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The Princess Royal Hospital Inadequate

Details of this locations CQC registration


Here you will find the list of services and areas where we, the Care Quality Commission, authorise and regulate this service to operate. If you think this service is operating services not listed here please contact us

Type of service
  • Hospital
Specialisms/services
  • Services for everyone
Local authority
  • Telford and Wrekin

Regulated services/activities

CQC register The Princess Royal Hospital to carry out the following legally regulated services here:

Transport services, triage and medical advice provided remotely

  • Mrs Hayley Flavell is responsible for these services.

Maternity and midwifery services

  • Mrs Hayley Flavell is responsible for these services.

Termination of pregnancies

  • Mrs Hayley Flavell is responsible for these services.

Treatment of disease, disorder or injury

  • Mrs Hayley Flavell is responsible for these services.
Condition of this registration relating to carrying out this regulated activity

The registered provider must ensure that within three days of this notice, it reviews and implements an effective system with the aim of ensuring that all children who present to the emergency department are assessed within 15 minutes of arrival in accordance with the relevant national clinical guidelines.

The registered provider must ensure that the staff required to implement the system as set out in the previous condition are suitably qualified and competent to carry out their roles in that system, and in particular to undertake triage, to understand the system being used, to identify and to escalate clinical risks appropriately.

The registered provider must ensure that the system makes provision for effective monitoring of the patient�s pathway through the department from arrival.

The registered provider must provide the Commission with a report setting out the steps it has taken to implement the system as required in conditions two to three, within five days.

The registered provider must ensure there is a system in place which ensures that all children who leave the emergency department without being seen are followed up in a timely way by a competent healthcare professional.

From 26 April 2019 and on the Friday of each week thereafter, the registered provider shall report to the Care Quality Commission describing the system in place for effective management of children through the emergency care pathway. The report must also include the following:

a. The actions taken to ensure that the system is implemented and is effective.

b. Action taken to ensure the system is being audited monitored and continues to be followed.

c. The report should include results of any monitoring data and audits undertaken that provide assurance that a process is in place for the management of children requiring emergency care and treatment.

d. The report should include redacted information of all children who left the department without being seen; details of any follow-up and details of any harm arising through the result of the child leaving the department without being seen.

The registered provider must ensure that the systems in place across the department can account for patient acuity and the location of patients at all times.

The registered provider must ensure that within three days of this notice, it implements an effective system with the aim of ensuring that all adults who present to the emergency department are assessed within 15 minutes of arrival in accordance with the relevant national clinical guidelines.

From 6 December 2019 and on the Friday of each week thereafter, the registered provider shall report to the Care Quality Commission, using the template provided, describing the system in place for effective management of deteriorating patients and sepsis at The Princess Royal Apley Castle, Apley, Telford, TF1 6TF. The report must also include the following:

a. The actions taken to ensure that the system is implemented and is effective

b. Action taken to ensure the system it is being audited monitored and continues to be followed.

c. The report should include results of any monitoring data and audits undertaken that provide assurance that an effective sepsis management and deteriorating patient system is in place.

From 6 December 2019 and on the Friday of each week thereafter, the registered provider shall report to the Care Quality Commission describing the system in place for effective management of service users under the age of 18 through the emergency care pathway at The Princess Royal Hospital Apley Castle, Apley, Telford, TF1 6TF.The provider must use the report template provided by the Care Quality Commission and include the following;

d. The number of service users under the age of 18 not triaged within 15 minutes of arrival to the emergency department or seen by the paediatric medical team within the hour and details of any harm arising as a result of the delay.

e. Results of any monitoring data and audits undertaken that provide assurance that a process is in place for the management of children requiring emergency care and treatment

f. Details of all children who left the department without being seen; details of any follow-up and details of any harm arising through the result of the child leaving the department without being seen.

The registered provider must ensure that there is an effective system in place at The Princess Royal Hospital Apley Castle, Apley, Telford, TF1 6TF to ensure de-escalation management and intervention holds are completed in line with relevant national guidance. This includes but not limited to the use of rapid tranquilisation. This applies to all wards and departments of The Princess Royal Hospital.

