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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 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. This includes ensuring staff are competent to undertake triage, understand the system being used, identify and escalate clinical risks appropriately. This system must also include effective monitoring of the patient’s pathway through the department from arrival and enable staff to locate patients.

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

From 29 June 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 clinically assess all patients within 15 minutes of arrival at the emergency department and progress on its implementation.

b) The process and outcome of auditing, monitoring and implementing this system.

c) Copies of all audits undertaken and assurance given to the Board of The Dudley Group NHS Foundation Trust that an effective system is in place.

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 all patients in all areas of the emergency department.

From 29 June 2018 and on the Friday of each week thereafter, the registered provider shall report to the Care Quality Commission describing:

a) The actions taken to ensure that 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 and copies of any audits undertaken that provide assurance to the board that an effective sepsis management and deteriorating patient system are in place.

The registered provider must ensure that there are sufficient numbers of suitably qualified, skilled, competent and experienced clinical staff at all times to meet the needs of patients within all areas of the Emergency Department including any area where patients are waiting to be seen.

From 29 June 2018 and on the Friday of each week thereafter, the registered provider shall report to the Care Quality Commission describing:

a) The staffing levels and leadership 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 the knowledge, skills and competence for the role they are deployed to.

The provider must ensure that specialist clinical expertise is secured to ensure expertise across the emergency department. The clinicians should provide the oversight of care provision, ensuring all patients receive care from senior clinicians that is safe, effective, timely and in line with best practice.

From 24 August 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 specialist clinical teams are resourced and have capacity to offer clinical oversight as required to meet the needs of patients.

b) The process and outcome of monitoring and implementing this additional clinical support for the department.

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