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Inspection Summary

Overall summary & rating


Updated 23 January 2018

Our rating of these services improved. We took into account the current ratings of services not inspected this time. We rated them as outstanding

A summary of our findings about West Suffolk Hospital appears in the overall summary

Inspection areas



Updated 23 January 2018



Updated 23 January 2018



Updated 23 January 2018



Updated 23 January 2018



Updated 23 January 2018

Checks on specific services

Maternity and gynaecology


Updated 4 August 2016

Maternity and gynaecology services were rated as good overall. Safe, effective, caring and responsive were rated as good with well-led rated as requires improvement.

All investigations of incidents were reported via an electronical incident reporting system. Approximately 70 incidents were reported on average per month from maternity and gynaecology services. Between December 2014 and November 2015 there were 835 incidents reported, of which two were classified as catastrophic, one classified as major, three classified as moderate, with 48 minor and 11 negligible. There was clear evidence of learning from these incidents with development for staff and changes in practice embedded. There was one never event declared from this service following a retained swab during gynaecology surgery. There are no separate obstetric theatres because patients are transferred to theatres for surgery under the care of the theatre staff.

The maternity service provided a ratio of one whole time equivalent (WTE) midwife to 29 births, which was against the national standard of 1:29. Between April 2015 and July 2015 the reported ratio was as high as 1:30, whilst In January 2016 the ratio was reported as 1:26. The last completed review of maternity staffing levels was in 2011. The Trust consistently achieves an average birth to midwife ratio of 1:29 using community and specialist midwives. This achieved a better than average coverage of 1:26 in January 2016.

Emergency drugs were stored securely and were not at risk of theft or tampering.

Appraisal rates for maternity and gynaecology nursing, midwifery, support and clerical staff was 95% overall. However, medical staff appraisal rates were reported at 93%. The six medical staff we spoke with all confirmed that they had completed their appraisal which supported revalidation.

Community midwives had access to information technology. However, we were informed that the wireless internet connection was more problematic for staff based at Bury St Edmunds rather than in the rural parts of the county. Senior staff were aware of this and the issue was recorded on the risk register which meant that the trust wide team were aware that this required addressing.

The gynaecology waiting times for 2015 received from the trust and discussed with the gynaecology lead consultant informed us of targets achieved. The 18 week to admission target had been achieved in 2015. There were no closures of the maternity unit between January 2015 and January 2016, which meant that the maternity team were consistently working to meet the needs of the local population. Quarter 1 report for 2015/16 showed the bed occupancy did not exceed 33%.This meant that staff had the capacity to deliver high quality care during this time.

The maternity service was operating with ratified guidelines but there was guidance cited relating to reviews that had no date.

Not all staff were aware of the vision of the maternity service which meant that it was not fully embedded. There were links to the trust wide strategy of “putting you first”, one vision with three priorities and seven ambitions, all displayed on the wards.

The national targets for unassisted birth, caesarean section and instrumental delivery rates had been met. There was an anaesthetic consultant on-call rota for the maternity service 24 hours a day, seven days a week providing epidurals when requested.

The women’s experience survey 2015 showed that the trust performed approximately the same as other trusts for all measures on the care they received and that they were supported to make informed choices.

There was 68% of medical staff trained to level three. The trust were supporting further training to promote staff awareness of safeguarding but had no action plans for addressing shortfall in safeguarding training.

The maternity service and the maternity services liaison committee (MSLC) was established but with recent multiple changes in leadership and interim cover there remained some instability. At the time of our inspection, there were no identified links with the trust and the clinical commissioning group (CCG) to improve care for women.

There had been a reported bullying and unsupportive culture involving a small number of senior staff since April 2015. The trust informed us of a number of actions which it had taken to address the situation. However, staff appeared unaware of these plans. Staff had some unease regarding the sustainability of improvements.

PROMPT (practical obstetric multi-professional training), compliance was 85% for midwifery staff.

At the time of our inspection, there were no identified links with the trust and the clinical commissioning group (CCG) to improve care for women.

Medical care (including older people’s care)


Updated 4 August 2016

Medical services at West Suffolk Hospital were rated as outstanding overall because patients were protected from avoidable harm and abuse and the concept of ‘safe’ was embedded in medical care service practice.

Quality improvement strategies were developed and outcomes were monitored and acted upon.

