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Evesham Community Hospital Requires improvement


Inspection carried out on 14 May to 29 May 2019

During a routine inspection

Our rating of services went down. We rated it them as requires improvement because:

  • Safety checks to prevent errors occurring in the operating theatres and hand hygiene procedures, were not consistently followed. We did not observe staff challenging poor practice. There was limited learning from incidents that occurred at other hospitals within the trust.
  • The environment in which some procedures were carried out was not suitable and equipment checks were not always completed daily.
  • There was limited monitoring of clinical outcomes for patients and adherence to best practice guidance at the hospital.
  • Patients waited longer than average from referral to treatment and capacity within surgery at the hospital was not fully utilised. The ward, operating theatre and clinical interventions unit were not used to capacity.
  • Governance processes were not fully effective. Risks to the service were not adequately identified and systematically managed. Risks and concerns we identified during the inspection had not been recognised by the management team.
  • There was uncertainty about the future sustainability of the service at the hospital and little evidence of learning or innovation. Some staff expressed concerns about the level of communication and engagement about the future of surgical services at Evesham Community Hospital.


  • There were sufficient nursing staff with the required competencies to provide safe and effective care for patients. Care was consultant led. Managers appraised staff performance.
  • Staff knew how to recognise abuse and how to report it. They worked with other organisations to protect people. They kept detailed records of patient’s care and treatment. Safe systems and processes were in place for the management of patients’ medicines.
  • Staff generally worked well together as a team for the benefit of patients and provide coordinated care. They were kind and compassionate and patients praised them for their friendly and professional approach.

Inspection carried out on 14-17th July 2015

During a routine inspection

Worcestershire Acute Hospitals NHS Trust (WAHNHST) was established on 1 April 2000 to cover all acute services in Worcestershire with approximately 900 beds. It provides a wide range of services to a population of around 570,000 people in Worcestershire as well as caring for patients from surrounding counties and further afield.

The Trust includes four hospital sites, Worcestershire Royal Hospital (WRH), Alexandra Hospital in Redditch (AHR) Kidderminster Treatment Centre (KTC) and one day ward and a theatre at Evesham Community Hospital (ECH), which is run by Worcestershire Health and Care NHS Trust

Worcestershire Acute Hospitals NHS Trust, maintain one operating theatre, and a surgical ward Burlingham Ward on Evesham Community Hospital site. These services are provided by Worcestershire Acute Hospitals NHS Trust staff.

We carried out this inspection between14th and 17th July 2015 as part of our comprehensive inspection programme.

We found the surgical services at Evesham Community Hospital to be good for safety, effectiveness, caring, responsiveness and leadership.

Our key findings were as follows:

  • The theatre and surgical ward were clean and free from clutter in patient areas
  • All patients are screened for Methicillin-resistant staphylococcus aureus (MSRA) prior to attending for surgery. There had been no outbreaks of (MRSA) and Clostridium Difficile at ECH during the previous twelve months
  • The theatre team was small and there were a high number of vacancies. This meant that the trust relied on staff from other clinical areas either within Evesham Community Hospital or from its sister hospitals, agency staff or supervisors giving up their protected time to achieve safe staffing.
  • ECH only provided day case surgery so most patients were required to fast prior to surgery, although drinks and snacks were available for after their operation

There was an area of poor practice where the trust needs to make improvements.

The trust should:

  • Review its arrangements for utilising its full theatre capacity to ensure patients are treated sooner

Professor Sir Mike Richards

Chief Inspector of Hospitals