Source · CQC inspection
Chorley and South Ribble Hospital
Type NHS Healthcare Organisation
Region North West
Last inspected 24 Nov 2023
Overall rating: Requires Improvement View full CQC report
Domain ratings
Safe
Requires Improvement
Effective
Good
Caring
Good
Responsive
Requires Improvement
Well-led
Good
Earlier inspection findings
Must-do actions (18)
Must-do action 1 of 18
Must do
Well-led
The trust must ensure staff complete mandatory training in accordance with the relevant schedule and receive sufficient training, supervision, and appraisal to perform their duties competently.
Must-do action 2 of 18
Must do
Well-led
The trust must ensure that medical staff complete all required mandatory training.
Must-do action 3 of 18
Must do
Safe
The trust must ensure that risk assessments are fully completed for patients attending with mental health needs and mitigating actions to limit identified risks are implemented.
Must-do action 4 of 18
Must do
Well-led
The service must ensure that staff complete patient records accurately and in a timely manner.
Must-do action 5 of 18
Must do
Caring
The trust must ensure that patient identifiable information is not visible to visitors to the department
Must-do action 6 of 18
Must do
Safe
The service must ensure patients receive antimicrobials in line with the national guidelines.
Must-do action 7 of 18
Must do
Safe
The service must improve compliance for resuscitation training for medical and nursing staff and compliance for sepsis training for medical staff.
Must-do action 8 of 18
Must do
Well-led
The service must ensure that patient records are kept secure.
Must-do action 9 of 18
Must do
Safe
The service must ensure they have enough medical staff to keep patients safe.
Must-do action 10 of 18
Must do
Responsive
The trust must continue to take actions to improve referral to treatment waiting time performance in line with national standards.
Must-do action 11 of 18
Must do
Safe
The trust must continue to take actions to improve the number of patients receiving a clinical assessment and daily review by a senior decision maker within target timescales.
Must-do action 12 of 18
Must do
Well-led
The service must ensure staff receives such appropriate training as is necessary to enable them to carry out the duties they are employed to perform. This includes but is not limited to life support and pool evacuation training.
Must-do action 13 of 18
Must do
Well-led
The trust must ensure that all staff, including medical staff, complete mandatory training requirements.
Must-do action 14 of 18
Must do
Safe
The trust must ensure that checks of consumables are completed including integrity of packaging and within expiry dates.
Must-do action 15 of 18
Must do
Caring
The trust must ensure that patient identifiable information is not visible to visitors to the department
Must-do action 16 of 18
Must do
Safe
The trust must ensure patients with a mental health concern are cared for in a room that is free from objects that could be used to self-harm
Must-do action 17 of 18
Must do
Well-led
The service must ensure staff receives such appropriate training as is necessary to enable them to carry out the duties they are employed to perform. This includes but is not limited to life support and pool evacuation training.
Must-do action 18 of 18
Must do
Safe
The service must ensure equipment is secure, suitable for the purpose for which it is being used and properly maintained. This includes but is not limited to emergency equipment and firefighting equipment.
Should-do actions (36)
Should-do action 1 of 36
Should do
Well-led
The trust should ensure that it continues to monitor pharmacy staffing to support continued improvement in medicines optimisation
Should-do action 2 of 36
Should do
Well-led
The trust should monitor the administration of files for the fit and proper persons checks.
Should-do action 3 of 36
Should do
Well-led
The service should ensure that patient identifiable details are not displayed on public boards.
Should-do action 4 of 36
Should do
Safe
The service should continue its focus on establishing sufficient numbers of medical staff and managing any risks occurring as a result of staffing lack in medical workforce.
Should-do action 5 of 36
Should do
Well-led
The service should continue its focus on improving local audit (STAR accreditation) outcomes.
Should-do action 6 of 36
Should do
Effective
The service should ensure that patients’ nutrition and hydration needs continue to be regularly monitored whilst they are waiting for treatment and care.
