Source · CQC inspection

Russells Hall Hospital

Provider The Dudley Group NHS Foundation Trust Type NHS Healthcare Organisation Region West Midlands Last inspected 22 Nov 2023

Overall rating: Requires Improvement  View full CQC report

Domain ratings

Five CQC key questions
Safe
Requires Improvement
Effective
Good
Caring
Good
Responsive
Requires Improvement
Well-led
Good

Earlier inspection findings

pre-2024 framework · 3 must-do 12 should-do

Must-do actions (3)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 3
Must do
Responsive
The trust must ensure they continue their work to improve ambulance handovers and patient flow within the department.
Regulation: Regulation 17 (Good governance)
⚠ The service was not meeting its target of 95% of patients offloaded from ambulances within 15 minutes. This was reported as being consistently low and on average was 25% (February 2023), 25% (March 2023) and 20% (April 2023). Patient offload delays have a detrimental impact on patient care on the …
Must-do action 2 of 3
Must do
Safe
The trust must ensure the service improves compliance in relation to national guidelines on staffing levels.
Regulation: Regulation 18 (Staffing)
⚠ The service did not always have enough nursing staff to ensure staffing ratios were met. On the children’s ward (C2) there were 6 long days in May 2023 (19%) when planned Royal College of Nursing staffing ratios were not met and 8 long nights (26%) that did not meet the …
Must-do action 3 of 3
Must do
Safe
The trust must ensure that they maintain an accurate, complete and contemporaneous record in respect of each service user, including a record of care and treatment provided to the service user and of decisions taken in relation to the care and treatment provided.
Regulation: Regulation 17 (Good governance)
⚠ Staff did not always keep detailed records including that of children and young people's care and treatment. We found gaps in record keeping was a consistent theme within patient notes, including missing information, gaps and inconsistent documentation in patient records including risk assessments.

Should-do actions (12)

Recommended improvements to enhance service quality.

Should-do action 1 of 12
Should do
Safe
The trust should ensure that all staff are up to date with their mandatory training.
Regulation: Regulation 12 (Safe care and treatment)
Should-do action 2 of 12
Should do
Responsive
Managers should ensure that services are planned to meet the needs of local people with regard to the resuscitation area.
Regulation: Regulation 17 (Good governance)
Should-do action 3 of 12
Should do
Responsive
The trust should ensure family discussions with children are consistently recorded and discussed.
Regulation: Regulation 17 (Good governance)
Should-do action 4 of 12
Should do
Safe
The trust should ensure they improve their performance in relation to their deteriorating patient pathway measures.
Regulation: Regulation 12 (Safe care and treatment)
Should-do action 5 of 12
Should do
Safe
The trust should ensure that medicines charts are completed correctly.
Regulation: Regulation 12 (Safe care and treatment)
Should-do action 6 of 12
Should do
Effective
The trust should continue to review and identify if their training meets the statutory learning disability and autism training requirements.
Regulation: Regulation 12 (Safe care and treatment)
Should-do action 7 of 12
Should do
Well-led
The trust should ensure all staff receive a regular appraisal.
Regulation: Regulation 17 (Good governance)
Should-do action 8 of 12
Should do
Effective
The trust should continue to act on the recommendations of the MBRACE-UK perinatal mortality report.
Regulation: Regulation 12 (Safe care and treatment)
Should-do action 9 of 12
Should do
Safe
The trust should ensure they improve their performance in relation to their deteriorating patient pathway measures.
Regulation: Regulation 12 (Safe care and treatment)
Should-do action 10 of 12
Should do
Safe
The trust should ensure they continue to improve compliance in relation to national guidelines on Quality in Service trained staff in line with its trajectory.
Regulation: Regulation 18 (Staffing)
Should-do action 11 of 12
Should do
Safe
The trust should ensure that all areas are organised, tidy and clutter free and that oxygen masks are kept organised for ease of access.
Regulation: Regulation 12 (Safe care and treatment)
Should-do action 12 of 12
Should do
Safe
The trust should ensure they continue to improve compliance in relation to mandatory training around resuscitation.
Regulation: Regulation 18 (Staffing)

Location details

CQC ID: RNA01
Local authority: Dudley
Region: West Midlands

Inspection report

Type: Location
Date: 22 November 2023
Rating: Requires Improvement
Actions: 3 must-do 12 should-do
AI-extracted 3 Jun 2026