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Provider: The Dudley Group NHS Foundation Trust Requires improvement

On 12 July 2019, we published a report on how well The Dudley Group NHS Foundation Trust uses its resources. The ratings from this report are:

  • Use of resources: Requires improvement  
  • Combined rating: Requires improvement  

Read more about use of resources ratings

Registration details


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

Maternity and midwifery services

  • Ms Diane Wake is responsible for these services.
Registered services

Termination of pregnancies

  • Ms Diane Wake is responsible for these services.
Registered services

Services in slimming clinics

  • Ms Diane Wake is responsible for these services.
Registered services

Nursing care

  • Ms Diane Wake is responsible for these services.
Registered services

Family planning services

  • Ms Diane Wake is responsible for these services.
Registered services

Treatment of disease, disorder or injury

  • Ms 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 at the Emergency Department at Russells Hall Hospital to fully clinically assess, identify and escalate clinical risk of all patients who present to the emergency department in line with relevant national clinical guidelines within 15 minutes of arrival. In particular, the registered provider must ensure that the clinical assessment and the rationale for level of care provided is clearly documented in patients’ records.

From 26 July 2019 and on the last Friday of each month 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 clinically assess all patients within 15 minutes of arrival at the Russells Hall Hospital Emergency Department and progress on its implementation

b) Details or description of the system or process implemented and the outcome of auditing, monitor

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. The provider must ensure staff are appropriately trained in delivering and documenting all parts of this process. This applies to all patients in all areas of the emergency department.

From 26 July 2019 and on the last Friday of each month thereafter, the registered provider shall report to the Care Quality Commission describing:

a) The actions taken to ensure that effective deteriorating patient and sepsis management systems are in place and

b) how these are being audited, monitored and acted upon. This should include results and copies of any audits undertaken that provide assurance to the board of The Dudley Group NHS Foundation Trust that an effective sepsis management and deteriorating patient system is in place.

The registered provider must ensure that the medical and nursing skill mix and the numbers of suitably qualified, skilled, competent and experienced nursing and medical staff deployed across all areas of the emergency department, including any areas where patients are waiting to be seen, are sufficient to meet conditions 1 and 2.

From 26 July 2019 and on the Friday of each week thereafter, the registered provider shall report to the Care Quality Commission describing:

a)The staffing levels for all areas of the emergency department including any area patients are waiting to be seen. This information should include grades of staff and numbers covering the 24-hour period and where they are deployed and how the board is assured they have knowledge, skills and competence for the role they are deployed to.

Registered services

Surgical procedures

  • Ms Diane Wake is responsible for these services.
Registered services

Diagnostic and screening procedures

  • Ms Diane Wake is responsible for these services.
Registered services

Management of supply of blood and blood derived products

  • Ms Diane Wake is responsible for these services.
Registered services