- SERVICE PROVIDER
Bedfordshire Hospitals NHS Foundation Trust
This is an organisation that runs the health and social care services we inspect
Registration details
The provider ID for Bedfordshire Hospitals NHS Foundation Trust is RC9. These are the registration details of the provider Bedfordshire Hospitals NHS Foundation Trust. They set out what services Bedfordshire Hospitals NHS Foundation Trust can legally provide, where they can provide them and who is responsible for them.
Maternity and midwifery services
Mr David Carter is responsible for these services.
Condition of this registration relating to carrying out this regulated activity
The registered provider must within 28 days of the condition coming into effect implement an effective risk and governance system which ensures that:
a. There is enhanced oversight at service, division, and board level in the management and closure of outstanding risks, incidents, and duty of candour within the maternity services to protect women, and babies.
b. Risk and occurrence of incidents are properly identified and managed, to include an effective system of recording actions taken and ensuring learning from any incidents.
c. All outstanding incidents within the backlog are reviewed, actioned and closed by an appropriate member of the multidisciplinary team. Learning from all outstanding incidents are shared with staff.
d. All outstanding duty of candour within the backlog are reviewed, actioned and closed by an appropriate member of the multidisciplinary team. Learning from all outstanding incidents are shared with staff and external stakeholders.
e. All outstanding complaints within the backlog are reviewed, actioned and closed by an appropriate member of the multidisciplinary team. Learning from all outstanding complaint investigations are shared with staff and external stakeholders.
f. All out-of-date policies, guidelines and standard operating procedures are reviewed and ratified by the multidisciplinary team and changes communicated to staff.
The registered provider must ensure maternity staff have completed their mandatory and maternity specific training in line with the trust policies within 90 days of these conditions taking effect and undertake regular and impromptu skills and drills in all clinical areas and community. This includes annual mandatory level 3 safeguarding adult and children's training, PROMPT and baby abduction drills to ensure all staff are trained to respond to emergency scenarios.
The registered provider must within 28 days of these conditions taking effect establish and implement an effective system to ensure regular staff appraisals take place at Luton and Dunstable Hospital and Bedford Hospital and provide written confirmation to CQC within 35 days of the summary of that system that had been put in place at both registered locations.
The registered provider must within 28 days of these conditions taking effect operate an effective clinical escalation system to ensure the triage telephone line at Bedford Hospital is managed by a dedicated and appropriately trained, skilled and competent, midwife to triage, assess, and prioritise women according to their clinical need.
Within 28 days of these conditions taking effect, the registered provider must provide a detailed action plan which includes:
a. Evidence of how investigation of complaints and incidents, and completion of duty of candour will be monitored, to include but not limited to documentary evidence such as a governance framework, incidents, audits, performance data, meeting minutes, terms of reference of all relevant meetings and evidence of trust board oversight. In addition, evidence of how findings and learning will be communicated with all staff and external stakeholders.
b. A detailed plan and timely estimated date of closure for all outstanding incidents, complaints and duty of candour.
c. A detailed plan and estimated date for the relocation of the telephone triage line out of triage area and the introduction of a dedicated, skilled and competent telephone triage midwife at Bedford Hospital.
d. A detailed plan providing details of an effective system and process to ensure that medical and midwifery staff have an annual appraisal of their work and performance.
e. A plan providing details of how you will ensure staff are suitably qualified, skilled, and competent to care for and meet the needs of women and babies within all areas of the maternity services. Relating to mandatory training and skills and drills.
f. Summary report of the actions taken to address the above risks to patients, this should include detailed evidence of how this will be achieved, sustained, and monitored going forward.
g. The action plan must include assigned responsibilities and timelines for completion.
Within 28 days of the conditions taking effect and thereafter by 4pm on the last Friday of every month, the registered provider must submit to the Care Quality Commission (CQC) the following:
a. An updated copy of the action plan provided in accordance with condition 5 which covers all conditions contained within this notice.
b. An updated progress report on the number of outstanding incidents, complaints and duty of candour.
c. All reports submitted in the last four weeks to the senior leadership team and trust board to demonstrate compliance with the conditions.
Registered services
Termination of pregnancies
Mr David Carter is responsible for these services.
Registered services
Family planning
Mr David Carter is responsible for these services.
Registered services
Treatment of disease, disorder or injury
Mr David Carter is responsible for these services.
Registered services
- Archer Unit
- Luton and Dunstable University Hospital Orthopaedic Centre
- Luton and Dunstable Hospital
- Chaul End Community Centre Health Suite
- Arndale House
- Bedford Hospital
Assessment or medical treatment for persons detained under the Mental Health Act 1983
Mr David Carter is responsible for these services.
Registered services
Surgical procedures
Mr David Carter is responsible for these services.
Registered services
Diagnostic and screening procedures
Mr David Carter is responsible for these services.
Registered services
- Gilbert Hitchcock House
- Luton and Dunstable University Hospital Orthopaedic Centre
- Luton and Dunstable Hospital
- Chaul End Community Centre Health Suite
- Arndale House
- Bedford Hospital
Management of supply of blood and blood derived products
Mr David Carter is responsible for these services.