01/02/2022
During a routine inspection
We rated it as good because:
- The patient’s environments were safe, clean and well maintained.
- The service implemented robust process with respect to safeguarding.
- The service always had enough staff. Managers ensured that these staff received training, and appraisal. The staff worked well together as a multidisciplinary team.
- Care plans were individualised and included discharge plans.
- Staff planned patient discharge well and liaised with services that would provide aftercare. Patients lengths of stay were short.
- Staff engaged in clinical audit to evaluate the quality of care they provided.
- Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood their individual needs. They involved patients and families and carers in care decisions.
- The service was well led, and the governance processes ensured that procedures ran smoothly.
However:
- Gaps were noted in the radiology risk assessments. We saw that the action by whom, action by what date, sign when complete fields were not always completed.
- Monitoring of spill kits checks was not documented in the outpatient’s area.
- It was not clearly identified that anaphylaxis audits had taken place as they were not identified on the resuscitation trolley audit documentation. The February 2022 resuscitation trolley checklist initially provided as evidence did not specify the areas or locations in which the resuscitation trolleys were located and / or checked. We noted on the resuscitation checklist provided post inspection that anaphylaxis kit checks were documented and had taken place. However, the checklist did not specify the actual location of which resuscitation trolley was checked.
- Signage and directions to the outpatient department location were not always clear.
The main service provided by this hospital was surgery. Where our findings on surgery– for example, management arrangements – also apply to other services, we do not repeat the information but cross-refer to the surgery service.