Standards of hand washing and cleanliness were consistently good and regularly audited.

Incident reporting was embedded amongst nursing and allied health care professionals and learning from incidents was promoted.

Staffing levels reflected the needs of the patients and the trust was proactive in its recruitment of staff.

Trust performance against national audits was outstanding especially in the Sentinel Stroke National Audit Programme (SSNAP) and Myocardial Ischaemia National Audit (MINAP). The trust was able to provide evidence of changes made in response to the feedback received. It was clear that staff and senior leaders saw clinical audit as an effective improvement tool.

Patients received compassionate care and were treated with dignity and respect and their privacy was preserved. Patients and relatives felt involved in their care and stated that they were given adequate information about their care and treatment. The trust had a higher response rate to the friends and family test than the England average. Complaints were used as a means to improve services.

The medical service was responsive to patients’ needs. Staff worked hard to reduce avoidable admissions and improve early discharges. Whilst out-of-hours transfers still occurred, these were kept to a minimum and reported to senior team members.

The acute medical unit was regularly used for inpatient beds during periods of escalation. This meant ambulatory care was either restricted or suspended on a regular occasion with patients having to attend the AMU separately or remain in the emergency department.

Leadership within the medical care service was good. Clear accountable governance structures existed and individuals owned and identified risks and were appropriately held to account. The culture within the medical care service was open and honest. The trust wide objectives were well known by all levels of staff and volunteers.

Urgent and emergency services (A&E)


Updated 4 August 2016

Urgent and emergency care services were rated as good overall, with safe as requiring improvement.

There were clear protocols for the management of stroke and sepsis and care pathways were completed appropriately. There were good examples of multi-disciplinary team working such as the early intervention team and psychiatric liaison team. There was good evidence and robust management of staff training.

Patients and families were positive about the care and service received. Between August 2014 and October 2015 the percentage of patients who would recommend the ED department ranged between 91 and 95% which was significantly higher than the England average.

There was a dedicated fast track process for gynaecology patients, and examinations occurred in a dedicated assessment area which enabled additional privacy and dignity for these patients.

The nursing workforce was a well-established team. There were clear indications of good engagement and staff felt confident in the leadership. The clinical lead and service manager had clear visions for the service and department. There was evidence of information sharing and staff had the opportunity to contribute to the development of the electronic patient records system. Nursing and medical staff worked effectively together and nurses felt well supported by consultant colleagues.

Safety of the service required improvement because the children’s emergency waiting area was not fit for purpose and was located within the main waiting area. There was no clear policy or escalation process for observing children for signs of deterioration. The trust told us that the reception staff would inform parents to escalate concerns but we did not see this at our inspection and staff were unaware of this process.

Nursing observations for both adult and paediatric patients was inconsistent. Documentation was inaccurate in 23 sets of notes out of 40 reviewed, and not escalated when observations were outside the recommended range.

Nurse staffing levels were insufficient for both registered nurses (RN) and paediatric nurses. This impacted on the clinical decisions unit, which admitted patients with a predicted length of stay of less than 24 hours. Nursing staff from the emergency department (ED) were often utilised to work in CDU but remained in the overall ED numbers. The current, and proposed increase in paediatric nurses, did not allow for overnight cover.

The department discussed complaints at governance meetings and issued a newsletter but there was no evidence of learning from complaints and implementing and embedding changes to improve patient care.

The policy and practice for admitting patients to CDU had the potential to not be compliant with the Department of Health 2010-2012 guidance on eliminating mixed sex accommodation which includes all admissions and assessment units including clinical decision units. The trust CDU policy states that patients that requiring a stay of less than 24 hours are admitted to CDU.



Updated 4 August 2016

Surgery services at West Suffolk Hospital were good overall.

Incident reporting and management were robust, with evidence of investigation, scrutiny and learning. Harm free care was actively promoted on wards, and risk assessments and checks were in place for all four harms (falls, pressure ulcers, urinary tract infections and venous thromboembolisms), including a regular audit and learning cycle. Equipment and resuscitation equipment was regularly safety checked and maintained. There were processes for checking and security of medicines, including controlled drugs. Management of surgical and nursing staffing was good with low sickness and vacancy rates.

