Must-do action 24 of 39
Must do
Safe
The trust must ensure that all staff complete the required mandatory training including safeguarding, mental capacity act and Deprivation of Liberty Safeguards.
Must-do action 25 of 39
Must do
Safe
The trust must ensure that the sepsis six bundle is completed within the recommended timescale for all relevant patients.
Must-do action 26 of 39
Must do
Safe
The trust must ensure that all assigned mortality reviews are completed within the 30-day target.
Must-do action 27 of 39
Must do
Safe
Ensure all surgical staff complete mandatory training including safeguarding training.
Must-do action 28 of 39
Must do
Responsive
Improve performance against 18-week referral to treatment times, with the aim of meeting operational standards.
Must-do action 29 of 39
Must do
Responsive
Improve performance against the national cancer standards for patients on 2 week waits and patients waiting less than 62 days for treatment.
Must-do action 30 of 39
Must do
Safe
Ensure MRI protocols reflect the nature of the service and the needs of patients and reduce the risk of delays.
Must-do action 31 of 39
Must do
Safe
Ensure all patients receive a timely initial clinical assessment to identify patients arriving with serious injuries and illnesses.
Must-do action 32 of 39
Must do
Safe
Ensure an evidenced-based review of the nursing establishment (including skill-mix) is carried out to ensure there are sufficient staff with the right skills and experience to meet the needs of patients who attend the minor injuries unit.
Must-do action 33 of 39
Must do
Well-led
Ensure governance processes include reviews of clinical guidelines to ensure that they follow current best practice.
Must-do action 34 of 39
Must do
Responsive
Improve performance against 18-week referral to treatment times, with the aim of meeting operational standards.
Must-do action 35 of 39
Must do
Responsive
Improve performance against the national cancer standards for patients on 2 week waits and patients waiting less than 62 days for treatment.
Must-do action 36 of 39
Must do
Safe
Ensure staff adhere to surgical safety checks prior to, during and following surgical procedures.
Must-do action 37 of 39
Must do
Safe
Improve the content of operating list information, to ensure that all pertinent information is recorded.
Must-do action 38 of 39
Must do
Safe
Ensure all staff adhere to infection prevention and control best practice.
Must-do action 39 of 39
Must do
Safe
Ensure surgical staff complete mandatory training.
Should-do actions (127)
Should-do action 1 of 127
Should do
Safe
Review levels of safeguarding children’s’ training required for all groups of staff and take steps to ensure all staff complete it.
Should-do action 2 of 127
Should do
Well-led
Monitor that all staff receive an annual appraisal.
Should-do action 3 of 127
Should do
Safe
The trust should ensure that staff complete the level 2 training about infection prevention and control (IPC) and hand hygiene.
Should-do action 4 of 127
Should do
Safe
The trust should ensure medical staff complete medicines’ management training.
Should-do action 5 of 127
Should do
Effective
The trust should ensure all staff complete and Mental Capacity Act and Deprivation of Liberty Safeguards to a level appropriate to their role.
Should-do action 6 of 127
Should do
Safe
The trust should ensure that venous thromboembolism (VTE) assessments are repeated for all identified patients after 24 hours.
Should-do action 7 of 127
Should do
Responsive
The trust should ensure systems support the tracking of and response to specialist referrals across the sites.
Should-do action 8 of 127
Should do
Safe
The trust should ensure that medicines are stored in their original containers.
Should-do action 9 of 127
Should do
Safe
The trust should review the medicines policy in line with new guidance: The Safe and Secure Handling of Medicines Guidance published by the Royal Pharmaceutical Society (RPS) December 2018.
Should-do action 10 of 127
Should do
Effective
The trust should ensure that dietitians’ and speech and language therapists’ dietary advice and recommendations are followed, and that electronic discharge summaries contain correct dietary information.
Should-do action 11 of 127
Should do
Effective
The trust should ensure that it reduces the HSMR mortality rate so that it is in line with the England figure.
Should-do action 12 of 127
Should do
Effective
The trust should ensure it improves patient outcomes in the 2018/9 Sentinel Stroke National Audit Programme (SSNAP); the National Lung Cancer Audit 2017; the Chronic Obstructive Pulmonary Disease Audit October 2017 to March 2018.
Should-do action 13 of 127
Should do
Responsive
The trust should ensure that patients are reviewed by a specialist consultant within 14 hours.
Should-do action 14 of 127
Should do
Caring
The trust should ensure that boarded patients always have their dignity maintained.
Should-do action 15 of 127
Should do
Caring
The trust should ensure that it has processes and procedures in place to increase the response rate for the Friends and Family Test response within the medicines service.
Should-do action 16 of 127
Should do
Responsive
The trust should ensure that patients can access services when required and improve patient flow across the hospital. For example, within the ambulatory emergency care unit, and acute stroke unit.
