Source · CQC inspection
Bridgewater CHCFT Bevan House
Provider Bridgewater Community Healthcare NHS Foundation Trust
Type NHS Healthcare Organisation
Region North West
Last inspected 4 Oct 2018
Overall rating: Good View full CQC report
Domain ratings
Safe
Good
Effective
Good
Caring
Good
Responsive
Good
Well-led
Good
Earlier inspection findings
Must-do actions (6)
Must-do action 1 of 6
Must do
Well-led
The trust must ensure it operates its information management systems effectively to assess, monitor and improve the quality and safety of the services it provides, and to assess, monitor and mitigate the risks to the health, safety and welfare of its service users and others in the provision of services.
Must-do action 2 of 6
Must do
Safe
The trust must ensure that care and treatment provided to children with complex needs at the Woodview Child Development Centre is provided in a safe way that assesses the risks to the health and safety of the child receiving care and treatment, doing all that is reasonably practicably to mitigate any such risks.
Must-do action 3 of 6
Must do
Safe
The trust must ensure where responsibility for care and treatment of the child is shared or transferred to other professionals, the service work with such other professionals to ensure timely care planning takes place to ensure the health, safety and welfare of the child.
Must-do action 4 of 6
Must do
Safe
The trust must ensure the proper and safe management of medicines by monitoring the recording system for the issuing of FP10 prescription pads.
Must-do action 5 of 6
Must do
Safe
The trust must ensure that where multiple sets of paper records are held for individual service users, that it maintains an accurate, complete and contemporaneous record of the care and treatment provided to the service user and decisions taken in relation to the care and treatment provided.
Must-do action 6 of 6
Must do
Responsive
The trust must ensure it reviews its existing processes for children, young people and families to raise concerns and complaints regarding care and treatment.
Should-do actions (34)
Should-do action 1 of 34
Should do
Well-led
The trust should ensure it continues to embed its talent management and succession planning framework to ensure middle manager levels have the necessary experience, knowledge, capacity, capability or integrity to lead effectively.
Should-do action 2 of 34
Should do
Well-led
The trust should ensure it develops a workforce and organisational development strategy so that future patient needs are met through the transformation and development of its workforce.
Should-do action 3 of 34
Should do
Well-led
The trust should ensure it continues to implement its arrangements for Freedom to Speak Up Guardians.
Should-do action 4 of 34
Should do
Well-led
The trust should ensure it implements detailed delivery plans and mechanisms for the Board to monitor and track progress against its strategy.
Should-do action 5 of 34
Should do
Responsive
The trust should ensure it delivers and implements its Patient Experience Strategy.
Should-do action 6 of 34
Should do
Well-led
The trust should ensure it continues to strengthen collaborative working with commissioners and external stakeholders.
Should-do action 7 of 34
Should do
Well-led
The trust should consider a review of its arrangements to enhance the equality and diversity agenda.
Should-do action 8 of 34
Should do
Safe
The trust should ensure all staff have access to mandatory training and submit their compliance in a timely way.
Should-do action 9 of 34
Should do
Well-led
The trust should ensure systems to monitor and record staff performance are functional and fit for purpose.
Should-do action 10 of 34
Should do
Effective
The trust should ensure staff have the knowledge and understanding of assessing patient’s mental capacity.
Should-do action 11 of 34
Should do
Safe
The trust should ensure processes to maintain equipment are effective.
Should-do action 12 of 34
Should do
Well-led
The trust should ensure it continues to support staff during the transformation of community services and integration of teams to share good practice across the services.
Should-do action 13 of 34
Should do
Effective
The trust should ensure it reviews its systems for clinical supervision which is documented and structured to meet individual staff requirements.
Should-do action 14 of 34
Should do
Safe
The trust should consider a review of its clinical areas so there are appropriate facilities to treat patients.
Should-do action 15 of 34
Should do
Safe
The trust should ensure it continues to focus on increasing compliance with basic life support training.
Should-do action 16 of 34
Should do
Safe
The trust should ensure it encourages a culture in which staff feel confident to raise incidents using the reporting process and provide feedback to staff when incidents are reported.
Should-do action 17 of 34
Should do
Safe
The trust should ensure it strengthens staff knowledge and training in the recognition and treatment of sepsis in children.
Should-do action 18 of 34
Should do
Responsive
The trust should ensure it improves service learning and improvement through recording and auditing themes of informal complaints.
Should-do action 19 of 34
Should do
Safe
The trust should ensure that all cleaning stores and cupboards containing cleaning materials are kept locked when not in use.
Should-do action 20 of 34
Should do
Effective
The trust should ensure it improves appraisal rates among non-clinical staff.
Should-do action 21 of 34
Should do
Safe
The trust should consider the benefits of introducing daily environmental cleaning logs to compliment cleaning schedules and to provide a more effective audit trail of all areas cleaned.
Should-do action 22 of 34
Should do
Safe
The trust should consider a review of its storage facility within the Woodview children’s development centre to ensure that community nursing team equipment is stored securely.
Should-do action 23 of 34
Should do
Well-led
The trust should consider how it can encourage similar services across different boroughs to work together, to share learning and examples of good practice.
Should-do action 24 of 34
Should do
Caring
The trust should consider undertaking an audit to review and improve the consistency of documentation of the ‘Voice of the Child’ within clinical records.
Should-do action 25 of 34
Should do
Responsive
The trust should consider how it can improve the availability of patient and carer information leaflets in a variety of languages and formats to meet the needs of the local populations.
Should-do action 26 of 34
Should do
Effective
The trust should ensure that clinical supervision is consistent across each borough.
Should-do action 27 of 34
Should do
Responsive
The trust should consider how it can improve formal feedback procedures so that patients and family experience can be better analysed and recorded.
Should-do action 28 of 34
Should do
Safe
The trust should consider its systems to monitor training for staff specific to end of life care.
Should-do action 29 of 34
Should do
Safe
The trust should ensure there are arrangements to store clinical waste securely in all its locations.
Should-do action 30 of 34
Should do
Safe
The trust should ensure that fridge temperature checks are carried out in line with best practice
Should-do action 31 of 34
Should do
Safe
The trust should ensure there are processes to check equipment has been maintained appropriately.
Should-do action 32 of 34
Should do
Safe
The trust should ensure emergency bags are standardised and checked appropriately.
Should-do action 33 of 34
Should do
Effective
The trust should ensure that all guideline flowcharts are clear to follow.
Should-do action 34 of 34
Should do
Responsive
The trust should consider ways to increase the home birth rate.