Source · CQC inspection
Halton Hospital
Provider North Cheshire and Mersey NHS Foundation Trust
Type NHS Healthcare Organisation
Region North West
Last inspected 24 Jul 2019
Overall rating: Good View full CQC report
Domain ratings
Safe
Good
Effective
Good
Caring
Good
Responsive
Good
Well-led
Good
Earlier inspection findings
Should-do actions (31)
Should-do action 1 of 31
Should do
Well-led
The trust should review the fit and proper persons processes so all the required information is retained for all directors
Should-do action 2 of 31
Should do
Well-led
The trust should consider how it records the delivery plans for the enabling strategies
Should-do action 3 of 31
Should do
Responsive
The trust should review the progress of the implementation of strategies for patients living with dementia and with a learning disability and consider the implementation of a strategy for patients with mental health needs.
Should-do action 4 of 31
Should do
Well-led
The trust should continue to review the plans to achieve financial sustainability and the action required to deliver financial plan for 2019-20.
Should-do action 5 of 31
Should do
Well-led
The trust should review the information reported in the finance report to consider including remedial action on the financial position, risk-based forecasting and the level of recurrent cost improvement plans.
Should-do action 6 of 31
Should do
Safe
The trust should review the processes for identifying, reporting and investigation of missed doses for critical medicines across the trust.
Should-do action 7 of 31
Should do
Safe
The trust should consider further development and investment in systems to improve medicines reconciliation rates across the trust.
Should-do action 8 of 31
Should do
Safe
The trust should review the root cause analysis form for serious incidents to consider how information about safeguarding, capacity, patient involvement is included.
Should-do action 9 of 31
Should do
Well-led
The trust should review the process for senior clinician input into structured judgement reviews.
Should-do action 10 of 31
Should do
Safe
The trust should continue to monitor staffing levels and follow escalation plans to ensure levels of nursing and medical staffing are sufficient to provide safe care and treatment.
Should-do action 11 of 31
Should do
Safe
The trust should review systems for medicines management regarding missed doses of medications.
Should-do action 12 of 31
Should do
Effective
The trust should continue to monitor audit performance to identify further potential improvements.
Should-do action 13 of 31
Should do
Effective
The trust should continue to sustain improvement and practice in application of capacity assessment and application of Deprivation of Liberty Safeguards where required.
Should-do action 14 of 31
Should do
Responsive
The trust should continue work to reduce delays in patient discharges where possible.
Should-do action 15 of 31
Should do
Safe
The trust should consider needs such as safeguarding and deprivation of liberty are highlighted.
Should-do action 16 of 31
Should do
Safe
The trust should make sure that all care plans in paper records are filled in consistently.
Should-do action 17 of 31
Should do
Safe
The trust should review the monitoring of expiry dates of sepsis bags.
Should-do action 18 of 31
Should do
Effective
The trust should ensure that mental capacity assessments and best interest decisions are recorded consistently in records.
Should-do action 19 of 31
Should do
Effective
The trust should continue to look at ways to reduce the risk of readmission for elective admissions.
Should-do action 20 of 31
Should do
Effective
The trust should continue to look at ways to improve outcomes on the national hip fracture database.
Should-do action 21 of 31
Should do
Safe
The trust should consider increasing the number of isolation rooms with negative and positive ventilation, in accordance with Department of Health guidelines.
Should-do action 22 of 31
Should do
Safe
The trust review the process for fridge checks so they are completed daily, in line with the trust’s medicines management policy.
Should-do action 23 of 31
Should do
Responsive
The trust should continue to review the number and occurrence of patients nursed in a recovery area while they await a critical care bed.
Should-do action 24 of 31
Should do
Safe
The trust should ensure that all midwives complete adult safeguarding training level three.
Should-do action 25 of 31
Should do
Safe
The trust should review the availability of nets in case of a pool evacuation.
Should-do action 26 of 31
Should do
Safe
The trust should ensure that controlled drugs are stored securely at all times in theatres.
Should-do action 27 of 31
Should do
Safe
The trust should review the levels of safeguarding training with reference to the intercollegiate documents on safeguarding.
Should-do action 28 of 31
Should do
Safe
The trust should review the process for monitoring consumables so they remain in date and fit for use.
Should-do action 29 of 31
Should do
Safe
The trust should review the process for monitoring maintenance of patient trolleys.
Should-do action 30 of 31
Should do
Safe
The trust should continue the work around safer surgery and the pre-operative briefing and documentation.
Should-do action 31 of 31
Should do
Safe
The trust should review the training available for staff on updating patients’ risk assessment records.