Should-do action 17 of 127
Should do
Safe
The trust should ensure there are enough acute occupational therapists to provide the right care and treatment at the right time.
Should-do action 18 of 127
Should do
Effective
The trust should ensure that all patients are ‘clerked’ in line with policies and procedures.
Should-do action 19 of 127
Should do
Responsive
The trust should ensure there are processes in place to manage the backlog within the endoscopy service.
Should-do action 20 of 127
Should do
Well-led
The trust should ensure that the divisional risk register has fields showing the evidence of the outcomes, what mitigation actions had been completed, and if the risk had reduced or increased.
Should-do action 21 of 127
Should do
Responsive
Continue with plans to improve performance in line with national referral to treatment times.
Should-do action 22 of 127
Should do
Effective
Improve the percentage of staff receiving training in the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards.
Should-do action 23 of 127
Should do
Responsive
Ensure that all patients who have their surgery cancelled are rebooked within 28 days.
Should-do action 24 of 127
Should do
Safe
Improve response times and the documentation of response times when patients deteriorate.
Should-do action 25 of 127
Should do
Safe
Further improve completion of VTE risk assessments and re-assessments.
Should-do action 26 of 127
Should do
Effective
Monitor pain assessments and effectiveness of pain relief.
Should-do action 27 of 127
Should do
Safe
Improve antibiotic stewardship.
Should-do action 28 of 127
Should do
Safe
Ensure all patients are cared for in a suitable environment.
Should-do action 29 of 127
Should do
Well-led
Improve the management and documentation of risks to the service.
Should-do action 30 of 127
Should do
Caring
Continue to monitor and review mixed sex breaches.
Should-do action 31 of 127
Should do
Safe
Improve the documentation of medical device training.
Should-do action 32 of 127
Should do
Safe
Clarify the mandatory training (including preventing radicalisation) requirements for medical staff in children’s services.
Should-do action 33 of 127
Should do
Caring
Improve the Friends and Family Test response rate on Riverbank ward and the children’s outpatient department.
Should-do action 34 of 127
Should do
Responsive
Continue to Improve the monitoring of delays in the CAMHS pathway.
Should-do action 35 of 127
Should do
Responsive
Improve the monitoring of assessment times in the PAU.
Should-do action 36 of 127
Should do
Effective
Improve compliance rates of electronic discharge summaries on Riverbank ward.
Should-do action 37 of 127
Should do
Safe
Improve the accuracy of the medical equipment asset database on Riverbank ward.
Should-do action 38 of 127
Should do
Well-led
Monitor the impact of changes to the neonatal tariff (income) on the provision of children’s services.
Should-do action 39 of 127
Should do
Well-led
Monitor the impact of delays by information technology systems for cancer and diabetes services.
Should-do action 40 of 127
Should do
Effective
Improve compliance with ‘Facing the Future’ standards to ensure all children are seen within 14 hours of admission by a consultant.
Should-do action 41 of 127
Should do
Responsive
Continue to improve referral to treatment performance across all specialties.
Should-do action 42 of 127
Should do
Safe
Monitor that World Health Organisation checklists are used for all invasive procedures, in all areas, including those undertaken outside of operating theatres.
Should-do action 43 of 127
Should do
Safe
Ensure that disposable curtains are used in all clinical areas to prevent the risk of infection due to cross contamination.
Should-do action 44 of 127
Should do
Safe
Review timescales for the development and implementation of local safety standards for invasive procedures and ensure that these are in place without further delay.
Should-do action 45 of 127
Should do
Well-led
Monitor that there is effective local leadership and leadership support available in all outpatient departments.
Should-do action 46 of 127
Should do
Well-led
Develop processes to ensure that cross division feedback and learning can be shared following the reporting of incidents in the outpatient department, which are investigated by different divisions.
Should-do action 47 of 127
Should do
Well-led
Monitor that all staff have an annual appraisal.
Should-do action 48 of 127
Should do
Effective
Seek to provide opportunities for staff to develop areas of clinical expertise within the outpatients service.
Should-do action 49 of 127
Should do
Caring
Make training available to all staff specific to understanding the additional needs of people with mental health conditions, a learning disability, autism or dementia.
Should-do action 50 of 127
Should do
Caring
Ensure that private clinical consultations space is available in all areas for staff to discuss confidential information with patients.
Should-do action 51 of 127
Should do
Responsive
Make available to patients copies of clinic letters and discharge letters sent by consultants to a patient’s GP.
Should-do action 52 of 127
Should do
Effective
Collect quality audit data, such as clinic wait times, in order to monitor the effectiveness of care and treatment and use these findings to achieve good patient outcomes.
Should-do action 53 of 127
Should do
Well-led
Develop systems for more joined up working across divisions to monitor and share referral to treatment time information and manage service capacity and demand.