Patient care was in accordance with national guidelines and best practice recommendations. National, regional and local clinical audits were completed. A range of clinical governance groups provided oversight to ensure the trust adhered to best practice guidelines and responded to changes in legislation. National and local guidelines were accessible to staff and local and national audits were performed regularly. The service performed better than the England average in the Hip Fracture audit and performance was good in the 2014 Lung Cancer Audit.

Staff were caring, compassionate, and treated patients in a professional and considerate manner with dignity and respect. Friends and family test (FFT) and patient survey results were consistently positive. Patients reported feeling involved in planning their care and received enough information about their conditions. Specialist nurses provided emotional support to patients.

Overall, lengths of stay were better than the England average and surgical outliers rarely occurred. The surgical wards worked together to ensure that access and flow through the service was well prioritised. Discharge planning was effective and involved a multidisciplinary team and the patient. Patients requiring additional support at home had their discharge facilitated by a dedicated complex discharge planning team.

The service was proactive in planning for known events such as industrial action. There was a high focus on meeting the needs of people living with dementia, including the use of hospital passports and bespoke knitted items. Complaints management had improved year on year.

Local leadership was good with staff feeling able to raise concerns.

Intensive/critical care


Updated 4 August 2016

Overall critical care was rated as ‘good’. Safe and caring were rated as good, effective and well led rated as outstanding and responsive rated as requires improvement.

This reflects consistently good staffing levels of doctors and nurses, which met the safe standards established by the Faculty of Intensive Care Medicine, the Royal College of Physicians and the Royal College of Nursing. Two dedicated professional development nurses managed mandatory training in the unit and provided substantial development support and opportunities to nursing staff.

There was consistent, seven-day input from a multidisciplinary team of specialists. The standard of medicine management was very high and the unit had a dedicated full time pharmacist. A follow-up nurse, audit nurse and technologist significantly extended the scope and effectiveness of the critical care service.

Staff practiced evidence-based care and treatment based on the best practice guidance of the National Institute for Health and Care Excellence and developed plans to improve the service by using the results of local and national audits.

There was a demonstrable focus on providing individualised care based on feedback from patients and their relatives and from the outcomes of pilot projects conducted by critical care staff. Additional support for critical care patients was provided by a follow-up nurse and a critical care outreach team, who also provided a cross-department education programme.

Staff were encouraged and supported to undertake novel research projects, which they were able to present at national conferences as a knowledge-sharing strategy. Senior staff had developed a robust five-year service plan in collaboration with unit staff, which was further evidence of the cohesive and supportive work culture we found.

Dedicated housekeeping staff maintained a very high level of cleanliness and hygiene and infection control evidence reflected this.

There were a number of areas within the service we judged to require improvement. For example, staff did not always understand or use incident-reporting processes and investigations did not always result in demonstrable learning. There was a lack of governance in relation to incidents.

The principles of infection control were not always evident in the unit for a patient who was potentially infectious. Staff did not always provide continuous and appropriate supervision for high dependency level two and level one patients when they were cared for in side rooms.

Services for children & young people


Updated 4 August 2016

Services for children and young people at West Suffolk Hospital were good.

The children’s wards and treatment areas were visibly clean.

Management and storage of medicines was appropriate and safe.

Staff knew how to safeguard children and undertook relevant specialist paediatric training.

The services managed risk well and used a paediatric early warning system to identify if a child’s health was deteriorating. There had been no serious incidents in the services in 2015 and staff learned from minor incidents and shared their learning.

The services planned and delivered children’s and neonatal care in line with national, regional and local guidelines and carried out clinical audits. Nursing staff and doctors had high levels of skills and competencies and worked well with other teams in the hospital to find the best solutions for children.

There was seven-day access to diagnostics and fast tracking was available for children’s x-rays for the same morning/afternoon if needed.

Nursing staff and doctors were compassionate and dedicated to the welfare of children. Care was tailored to individual children. The services offered a high level of psychological and emotional support.

Consultants worked to provide access for patients. They set up outreach clinics in GP premises and held telephone clinics so that patients could stay in their own surroundings. Staff saw and treated children promptly in the hospital in most cases.

Nurses, doctors and managers had a vision for children and neonatal services which reflected the trust’s strategy of working with other providers in the community. There was clear leadership in the services and staff told us they enjoyed working for the services. Staff listened to children and their parents and had made improvements in response to feedback.

