Source · CQC inspection
Hammersmith Hospitals
Provider Imperial College Healthcare NHS Trust
Type NHS Healthcare Organisation
Region London
Last inspected 23 Jul 2019
Overall rating: Requires Improvement View full CQC report
Domain ratings
Safe
Requires Improvement
Effective
Good
Caring
Good
Responsive
Requires Improvement
Well-led
Requires Improvement
Earlier inspection findings
Must-do actions (1)
Must-do action 1 of 1
Must do
Safe
The trust must ensure the premises and environment are suitable for the services being provided. The risk of cross-infection must be managed safely in the PICU, especially while building work is ongoing.
Should-do actions (47)
Should-do action 1 of 47
Should do
Effective
Ensure that consideration is given to the inclusion of the level 2 acute respiratory beds in clinical audit data submission.
Should-do action 2 of 47
Should do
Responsive
Ensure there is a formalised approach to organising follow up clinics for patients discharged from critical care areas.
Should-do action 3 of 47
Should do
Safe
Ensure that an intensivist review all critically ill patients twice daily.
Should-do action 4 of 47
Should do
Safe
Ensure that learning from incidents shared promptly between all staff working in areas where similar incident could occur.
Should-do action 5 of 47
Should do
Caring
The service should ensure there is designated psychological service to meet needs of all critical care patients.
Should-do action 6 of 47
Should do
Responsive
The service should ensure there are no delays to patients discharges and patients that are not critically ill are cared for in a suitable environment.
Should-do action 7 of 47
Should do
Safe
To ensure venous thromboembolism (VTE) assessments are completed for all critically ill patients.
Should-do action 8 of 47
Should do
Safe
The hospital should ensure emergency equipment is checked and recorded consistently.
Should-do action 9 of 47
Should do
Safe
The hospital should consider improvements to the hospital estate and facilities for the lifts and temperature of some maternity ward areas.
Should-do action 10 of 47
Should do
Effective
The trust should ensure policies and guidelines available in hard copies are regularly reviewed and updated.
Should-do action 11 of 47
Should do
Safe
The hospital should ensure the maternity early warning scores are completed and scored appropriately by staff.
Should-do action 12 of 47
Should do
Safe
The trust should review the cleaning provision of the service to ensure the cleaning environment and equipment are clean to prevent the risk of infection.
Should-do action 13 of 47
Should do
Safe
The trust should ensure adequate equipment is available for the HDU beds that are part of PICU on the Grand Union Ward.
Should-do action 14 of 47
Should do
Safe
The trust should ensure there are adequate defibrillators available in all areas.
Should-do action 15 of 47
Should do
Safe
The trust should consider how to ensure there is adequate oversight of all safeguarding cases.
Should-do action 16 of 47
Should do
Responsive
The trust should continue to develop transitional services for adolescents.
Should-do action 17 of 47
Should do
Responsive
The trust should consider how to ensure there is adequate mental healthcare provision.
Should-do action 18 of 47
Should do
Safe
Improve compliance with mandatory training levels for doctors in training.
Should-do action 19 of 47
Should do
Caring
Minimise mixed sex breaches to ensure patients’ privacy and dignity is maintained.
Should-do action 20 of 47
Should do
Responsive
Consider follow-up clinics are established and the use of patient diaries to support the recovery process of patients.
Should-do action 21 of 47
Should do
Safe
Consider addressing the issue of tailgating into the intensive care unit.
Should-do action 22 of 47
Should do
Responsive
Continue to work with the rest of the hospital to reduce the delayed discharges of patients from the intensive care unit to the wards.
Should-do action 23 of 47
Should do
Safe
Continue to ensure the intensive care unit transitions to a fully electronic patient record system.
Should-do action 24 of 47
Should do
Well-led
Consider when trust wide policies are used, that any guidance, instruction or tools specifically related to critical care is sufficiently signposted for staff.
Should-do action 25 of 47
Should do
Safe
Ensure that ongoing review on becoming compliant with intensive care staffing standards is seen through to conclusion and action.
Should-do action 26 of 47
Should do
Safe
Ensure that staffing of the renal high dependency beds is benchmarked against national standards.
Should-do action 27 of 47
Should do
Effective
Ensure that pharmacy support enables staff to support ward rounds.
Should-do action 28 of 47
Should do
Safe
Ensure that the service risk assess the inconsistent staffing support provided to non-invasive ventilated patients being cared for outside of intensive care units.
Should-do action 29 of 47
Should do
Safe
Ensure that wards make timely referrals to the critical care outreach team and that wards act on plans provided by them.
Should-do action 30 of 47
Should do
Well-led
Ensure that work to standardise compliance and identify a structure for critical services on the site is worked through to conclusion and action.
Should-do action 31 of 47
Should do
Well-led
Ensure that consideration is given to the inclusion of the level 2 renal beds in the steering group work to standardise compliance and identify a structure for critical services on the hospital site.
Should-do action 32 of 47
Should do
Well-led
Ensure that identified risks are worked through and resolved.
Should-do action 33 of 47
Should do
Safe
The trust should ensure the unit has a formal protocol in place for how often and when toys should be cleaned.
Should-do action 34 of 47
Should do
Safe
The trust should ensure that the role of the ‘safe to wait’ nurse is formalised in order to maintain the safety of patients waiting to be triaged in the ambulatory care unit.
Should-do action 35 of 47
Should do
Well-led
The trust should consider putting into place appropriate formal interim arrangements until the band 7 unit manager position is filled.
Should-do action 36 of 47
Should do
Well-led
The trust should follow through with plans introduce videoconferencing capability to the unit to enable greater unit involvement in wider directorate and divisional meetings.
Should-do action 37 of 47
Should do
Well-led
The services should consider routinely collating data such as waiting times and the time it takes patients to be treated and discharged.
Should-do action 38 of 47
Should do
Well-led
The trust should consider putting into place a formalised strategy in place for the service.
Should-do action 39 of 47
Should do
Safe
The trust should improve the monitoring of emergency equipment to ensure it is safe and effective for patient use.
Should-do action 40 of 47
Should do
Safe
The trust should improve the midwife to birth ratio in line with national recommendations.
Should-do action 41 of 47
Should do
Safe
The service should continue efforts to reduce nurse vacancy rates.
Should-do action 42 of 47
Should do
Safe
The service should consider options to improve limited space around cots.
Should-do action 43 of 47
Should do
Safe
The service should continue efforts to improve hand hygiene compliance.
Should-do action 44 of 47
Should do
Effective
Managers should appraise all staff’s work performance.
Should-do action 45 of 47
Should do
Caring
The service should consider using pain assessment tools.
Should-do action 46 of 47
Should do
Effective
The service should offer guidance regarding parental capacity.
Should-do action 47 of 47
Should do
Well-led
The service should address staff survey results regarding relation with senior management.