Should-do action 54 of 127
Should do
Safe
Ensure that ultrasound equipment is cleaned using appropriate methods and continue working towards best practice high level decontamination procedures.
Should-do action 55 of 127
Should do
Safe
Ensure that all staff follow and use The Society of Radiographers “pause and check” system.
Should-do action 56 of 127
Should do
Safe
Review the out of hours cover for CT radiographers.
Should-do action 57 of 127
Should do
Well-led
Ensure the service continues to work towards the ISAS accreditation scheme, and that robust plans including defined timescales are in place to support delivery.
Should-do action 58 of 127
Should do
Safe
Ensure maintenance and replacement plans for equipment are in place.
Should-do action 59 of 127
Should do
Caring
Ensure that where possible, all patients required to wear hospital gowns are provided with sufficient privacy to prevent them being observed by a member of the opposite sex.
Should-do action 60 of 127
Should do
Safe
The serviceshould ensure that all emergency equipment checks are done in line with trust policy and that all staff are aware of local checking procedures.
Should-do action 61 of 127
Should do
Caring
The serviceshould review methods of gaining patient feedback and improve their response rates.
Should-do action 62 of 127
Should do
Responsive
The serviceshould display current waiting times in the waiting room.
Should-do action 63 of 127
Should do
Safe
The serviceshould review the practical skills required of an ED nurse, and ensure training is provided. The service should ensure all staff complete competency frameworks appropriate to their role and that they have documented evidence of their skills. This should include competencies relevant for all nurses who work in the resuscitation bay.
Should-do action 64 of 127
Should do
Effective
The serviceshould consider implementing an electronic notes system.
Should-do action 65 of 127
Should do
Well-led
The serviceshould ensure its plans for a re-design are fully implemented to improve patient care and experience.
Should-do action 66 of 127
Should do
Safe
The trust should ensure that staff complete the level 2 training about infection prevention and control (IPC) and hand hygiene.
Should-do action 67 of 127
Should do
Safe
The trust should ensure that prescribed medicines have the doctors name and GMC registration printed to recognise who was responsible for the prescribing.
Should-do action 68 of 127
Should do
Effective
The trust should ensure that it reduces the HSMR mortality rate so that it is in line with the England figure.
Should-do action 69 of 127
Should do
Well-led
The trust should ensure that medical staff complete their professional appraisal rate.
Should-do action 70 of 127
Should do
Caring
The trust should ensure that the medicine service reviews the response rate for the friends and family test.
Should-do action 71 of 127
Should do
Responsive
The trust should ensure that patients are assessed by a consultant within 14 hours of admission.
Should-do action 72 of 127
Should do
Caring
The trust should ensure that it has processes and procedures in place to increase the response rate for the Friends and Family Test response within the medicines service.
Should-do action 73 of 127
Should do
Well-led
The trust should ensure that the divisional risk register has fields showing the evidence of the outcomes, what mitigation actions had been completed, and if the risk had reduced or increased.
Should-do action 74 of 127
Should do
Responsive
The trust should ensure that there are processes in place to document the actions taken regarding the home first action plans’ length of stay.
Should-do action 75 of 127
Should do
Responsive
The trust should ensure there are processes in place to manage the backlog within the endoscopy service.
Should-do action 76 of 127
Should do
Responsive
Continue with plans to improve performance in line with national referral to treatment times.
Should-do action 77 of 127
Should do
Responsive
Ensure that all patients who have theirs surgery cancelled are rebooked within 28 days.
Should-do action 78 of 127
Should do
Safe
Personal protective equipment should be worn in line with recommended infection prevention guidance.
Should-do action 79 of 127
Should do
Safe
All do not attempt cardiopulmonary resuscitation (DNAR CPR) records should be reviewed on admission within the surgical service when transferred from the community services.
Should-do action 80 of 127
Should do
Effective
Patients should receive physiotherapy during out of hours if required.
Should-do action 81 of 127
Should do
Well-led
The senior management team should ensure that all staff within the surgical service at the Alexandra hospital are aware of proposed refurbishment and ward changes.
Should-do action 82 of 127
Should do
Safe
All medical staff should receive a robust induction process.
Should-do action 83 of 127
Should do
Safe
Improve the documentation of medical device training.
Should-do action 84 of 127
Should do
Effective
Monitor turnaround times for clinic letters to be issued to GPs to ensure national standards are met.
Should-do action 85 of 127
Should do
Effective
Monitor that participation with the national ophthalmology audit database (NOD) participation takes place.
Should-do action 86 of 127
Should do
Caring
Review how patients’ privacy is protected in the phlebotomy department.
Should-do action 87 of 127
Should do
Responsive
Monitor clinic waiting times are audited so areas of concern can be identified, and actions taken to improve performance.
Should-do action 88 of 127
Should do
Responsive
Consider establishing a process for the routine review of patients waiting over 18 weeks from referral to treatment in order for staff to monitor and manage any risks to patients.