End of life care


Updated 23 January 2018

The hospital does not have a dedicated ward for end of life care. The specialist palliative care team (SPCT), which consists of specialist consultants and nurses, provide advice, assessment and treatment to patients across all clinical areas within the hospital. The SPCT also supports ward staff to deliver care to patients at the end of life.

Between 1 Jan 2017 and 31 Oct 2017, there were 8,404 patients referred as suspected cancer and first seen in the West Suffolk hospital. Of these 658 patients commenced treatment for a new cancer during that period, giving the cancer conversion rate of 7.8%.

Our rating of this service improved. We rated it as outstanding because:

  • The trust had enough staff with the right qualifications, skills, training, and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment. The nurse staffing for the specialist palliative care team (SPCT) was in line with national guidance. This was an improvement since our last inspection.
  • The trust managed patient safety incidents well. Staff recognised incidents and reported them appropriately using the services electronic incident-reporting tool.
  • The trust controlled infection risk. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection.
  • The trust had suitable premises and equipment and looked after them.
  • The trust prescribed, gave, recorded and stored medicines. Patients received the right medication at the right dose at the right time.
  • Staff kept appropriate records of patients’ care and treatment. Records were clear, up-to-date, and available to all staff providing care. The service had implemented an electronic patient records system since our last inspection. Staff completed individualised care, which was in line with national guidance, and record keeping had improved since our last inspection.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.
  • The trust had enough staff with the right qualifications, skills, training, and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment. The nurse staffing for the specialist palliative care team (SPCT) was in line with national guidance. This was an improvement since our last inspection.
  • The trust provided care and treatment based on national guidance and evidence of its effectiveness. Where the organisation did not meet clinical indicators there were actions from audits in place.
  • The trust provided care and treatment based on national guidance and evidence of its effectiveness. We reviewed end of life care clinical guidelines and found that they were version controlled, ratified and in date for review. Staff in the SPCT informally monitored their response times, preferred place of death and preferred place of care, and audited this data.
  • Staff gave patients enough food and drink to meet their needs and improve their health. They used special feeding and hydration techniques when necessary. The service made adjustments for patients’ religious, cultural, and other preferences.
  • The trust monitored the effectiveness of care and treatment and used the findings to improve them. They compared local results with those of other services to learn from them.
  • The trust made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service.
  • Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
  • Staff always had access to up-to-date, accurate, and comprehensive information on patients’ care and treatment. All staff had access to an electronic records system that they could all update patient care records.
  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care.
  • Consent to treatment was sought in line with legislation and guidance. Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) forms completed well. We reviewed seven DNACPR forms and found that these included records of discussions with patients and relatives and signed by a senior clinician, this was an improvement since our last inspection.
  • Staff truly respected and valued patients as individuals and empowered them as partners in their care, practically and emotionally, by offering an exceptional and distinctive service.
  • Feedback from people who used the service, those who are close to them and stakeholders was continually positive about the way staff treated people. Patients said that staff went that extra mile and their care and support exceeded their expectations.
  • The end of life service had a strong, visible person-centred culture. Staff were highly motivated and inspired to offer care that was kind and promoted people’s dignity. We found strong caring, respectful and supportive relationships between people who used the service, those close to them and staff. Staff highly valued these relationships and felt promoted by leaders.
  • Staff recognised and respected the totality of people’s needs. They always considered people’s personal, cultural, social, and religious needs, and found innovative ways to meet them.
  • Staff consideration of people’s privacy and dignity was consistently embedded in everything that staff did, including awareness of any specific needs as these are recorded and communicated.
  • Staff saw people’s emotional and social needs as being as important as their physical needs.
  • Staff at the service treated patients with compassion, dignity, and respect and involved them in their care. All patients we spoke to were positive about the care given by staff and staff went over and above their normal roles to provide addition care and support.
  • The service took account of patients’ individual needs. Staff took account of the spiritual and religious needs of patients and actively sought to promote these within individual care plans.

