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Provider: The Dudley Group NHS Foundation Trust Requires improvement

Registration details


CQC register The Dudley Group NHS Foundation Trust to carry out the following legally regulated activities.

Maternity and midwifery services

  • Diane Wake is responsible for these services.
Registered services

Termination of pregnancies

  • Diane Wake is responsible for these services.
Registered services

Services in slimming clinics

  • Diane Wake is responsible for these services.
Registered services

Nursing care

  • Diane Wake is responsible for these services.
Registered services

Family planning services

  • Diane Wake is responsible for these services.
Registered services

Treatment of disease, disorder or injury

  • Diane Wake is responsible for these services.
Condition of this registration relating to carrying out this regulated activity

The registered provider must ensure that there is an effective system in place to identify, escalate and manage patients who may present with sepsis or a deteriorating medical condition in line with the relevant national clinical guidelines. This applies to the Emergency Department and immediate medical assessment unit at Russell's Hall Hospital. This includes any area used as an inpatient bed or a space within the department.

From 19 January and on the Friday of each week thereafter, the registered provider shall report to the Care Quality Commission describing: The actions taken to ensure than an effective deteriorating patient and sepsis management systems are in place and how these are being audited, monitored and acted upon.

This should include results of any audits undertaken that provide assurance to the board that an effective sepsis management and deteriorating patient system is in place.

The registered provider must ensure that there are sufficient numbers of suitably qualified, skilled and experienced registered nurses at all times within the emergency department and immediate medical assessment unit to meet the needs of the patients, This includes any area used to accommodate patients either waiting for admission to an impatient bed or a space within the department.This is to also include appropriate clinical leaders with suitable and relevant experience to lead and support staff in this area.

The registered provider must ensure that there is an effective system in place to robustly clinically assess all patients who present to the emergency department in line with relevant national clinical guidelines within 15 minutes of arrival. This applies to the Emergency department at Russells Hall Hospital.

The registered provider must ensure that the clinical assessment and the rationale for level of care provided is clearly documented in patents records

From the 5th to the 9th February 2018, daily by 4pm the registered provider shall give written assurance to the Care Quality Commission that interim arrangements are in place and implemented to clinically assess all patients within 15 minutes of arrival at the emergency department.

From 9th February 2018 and on the Friday of each week thereafter by 4pm until further notice, the registered provider shall report to the Care Quality Commission confirming:

a) The action taken to ensure that an effective system is in place to clinica

The provider must ensure that effective governance arrangements exist with all third party organisations providing healthcare services at the Emergency Department at Russells Hall Hospital.

The governance arrangements with all third party organisations providing healthcare services at the Emergency Department at Russells Hall hospital must include feedback mechanisms to the registered provider to communicate concerns relating to any and all care delivered in order to ensure patient safety.

By 4pm on 5th February 2018 the provider must confirm in writing to the Care Quality Commission the arrangements in place with all third party organisations providing healthcare services at the Emergency Department at Russells Hall Hospital to communicate concerns relating to any and all care delivered in order to ensure patient safety.

From 9th February on the last Friday of each month thereafter until further notice, the registered provider shall report to the Care Quality Commission confirmin

Registered services

Surgical procedures

  • Diane Wake is responsible for these services.
Registered services

Diagnostic and screening procedures

  • Diane Wake is responsible for these services.
Registered services

Management of supply of blood and blood derived products

  • Diane Wake is responsible for these services.
Registered services