Source · CQC inspection
Royal Shrewsbury Hospital
Type NHS Healthcare Organisation
Region West Midlands
Last inspected 15 May 2024
Overall rating: Requires Improvement View full CQC report
Domain ratings
Safe
Requires Improvement
Effective
Requires Improvement
Caring
Requires Improvement
Responsive
Requires Improvement
Well-led
Requires Improvement
Earlier inspection findings
Must-do actions (21)
Must-do action 1 of 21
Must do
Well-led
The trust must ensure there is a timely review of all open risks dated from 2009 to 2019.
Must-do action 2 of 21
Must do
Safe
The service must ensure all staff complete mandatory and legally required training and medical staff complete safeguarding children’s level 3 training in line with trust targets.
Must-do action 3 of 21
Must do
Safe
The trust must ensure there is clear oversight of all patients in waiting areas.
Must-do action 4 of 21
Must do
Safe
The service must ensure patients are risk assessed in a timely way and that risks associated with the delivery of healthcare is mitigated as far as is reasonably practicable.
Must-do action 5 of 21
Must do
Caring
The service must ensure that service users are treated with dignity and respect.
Must-do action 6 of 21
Must do
Responsive
The service must provide care that meets the needs, and reflect the preferences, of patients.
Must-do action 7 of 21
Must do
Responsive
The service must ensure patients can access care and treatment in a timely way.
Must-do action 8 of 21
Must do
Safe
The trust must ensure that all risk assessments, with particular attention to venous thromboembolism risk assessments are completed in line with trust policy, to reduce the risk of harm to patients.
Must-do action 9 of 21
Must do
Caring
The trust must ensure they adhere to the policies in place around mixed sex breaches.
Must-do action 10 of 21
Must do
Responsive
The trust must ensure they continue to work on meeting their referral to treatment targets for all pathways.
Must-do action 11 of 21
Must do
Effective
The trust must ensure all staff complete mandatory and legally required training and receive an appraisal.
Must-do action 12 of 21
Must do
Safe
The trust must ensure medicines are stored safely and there is oversight and governance processes in place for the safe storage of medicines including but not limited to patients own medicines and effective monitoring of refrigerator temperatures in order to store medicines safely.
Must-do action 13 of 21
Must do
Safe
The trust must ensure that staff comply with nationally recognised infection control standards.
Must-do action 14 of 21
Must do
Responsive
The trust must ensure that all patients are triaged in a timely way.
Must-do action 15 of 21
Must do
Responsive
The trust must ensure patients can access care and treatment in a timely way. This includes ambulance handover times and patient waiting times for treatment and arrangements to admit, treat and discharge patients.
Must-do action 16 of 21
Must do
Safe
The trust must ensure the mental health room exit complies with statutory requirement.
Must-do action 17 of 21
Must do
Safe
The trust must ensure bed rails assessments are carried out on patients who require them in line with national standards.
Must-do action 18 of 21
Must do
Safe
The trust must ensure systems and processes to safeguard patients from abuse and improper treatment are fully implemented. This includes safeguarding checks and assessments are completed and actions taken to safeguard patients are documented.
Must-do action 19 of 21
Must do
Caring
The trust must ensure that patients within all areas of the emergency department consistently have their right to privacy respected.
Must-do action 20 of 21
Must do
Safe
The trust must ensure that environment in all areas within the emergency department are suitable for the purpose for which they are being used.
Must-do action 21 of 21
Must do
Well-led
The service must operate effective governance systems to ensure compliance with all relevant sections, such as but not limited to the risk register.
Should-do actions (58)
Should-do action 1 of 58
Should do
Well-led
The trust should ensure compliance for declarations of interest by decision making staff is in line with the NHS Counter Fraud Authority recommended compliance standard of 80%.
Should-do action 2 of 58
Should do
Well-led
The trust should ensure systems to identify where action should be taken, through internal audit, are robust.
Should-do action 3 of 58
Should do
Well-led
The trust should consider increasing the exposure of direct reports to trust board in order that succession planning and empowerment continues to develop within the senior team.
Should-do action 4 of 58
Should do
Well-led
The trust should consider strengthening the Board by the appointment of additional specialists in financial management.
Should-do action 5 of 58
Should do
Well-led
The trust should consider reviewing the governance structure throughout the organisation in order to ensure that only relevant information is presented to trust board.
Should-do action 6 of 58
Should do
Responsive
The trust should ensure that they audit patient discharges undertaken under the fast track system.
Should-do action 7 of 58
Should do
Caring
The trust should ensure the mortuary viewing glass is fit for purpose.
Should-do action 8 of 58
Should do
Effective
The trust should ensure staff are knowledgeable and understand the Mental Capacity Act 2005 and the procedures and documentation used to assess a patient’s capacity.
Should-do action 9 of 58
Should do
Safe
The trust should ensure that ReSPECT forms are completed appropriately and consistently.
Should-do action 10 of 58
Should do
Safe
The service should ensure records are completed consistently to assess and mitigate individual patient safety risks.
Should-do action 11 of 58
Should do
Safe
The service should ensure that deteriorating patients are consistently identified and escalated in line with trust policy.
Should-do action 12 of 58
Should do
Safe
The trust should ensure checks on resus trolley are recorded as per policy.
Should-do action 13 of 58
Should do
Safe
The trust should ensure nursing and healthcare assistant staffing levels are as planned.
Should-do action 14 of 58
Should do
Well-led
The trust should ensure there is consistent leadership and staffing on the escalation wards.