  • Staff involved patients and those close to them in decisions about their care and treatment.
  • Staff provided emotional support to patients to minimise their distress.
  • The trust planned and provided services in a way that met the needs of local people.
  • The service took account of patients’ individual needs.
  • The end of life care services received no complaints in the 12 months prior to our inspection. However, staff knew how to treat concerns and complaints seriously, investigate them and learn lessons from the results, to share with all staff.
  • The trust had compassionate, inclusive, and effective leadership at all levels. Leaders at all levels demonstrated high levels of experience, capacity, and capability needed to deliver excellent and sustainable care.
  • Comprehensive and successful leadership strategies were in place to ensure and sustain service delivery and to develop the desired culture. Leaders had a deep understanding of issues, challenges, and priorities in their service, and beyond.
  • The end of life strategy, supporting objectives and plans were stretching, challenging and innovative, while remaining achievable. Strategies and plans were fully aligned with plans in the wider health economy, and there was a demonstrated commitment to system-wide collaboration and leadership.
  • The SPCT were proud of the organisation as a place to work and spoke highly of the culture. Staff were actively encouraged to speak up and raise concerns, and all policies and procedures positively supported this process.
  • There was strong collaboration, team working, and support across all functions with a common focus on improving the quality and sustainability of care and people’s experiences within end of life care. The trust celebrated safe innovation and there was a clear, systematic, and proactive approach to seeking out and embedding new and more sustainable models of care.



Updated 23 January 2018

West Suffolk NHS Foundation Trust provides its main outpatients services at West Suffolk Hospital. It also provides outpatients clinics at services based at Newmarket Hospital and in local health centres. These satellite services are managed by the same team who oversee main outpatients. We did not inspect any of the other locations during this inspection.

See guidance note AL4 then add your text after the standard text paragraph below (and delete this help text).

Our rating of this service stayed the same. We rated it it as good because:

  • Staff ensured equipment and premises were clean and ready to use and used appropriate practises to prevent and protect people from a healthcare associated infection.
  • Medicines and prescriptions were stored and monitored safely and records were accessible clear and up to date.
  • Staff understood how to protect patients from abuse and had training on how to recognise and report abuse and they knew how to apply it.
  • Staff cared for patients with compassion and empathy.
  • Staff involved patients and those close to them in decisions about their treatment and provided emotional support. Many of the specialist services had telephone advice lines to where patients were able to access advice and support.
  • The service provided care and treatment based on national guidance and monitored evidence of its effectiveness to improve outcomes.
  • There were sufficient staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment and there was good support and access to training for staff to develop.
  • Staff of different kinds worked together as a team. Staff also worked well with other health care providers to benefit patients.
  • The trust planned and provided services in a way that met the needs of local people and of individuals who required additional support. Clinics were easily accessible and the newer specialist clinics were well planned and comfortable.
  • The trust has consistently performed better than the England average for people being seen within two weeks of an urgent GP referral, and receiving treatment within 31 days for a suspected cancer.
  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with all staff.
  • The service had managers at all levels with the right skills and abilities to run the service providing high-quality sustainable care and had vision for what it wanted to achieve and workable plans to turn it into action.
  • Managers across the trust promoted a positive culture that supported and valued staff. There was good team work within the teams and staff were proud of their service and this was evident in the family like atmosphere and good interpersonal relationships.
  • The concerns following a change to electronic patient recording when the trust had been unable to accurately report referral to treatment time data had been resolved and we were assured that the trust collected, analysed, managed and used information well.
  • The service engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively.
  • The trust was committed to improving services by learning from when things go well and when they go wrong, promoting training, research and innovation.


  • Appraisal rates were not consistent across staff groups and did not meet trust targets. Mandatory training was below trust targets and the trust had not addressed the training of clinicians to Safeguarding level three for children despite them seeing 4,742 children between May and October.
  • We were not assured that all equipment was regularly tested for electrical safety.
  • There was no obvious information available to patients regarding the availability of chaperones which meant that patients did not know to ask for a chaperone if required.
  • The overall referral to treatment times for non-admitted pathways were worse than the England average between September 2016 and August 2017 (89.6% versus 85.9%). However 11 specialties were better than the England average with 7 worse. The trust had a cohort of patients on a ‘backlog’ or patient tracking list (PTL) awaiting outpatient appointments some of whom had been waiting more than 52 weeks for first treatment .
  • There were concerns raised in the inspection in 2016 regarding ward and clinic staff compliance with standards of photographic image governance, and this remained an issue on this inspection. The trust was in the final stages of implementing a secure app to capture patient consent and upload image data securely to trust systems but there was no implementation date as yet.
  • Although outpatient services had regular team meetings we were not provided with minutes to ascertain content so were not assured that all information was passed to all staff from ‘board to ward’.