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The Princess Royal Hospital

Type NHS Healthcare Organisation Region West Midlands Last inspected 15 May 2024

Overall rating: Requires Improvement  View full CQC report

Domain ratings

Five CQC key questions
Safe
Requires Improvement
Effective
Requires Improvement
Caring
Good
Responsive
Requires Improvement
Well-led
Requires Improvement

Earlier inspection findings

pre-2024 framework · 21 must-do 58 should-do

Must-do actions (21)

Legal requirements based on regulation breaches identified during inspection.

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.
Regulation: Regulation 17 (Good governance)
⚠ Arrangements for identifying, recording and managing risks, issues and mitigating actions had not been robust. In July 2023, 110 open risks had been identified by the risk management group (RMG), dated from 2009 to 2019. At that time, this equated to approximately 25% of the open risk register.
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.
Regulation: Regulation 18(1)(2)(a)
⚠ Medical and nurses mandatory training including safeguarding children and adults’ level 3 training did not meet the trust’s target.
Must-do action 3 of 21
Must do
Safe
The trust must ensure there is clear oversight of all patients in waiting areas.
Regulation: Regulation 12(2)(a)(b)
⚠ We had significant concerns around oversight of the patients who were waiting to be seen and the lack of flow through the emergency department which contributed to delays.
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.
Regulation: Regulation 12(1)(2)(a)(b)
⚠ Staff did not always complete all risk assessments.
Must-do action 5 of 21
Must do
Caring
The service must ensure that service users are treated with dignity and respect.
Regulation: Regulation 10(1)(2)(a)
⚠ Staff in some areas did not always treat patients with compassion and kindness, respect their privacy and dignity, take account of their individual needs, or consistently support patients to make decisions about their care.
Must-do action 6 of 21
Must do
Responsive
The service must provide care that meets the needs, and reflect the preferences, of patients.
Regulation: Regulation 9(1)(a)(b)(c)
⚠ Staff in some areas did not always treat patients with compassion and kindness, respect their privacy and dignity, take account of their individual needs, or consistently support patients to make decisions about their care.
Must-do action 7 of 21
Must do
Responsive
The service must ensure patients can access care and treatment in a timely way.
Regulation: Regulation 12(1)(2)(a)(b)
⚠ People could not always access the service when they needed it and sometimes had to wait a long time for treatment. The service could not always be delivered to meet the changing needs of the local population.
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.
Regulation: Regulation 12(1)(2)(a)
⚠ We reviewed 22 venous thromboembolism (VTE) risk assessments and observed failures to complete the risk assessment in line with trust policy within all of those records. There were no VTE risk assessments completed on admission for 8 patients with a further 4 records appearing to show a delay in them …
Must-do action 9 of 21
Must do
Caring
The trust must ensure they adhere to the policies in place around mixed sex breaches.
Regulation: Regulation 10
⚠ The service had reported 347 mixed sex accommodation breaches between April and September 2023. The majority of these (345) were recorded within the acute medical assessment (AMA) area which was part of the acute medical unit (AMU). This had been due to capacity issues which lead to patients needing to …
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.
Regulation: Regulation 17(1)(2)(a)
⚠ Information received after the inspection showed many of the medical specialities were below the trust target of 92% for their referral to treatment (RTT) performance. On the admitted pathway, only respiratory medicine was meeting the trust target (recorded as 100%). On the non-admitted pathway, only dermatology was meeting the trust …
Must-do action 11 of 21
