Source · CQC inspection
Bushey Fields Hospital
Provider Dudley Integrated Health and Care NHS Trust
Type NHS Healthcare Organisation
Region West Midlands
Last inspected 23 Jan 2020
Overall rating: Good View full CQC report
Domain ratings
Safe
Not Yet Rated
Effective
Not Yet Rated
Caring
Not Yet Rated
Responsive
Not Yet Rated
Well-led
Not Yet Rated
Earlier inspection findings
Must-do actions (3)
Must-do action 1 of 3
Must do
Safe
The registered person must take proper steps to ensure that each service user is protected against the risks of receiving care or treatment that is inappropriate or unsafe, by means of – b) the planning and delivery of care and, where appropriate, treatment in such a way as to – i) meet the service users individual needs, ii) ensure the welfare and safety of the service user iii) reflect, where appropriate, published research evidence and guidance issued by the appropriate professional and expert bodies as to good practice in relation to such care and treatment
Must-do action 2 of 3
Must do
Safe
The registered person must protect service users, and others whom may be at risk, against the risks of inappropriate or unsafe care and treatment, by means of the effective operation of systems designed to enable the registered person to – b) identify, assess and manage risks relating to the health, welfare and safety of service users and others whom may be at risk from the carrying on of the regulated activity.
Must-do action 3 of 3
Must do
Caring
17.—(1) The registered person must, so far as reasonably practicable, make suitable arrangements to ensure— (a) the dignity, privacy and independence of service users;
Should-do actions (11)
Should-do action 1 of 11
Should do
Well-led
Develop a clear vision for older people’s services and share with staff, patients, relatives and stakeholders.
Should-do action 2 of 11
Should do
Effective
Ensure that specialist training is provided to all staff working in specialist areas of the trust.
Should-do action 3 of 11
Should do
Safe
Risk management plans should be developed and implemented from individuals’ risk assessments, and people should be involved in developing these plans and advance decisions where appropriate.
Should-do action 4 of 11
Should do
Well-led
Develop and implement audits to assess practice against the Mental Health Act Code of Practice as well as the legal documentation in use. Ensure the Mental Health Act scrutiny committee are informed of the outcomes of these audits and develop action plans where needed.
Should-do action 5 of 11
Should do
Caring
Identify ways in which informal patients can leave the ward and understand their rights to leave.
Should-do action 6 of 11
Should do
Caring
Improve levels of engagement with the IMHA service
Should-do action 7 of 11
Should do
Safe
Ensure that the environment on Holyrood ward at Bushey Fields Hospital reflects national guidance to safely meet the care needs of peoples suffering with dementia.
Should-do action 8 of 11
Should do
Effective
Ensure that the quality of care and treatment within older people’s services reflects best practice and national guidance, and that practice is monitored and evaluated on a regular basis.
Should-do action 9 of 11
Should do
Safe
The use of seclusion must be correctly recorded and practice monitored against the Code of Practice. The trust must ensure that areas used for seclusion are safe and risks removed and the appropriate safeguards put into place.
Should-do action 10 of 11
Should do
Caring
Ensure that the mixed gender units comply fully with the national guidance.
Should-do action 11 of 11
Should do
Safe
Ensure that the health-based places of safety reflect the national guidance regarding environment to ensure people using services are protected against the risks of potentially unsafe or unsuitable premises.