Should-do action 15 of 58
Should do
Safe
The trust should ensure wards are appropriately equipped to meet patient’s needs.
Should-do action 16 of 58
Should do
Safe
The service should ensure the storage of medicines within wards are stored safely and securely.
Should-do action 17 of 58
Should do
Effective
The trust should ensure advanced life support and immediate life support training is captured on the trust learning management system.
Should-do action 18 of 58
Should do
Responsive
The trust should ensure waiting times from referral to treatment and arrangements to admit, treat and discharge patients are in line national standards.
Should-do action 19 of 58
Should do
Safe
The trust should ensure the store cupboard for clean equipment is moved from the dirty utility room into the discharge lounge.
Should-do action 20 of 58
Should do
Safe
The trust should ensure staff continue to receive hand hygiene training.
Should-do action 21 of 58
Should do
Safe
The trust should consider how it communicates the emergency department is a bare below the elbow environment to internal visitors to the department.
Should-do action 22 of 58
Should do
Safe
The trust should consider how to ensure the premises are secure to protect patients from the risk of harm.
Should-do action 23 of 58
Should do
Safe
The service should ensure fire doors are in good working order at all times.
Should-do action 24 of 58
Should do
Safe
The service should consider how it segregates children and adults in the main waiting area.
Should-do action 25 of 58
Should do
Caring
The service should ensure patients have reasonable access to toilet facilities and showers.
Should-do action 26 of 58
Should do
Safe
The service should ensure all patients are issued with an identity band at the earliest opportunity.
Should-do action 27 of 58
Should do
Safe
The service should introduce a robust way of measuring temperatures for the effective storage of medicines.
Should-do action 28 of 58
Should do
Safe
The service should continue to ensure records are stored securely and contain a clear and contemporaneous account of the care and treatment provided.
Should-do action 29 of 58
Should do
Effective
The service should consider how it introduces a system to ensure the correct use of fluid balance charts.
Should-do action 30 of 58
Should do
Effective
The service should consider applying for a Deprivation of Liberty Safeguard for patient’s whose liberty is deprived for extended periods of time in the emergency department.
Should-do action 31 of 58
Should do
Caring
The service should ensure consideration is given to separating people of different genders in escalation areas.
Should-do action 32 of 58
Should do
Well-led
The service should consider how it introduces a system to monitor 30-day mortality rates for patients delayed for over 5 hours in emergency department.
Should-do action 33 of 58
Should do
Effective
The trust should consider how it develops a system to ensure all staff receive an annual appraisal.
Should-do action 34 of 58
Should do
Effective
The trust should ensure that they complete audits to monitor effectiveness and care for children on neonates.
Should-do action 35 of 58
Should do
Effective
The trust should ensure that the neonates staff receive appraisals.
Should-do action 36 of 58
Should do
Safe
The trust should ensure that all staff in neonates have completed sepsis training.
Should-do action 37 of 58
Should do
Effective
The trust should ensure that all staff complete Mental Capacity Act and Deprivation of Liberty Safeguards training.
Should-do action 38 of 58
Should do
Effective
The trust should ensure that staff are trained and Qualified in Speciality.
Should-do action 39 of 58
Should do
Safe
The trust should ensure that cleaning rotas are completed.
Should-do action 40 of 58
Should do
Safe
The trust should ensure that sepsis trolley within neonates is checked daily.
Should-do action 41 of 58
Should do
Safe
The trust should ensure that fridges are monitored and if broken fixed or replaced.
Should-do action 42 of 58
Should do
Effective
The trust should ensure that the service use electronicsystem for patient’s records.
Should-do action 43 of 58
Should do
Effective
The service should consider when clinical supervisions take place, for these to be documented and a record is kept.
Should-do action 44 of 58
Should do
Responsive
The trust should ensure that they audit patient discharges undertaken under the fast tracksystem.
Should-do action 45 of 58
Should do
Caring
The trust should ensure the mortuary viewing glass is fit for purpose.
Should-do action 46 of 58
Should do
Effective
The trust should ensure staff are knowledgeable and understand the Mental Capacity Act 2005 and the procedures and documentation used to assess a patient’s capacity.
Should-do action 47 of 58
Should do
Safe
The trust should ensure that ReSPECT forms are completed appropriately and consistently.
Should-do action 48 of 58
Should do
Well-led
The trust should ensure the governance system in place is effectively supporting all aspects of safe, quality care.
Should-do action 49 of 58
Should do
Safe
The trust should ensure that patients are screened and treated for sepsis in line with recommended guidance and trust policy.
Should-do action 50 of 58
Should do
Effective
The trust should continue to work on the completion and quality of care records.
Should-do action 51 of 58
Should do
Effective
The trust should ensure to continue to use the audit data to drive improvements for patient care and treatment.
Should-do action 52 of 58
Should do
Responsive
The trust should continue to work with partner organisationsto improvedischarges.
Should-do action 53 of 58
Should do
Caring
The service should continue to improve the care provided to patients living with dementia which includes improving the environment.
Should-do action 54 of 58
Should do
Caring
The service should ensure all patients are able to discuss any concerns with staff.
Should-do action 55 of 58
Should do
Safe
The trust should ensure that emergency department records are stored securely in all areas.
Should-do action 56 of 58
Should do
Safe
The trust should ensure regular medication is prescribed in a timely manner.
Should-do action 57 of 58
Should do
Safe
The trust should ensure all staff caring for patients receive a handover to enable them to provide safe care and treatment.
Should-do action 58 of 58
Should do
Caring
The trust should ensure the privacy and dignity of all patients is maintained at all times.