CQC Improvements

March 2021

The following improvements have been implemented at Blackpool Teaching Hospitals following an unannounced visit by the Care Quality Commission in January 2021.

They are grouped as per the must do actions from the CQC and correlate directly to their full report which can be found here.

Emergency department

CQC said: The flow of patients through the emergency department and the hospital so that patients are assessed, treated, admitted and discharged in a safe, timely manner.

BTH has done: Since the inspection took place the first phase of the Trust’s Emergency Village has opened which is helping to improve the flow of patients and their care while seeking support and treatment in the emergency department at Blackpool Victoria.

The Trust has vastly improved the levels of both nurse and medical staffing, including the ability to flex staffing against patient acuity. Internal professional standards have been introduced as well as improvements to processes around bed management.

Medical care 

CQC said: Ensure that patient records are complete, legible and kept securely at all times, so that they are up to date, clear and only accessed by those authorised to do so.

BTH has done: The Trust recognises these issues and is actively working on implementation of tangible improvements which include a phased Electronic Patient Record (EPR) system to upgrade and restructure the current health record storage system to allow us to digitally store and track patient health records.

Since the inspectors visited in January the Trust has put in place lockable trolleys for all key wards and areas which means records can only be accessed by people authorised to do so.

Streamlined nursing assessment documentation has also been introduced.

CQC said: Medical staffing is sufficient to meet the needs of patients and ensure actual staffing meets with, or is close to, the planned numbers. They should continue work to improve the recruitment and retention of medical staffing to reduce vacancies.

BTH has done: The Trust is reviewing staffing levels and also proactively recruiting to areas where there is increased pressure. This is a challenging issue for the NHS nationally where shortages of staff are well documented. The Trust continues to do everything possible to attract qualified staff but has concurrently launched a major development programme for current colleagues to ensure they are able to progress in the organisation and are retained by the Trust. Staffing risks to patients are mitigated by flexing staffing across teams and areas as well as employing Locum staff and temporary staff.

CQC said: Make sure that when a patient is unable to consent to their care and treatment staff follow trust policy and the requirements of the Mental Capacity Act 2005. Patients and/or their families should be involved in decisions made about their care and treatment.

BTH has done: An area for improvement already recognised by the Trust before the inspection, the Trust has implemented additional training and education programmes through the safeguarding team. More and regular audits are now in place to ensure this is happening and monitor compliance levels.

CQC said: Qualified staffing level concerns

BTH has done: The Trust has now launched its Safe Care Staffing Tool which gives greater assurance that staff with the right skills are in the right place to reflect the needs of the patients in their care. This was observed by the CQC during their visit and the Trust was commended by the inspection team for the way it was managing nurse staffing across the Trust.

Posted in Uncategorized.