Should-do action 7 of 36
Should do
Effective
The trust should ensure patients receive daily, timely review when not being provided care and treatment on the correct medical speciality ward.
Should-do action 8 of 36
Should do
Safe
The service should ensure that staff follow infection prevention control principles.
Should-do action 9 of 36
Should do
Safe
The service should ensure that premises are safe to use for patients.
Should-do action 10 of 36
Should do
Safe
The service should ensure risk assessments, care plans and intentional rounding is completed regularly for all patients.
Should-do action 11 of 36
Should do
Safe
The service should continue to monitor the correct recording of NEWS2 observations.
Should-do action 12 of 36
Should do
Safe
The service should ensure that equipment is properly maintained, including the patient call bells and showering facilities.
Should-do action 13 of 36
Should do
Responsive
The service should ensure that complaints are managed in a timely manner.
Should-do action 14 of 36
Should do
Responsive
The service should continue to improve waiting times for patients accessing neurology cancer treatment.
Should-do action 15 of 36
Should do
Well-led
The service should improve staff attendance at governance meetings.
Should-do action 16 of 36
Should do
Caring
The trust should continue to improve the provision of single sex washing facilities for patients.
Should-do action 17 of 36
Should do
Well-led
The Trust should continue to recruit allied health professions within medical care.
Should-do action 18 of 36
Should do
Safe
The trust should monitor and review arrangements to ensure that medicines with a minimum dosage interval are administered as prescribed.
Should-do action 19 of 36
Should do
Safe
The trust should continue to use medicines data to support improvement in medicines safety.
Should-do action 20 of 36
Should do
Safe
The trust should monitor and review arrangements to ensure that medicines with a minimum dosage interval are administered as prescribed.
Should-do action 21 of 36
Should do
Safe
The trust should continue to use medicines data and keep pharmacy staffing under review to support continued improvement in medicines safety, including medicines reconciliation.
Should-do action 22 of 36
Should do
Responsive
The service should consider how wards and theatre areas can be made more dementia friendly.
Should-do action 23 of 36
Should do
Safe
The service should ensure the maternity assessment service has the right number of qualified staff and the triage telephone line is answered and monitored by a trained midwife.
Should-do action 24 of 36
Should do
Well-led
The service should improve the culture where staff feel listened to.
Should-do action 25 of 36
Should do
Responsive
The service should ensure they monitor delays in the induction of labour process and all reasons for the delays are documented.
Should-do action 26 of 36
Should do
Well-led
The service should ensure there is an accurate overview of risks faced, including the monitoring of delays in induction of labour, monitoring of missed telephone calls and telephone call drop off rates within triage and to rate all 3rd and 4th degree tears and post-partum haemorrhages as incidents.
Should-do action 27 of 36
Should do
Caring
The trust should ensure that all conversations with patients, and their families take place in an environment where they are not overheard
Should-do action 28 of 36
Should do
Safe
The trust should ensure that all noticeboards include current information such as safeguarding.
Should-do action 29 of 36
Should do
Caring
The trust should ensure that all patients with protected characteristics are supported such as availability of information in formats that patients understand.
Should-do action 30 of 36
Should do
Responsive
The trust should ensure that complaints are managed in a timely manner
Should-do action 31 of 36
Should do
Safe
The trust should consider including checks of the transfer bag with other daily checks.
Should-do action 32 of 36
Should do
Safe
The trust should consider locating paediatric emergency information where children would be treated.
Should-do action 33 of 36
Should do
Responsive
The trust should consider reviewing the environment where paediatrics are treated to be more child friendly.
Should-do action 34 of 36
Should do
Responsive
The trust should consider sourcing comfortable chairs appropriate for patients with additional needs such as mobility or bariatric.
Should-do action 35 of 36
Should do
Safe
The service should review use of patient group directions and storage of aromatherapy oils to assure themselves medicines management is in line with best practice.
Should-do action 36 of 36
Should do
Safe
The service should ensure staff carry out newborn observations using track and trigger system in a timely way in line with local guidance.