Should-do action 89 of 127
Should do
Safe
Implement more robust staffing models for radiology specialties and CT radiographers to improve service reliability.
Should-do action 90 of 127
Should do
Safe
Ensure all staff have up to date, relevant, resuscitation training.
Should-do action 91 of 127
Should do
Safe
Review plans for equipment replacement in line with incident reports and service disruption.
Should-do action 92 of 127
Should do
Safe
Ensure there is sufficient quantities of serviceable, fully accessible resuscitation equipment in all diagnostics areas.
Should-do action 93 of 127
Should do
Effective
Identify opportunities for staff to develop, including through access to training.
Should-do action 94 of 127
Should do
Safe
Support staff to report incidents consistently.
Should-do action 95 of 127
Should do
Safe
Establish assurance that staff knowledge and understanding of resuscitation practices are consistent with the rest of the hospital and review the availability of resuscitation equipment in all areas.
Should-do action 96 of 127
Should do
Effective
Support staff to undertake audits that enhance their work and provide opportunities for service improvement and development.
Should-do action 97 of 127
Should do
Well-led
Establish more robust, consistent lines of communication between senior directorate staff and the team based in hospital services.
Should-do action 98 of 127
Should do
Well-led
Provide all staff with engagement opportunities with senior directorate and trust teams.
Should-do action 99 of 127
Should do
Safe
Facilitate access to rapid repairs and maintenance to failed equipment to ensure safety and continuity of the service.
Should-do action 100 of 127
Should do
Well-led
Implement systems that ensure concerns and incidents raised by non-clinical staff are addressed.
Should-do action 101 of 127
Should do
Effective
Provide staff with opportunities for cross-site training and learning.
Should-do action 102 of 127
Should do
Effective
All patients are assessed and monitored for pain and that timely pain relief is administered.
Should-do action 103 of 127
Should do
Well-led
The management structure produces leaders with the capacity and capability to identify issues and priorities in the minor injuries unit and to act upon them.
Should-do action 104 of 127
Should do
Well-led
The needs of patients with minor injuries are included in the new strategy for the urgent care division.
Should-do action 105 of 127
Should do
Well-led
Staff have the opportunity to discuss learning from incidents and audits at regular staff meetings.
Should-do action 106 of 127
Should do
Safe
Review the provision of the changing room facilities in endoscopy which were not appropriate as they contained the only staff toilet in the department.
Should-do action 107 of 127
Should do
Effective
The service should continue working towards achieving Joint Advisory Group (JAG) accreditation.
Should-do action 108 of 127
Should do
Effective
Improve staff knowledge of audit and performance related to audit within endoscopy which was variable.
Should-do action 109 of 127
Should do
Responsive
Improve patients accessing endoscopy services in a timely way.
Should-do action 110 of 127
Should do
Safe
Improve compliance with five steps to safer surgery including the brief and debrief.
Should-do action 111 of 127
Should do
Responsive
Continue with plans to improve performance with the national referral to treatment targets.
Should-do action 112 of 127
Should do
Effective
Ensure that all staff complete Mental Capacity Act training.
Should-do action 113 of 127
Should do
Safe
Ensure medicine charts are audited to include missed doses.
Should-do action 114 of 127
Should do
Safe
Ensure that there is evidence of staff medical device training
Should-do action 115 of 127
Should do
Safe
Ensure that all admission letters for elective patients ask them to highlight if they have been an inpatient in hospital within the last 12 months.
Should-do action 116 of 127
Should do
Responsive
Ensure that all patients who have their surgery cancelled are rebooked within 28 days.
Should-do action 117 of 127
Should do
Well-led
Review how the service fed quality information into the division and how shared learning was identified.
Should-do action 118 of 127
Should do
Safe
The trust should review the alerts system on their electronic record system to ensure that erroneous blank alerts are not flagged.
Should-do action 119 of 127
Should do
Well-led
The trust should consider reporting incidents under the outpatients’ department for delayed or overbooked clinics, as opposed to just reporting them under the medical specialty of the clinic.
Should-do action 120 of 127
Should do
Well-led
The trust should ensure all staff know how to access the policies they need for their work.
Should-do action 121 of 127
Should do
Effective
The trust should consider participating in the Improving Quality in Physiological Services scheme.
Should-do action 122 of 127
Should do
Caring
The trust should review its patient information leaflets regularly.
Should-do action 123 of 127
Should do
Responsive
The trust should consider the timing of outpatient clinics when staff need to travel to different sites.
Should-do action 124 of 127
Should do
Well-led
The trust should consider breaking down data to site level, so that leaders could identify any outliers or risks at specific sites.
Should-do action 125 of 127
Should do
Responsive
Continue with plans to improve performance in line with national referral to treatment times.
Should-do action 126 of 127
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 127 of 127
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.