Must do
Safe
The trust must ensure all staff complete mandatory and legally required training and receive an appraisal.
Regulation: Regulation 18(1)(2)(a)
⚠ Information received after the inspection showed the training compliance for all staff within the medical service at this location just met the trust’s 90% target. However, the information identified there were challenges with a number of the key elements of the mandatory training, as well as departments or wards also …
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.
Regulation: Regulation 12(1)(2)(e)(g)
⚠ In resus, we observed disorganised storage arrangements with loose strips of medicines not in their original containers, tablets and liquid medicines stored together and no coordinated system in place to easily locate a medicine. There was a disorganised system of top up. We were told that medicines were taken from …
Must-do action 13 of 21
Must do
Safe
The trust must ensure that staff comply with nationally recognised infection control standards.
Regulation: Regulation 12(1)(2)(h)
⚠ We witnessed 5 staff caring for patients with suspected air-borne respiratory diseases within the RIU with no PPE. This posed a risk of cross contamination. We raised this with senior staff at the time of our inspection who alerted staff about the need to wear PPE in the area. However, …
Must-do action 14 of 21
Must do
Safe
The trust must ensure that all patients are triaged in a timely way.
Regulation: Regulation 12(1)(2)(a)
⚠ At the time of our inspection, 17 out of 20 patients had not been triaged by a triage coordinator/nurse within 15 minutes. This concern had been raised during our last 2 inspections in 2019 and 2021 and the trust was served a section 31 condition on their registration to ensure …
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.
Regulation: Regulation 12(1)(2)(a)(b)
⚠ During day 1 of our inspection, we witnessed 7 ambulances holding patients outside of the department. Most of these patients had been waiting for over 4 hours, including 2 patients who had chest pain with previous cardiac issues but had not been assessed by a doctor. As diagnostic tests, for …
Must-do action 16 of 21
Must do
Safe
The trust must ensure the mental health room exit complies with statutory requirement.
Regulation: Regulation 12(1)(2)(a)
⚠ The mental health room was free from ligature points and had a separate door for staff members to exit in the event of an emergency. The door clearly stated; ‘emergency exit, do not block door’. However, this door was locked and also blocked from outside with a drip stand and …
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.
Regulation: Regulation 12(1)(2)(a)(b)
⚠ However, we observed a patient who had been assessed as being at risk of falls attempting to climb out of their bed (with attached bed rails) in the escalation area. No specific risk assessment for the use of bed rails was found in the patient’s record we reviewed.
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.
Regulation: Regulation 13(1)(2)(3)
⚠ However, during our inspection, we saw an example when staff had not raised a safeguarding referral with other agencies to safeguard a child and ensure a safe discharge. The child had attended 3 times within 2 months and concerns had been raised, but there was no evidence of actions being …
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.
Regulation: Regulation 15(1)(c)
⚠ We observed 5 patient records left on a table in the escalation area and also found 2 trolleys left unlocked in majors. There was a potential risk of breach of information governance as these records could be accessed by unauthorised individuals.
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.
Regulation: Regulation 15(1)(c)
⚠ During day 1 of our inspection, the passageway outside the urgent and emergency care service leading to other areas was used as a new escalation area with 5 beds in the morning. The area had screens to stop staff, patients or members of the public from using it as a …
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.
Regulation: Regulation 17(1)