From 6 December 2019 and on the Friday of each week thereafter, the registered provider shall report to the Care Quality Commission describing the system in place for ensuring de-escalation management and intervention holds are completed in line with national guidance at The Princess Royal Hospital Apley Castle, Apley, Telford, TF1 6TF. The provider must use the report template provided by the Care Quality Commission and include the following:

a. Details of de-escalation management and intervention (DMI) holds including type and length of hold and post hold action.

b. Results of any monitoring data and audits undertaken that provide assurance that a process is in place for the management of physical intervention.

The registered provider must ensure that there is an effective system in place to ensure mental health risk assessments are completed in line with relevant national guidance. This applies to all areas of the emergency department at The Princess Royal Hospital Apley Castle, Apley, Telford, TF1 6TF.

The registered provider must ensure that there is an effective system in place to identify, escalate and manage all services users in line with the relevant national clinical guidelines who present with possible sepsis or a deteriorating medical condition. This applies to all services users in all areas of the Emergency Departments and Medical Wards at The Princess Royal Apley Castle, Apley, Telford, TF1 6TF.

The registered provider must ensure that emergency department premises at The Princess Royal Hospital are safe for their intended purpose with equipment stored safely. The registered provider must ensure that risk assessments are carried out and reviewed to ensure the environment remains safe for its intended purpose and that all staff are aware of and adhere to protocols.

From 7 September 2018 and on the Friday of each week thereafter, the registered provider shall report to the Care Quality Commission confirming that there is a system in place to ensure effective environmental risk assessment and management across the emergency department of The Princess Royal Hospital. The report must include the following:

a. The results of any monitoring data and audits undertaken that provide assurance that the system of risk assessment and risk management in place is effective.

The Registered Provider must devise a process and undertake a review of current and future service users accurate clinical risk assessment and care planning, in particular ensure that the level of patients’ needs are individualised, recorded and acted upon. This must include but not limited to nutritional needs, pressure ulcers, risk assessment/falls and medical equipment from home.

The Registered Provider must devise, review and assess the effectiveness of the system, process for care planning records and provide the Care Quality Commission with a report setting out the actions taken or to be taken in relation to condition 1 above by 03 July and on the last Friday of each month.

The registered provider must ensure that:

a. there are sufficient numbers of suitably qualified, skilled, competent and experienced staff at all times to meet the needs of patients within all wards. Including for care planning and Deprivation of Liberty Safeguards (DoLs)

b. staff undertaking care planning and DoLs do so in line with the provider’s policy and protocol.

c. there is clear documentation to inform staff of the current care planning and DoLs where applicable, of all patients this includes details of any changes to patients’ individualised needs are clearly recorded and are easily accessible to relevant staff and acted upon.

d. Monitoring conducted to ensure that the above is measurable.

From 3 July 2020 and on the last Friday of each month thereafter, the Registered Provider shall report to the Care Quality Commission describing the learning from all incidents, and the system(s) in place for effective management of such incidents, the report must include:

a) confirmation that system(s) is implemented and is effective, with the inclusion of the incident investigation report

b) details of action taken to ensure the system(s) is being audited monitored and continues to be followed

c) results of monitoring data and audits undertaken that provide assurance that action is taken to improve the quality and safety of services.

The Registered Provider must provide the Care Quality Commission with a report setting out the actions taken or to be taken in relation to conditions 1-4 above by 03 July and on the last Friday of each month thereafter. The report must also include the following:

a. details of the system(s) and processes that are implemented to comply with the conditions,

b. details and confirmation of action taken to ensure the system(s) are being audited and monitored to improve the quality and safety of services.

Assessment or medical treatment for persons detained under the 1983 Act

  • Mrs Hayley Flavell is responsible for these services.

Surgical procedures

  • Mrs Hayley Flavell is responsible for these services.

Diagnostic and screening procedures

  • Mrs Hayley Flavell is responsible for these services.

Management of supply of blood and blood derived products

  • Mrs Hayley Flavell is responsible for these services.