Should-do actions (58)

Recommended improvements to enhance service quality.

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%.
Regulation: Regulation 19 (Fit and proper persons employed)
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.
Regulation: Regulation 17 (Good governance)
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.
Regulation: Regulation 12
Should-do action 7 of 58
Should do
Safe
The trust should ensure the mortuary viewing glass is fit for purpose.
Regulation: Regulation 15
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.
Regulation: Regulation 12
Should-do action 9 of 58
Should do
Effective
The trust should ensure that ReSPECT forms are completed appropriately and consistently.
Regulation: Regulation 12
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.
Regulation: Regulation 12(1)(2)(a)(b)
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.
Regulation: Regulation 12(2)(a)
Should-do action 12 of 58
Should do
Safe
The trust should ensure checks on resus trolley are recorded as per policy.
Regulation: Regulation 12(2)(e)
Should-do action 13 of 58
Should do
Safe
The trust should ensure nursing and healthcare assistant staffing levels are as planned.
Regulation: Regulation 18(1)
Should-do action 14 of 58
Should do
Well-led
The trust should ensure there is consistent leadership and staffing on the escalation wards.
Regulation: Regulation 17 (Good Governance (2)(b))
Should-do action 15 of 58
Should do
Safe
The trust should ensure wards are appropriately equipped to meet patient’s needs.
Regulation: Regulation 12 (Safe Care & Treatment (2)(f))
Should-do action 16 of 58
Should do
Safe
The service should ensure the storage of medicines within wards are stored safely and securely.
Regulation: Regulation 12(1)(2)(g)
Should-do action 17 of 58
Should do
Well-led
The trust should ensure advanced life support and immediate life support training is captured on the trust learning management system.
Regulation: Regulation 17 (Good governance (1)(2)(b))
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.
Regulation: Regulation 17 (Good Governance (1)(2)(a))
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.
Regulation: Regulation 15 (Premises and equipment (1)(f))
Should-do action 20 of 58
Should do
Safe
The trust should ensure staff continue to receive hand hygiene training.
Regulation: Regulation 12
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.
Regulation: Regulation 12
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.
Regulation: Regulation 15
Should-do action 24 of 58
Should do
Safe
The service should consider how it segregates children and adults in the main waiting area.
Regulation: Regulation 15
Should-do action 25 of 58
Should do
Responsive
The service should ensure patients have reasonable access to toilet facilities and showers.
Regulation: Regulation 9
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.
Regulation: Regulation 12
Should-do action 27 of 58
Should do
Safe
The service should ensure they introduce a robust way of measuring temperatures for the effective storage of medicines.
Regulation: Regulation 12
Should-do action 28 of 58
Should do
Well-led
The service should continue to ensure records are stored securely and contain a clear and contemporaneous account of the care and treatment provided.
Regulation: Regulation 17
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.
Regulation: Regulation 12
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.
Regulation: Regulation 12
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.
Regulation: Regulation 10
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.
Regulation: Regulation 17
Should-do action 33 of 58
Should do
Well-led
The trust should consider how it develops a system to ensure all staff receive an annual appraisal.
Regulation: Regulation 17
Should-do action 34 of 58
Should do
Well-led
The trust should ensure that they complete audits to monitor effectiveness and care for children on neonates.
Regulation: Regulation 17
Should-do action 35 of 58
Should do
Effective
The trust should ensure that the neonates staff receive appraisals.
Regulation: Regulation 18
Should-do action 36 of 58
Should do
Safe
The trust should ensure that all staff in neonates have completed sepsis training.
Regulation: Regulation 18
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.
Regulation: Regulation 18
Should-do action 38 of 58
Should do
Effective
The trust should ensure that staff are trained and Qualified in Speciality.
Regulation: Regulation 18
Should-do action 39 of 58
Should do
Safe
The trust should ensure that cleaning rotas are completed.
Regulation: Regulation 12
Should-do action 40 of 58
Should do
Safe
The trust should ensure that sepsis trolley within neonates is checked daily.
Regulation: Regulation 12
Should-do action 41 of 58
Should do
Safe
The trust should ensure that fridges are monitored and if broken fixed or replaced.
Regulation: Regulation 12
Should-do action 42 of 58
Should do
Well-led
The trust should ensure that the service use electronic system for patient’s records.
Regulation: Regulation 17
Should-do action 43 of 58
Should do
Well-led
The service should consider when clinical supervisions take place, for these to be documented and a record is kept.
Regulation: Regulation 17
Should-do action 44 of 58
Should do
Responsive
The trust should ensure that they audit patient discharges undertaken under the fast track system.
Regulation: Regulation 12
Should-do action 45 of 58
Should do
Safe
The trust should ensure the mortuary viewing glass is fit for purpose.
Regulation: Regulation 15
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.
Regulation: Regulation 12
Should-do action 47 of 58
Should do
Effective
The trust should ensure that ReSPECT forms are completed appropriately and consistently.
Regulation: Regulation 12
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.
Regulation: Regulation 17
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.
Regulation: Regulation 12
Should-do action 50 of 58
Should do
Well-led
The trust should continue to work on the completion and quality of care records.
Regulation: Regulation 17
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.
Regulation: Regulation 12
Should-do action 52 of 58
Should do
Responsive
The trust should continue to work with partner organisations to improve discharges.
Regulation: Regulation 12
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.
Regulation: Regulation 12
Should-do action 54 of 58
Should do
Caring
The service should ensure all patients are able to discuss any concerns with staff.
Regulation: Regulation 12
Should-do action 55 of 58
Should do
Safe
The trust should ensure that emergency department records are stored securely in all areas.
Regulation: Regulation 15
Should-do action 56 of 58
Should do
Safe
The trust should ensure regular medication is prescribed in a timely manner.
Regulation: Regulation 12
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.
Regulation: Regulation 12
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.
Regulation: Regulation 10

Location details

CQC ID: RXWAT
Local authority: Telford and Wrekin
Region: West Midlands

Inspection report

Type: Location
Date: 15 May 2024
Rating: Requires Improvement
Actions: 21 must-do 58 should-do
AI-extracted 3 Jun 2026

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