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Norfolk and Norwich University Hospital Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 16 March 2016

The Care Quality Commission (CQC) carried out a comprehensive inspection between 10 and 13 November 2015. We also carried out unannounced inspections on 20 and 25 November 2015. We carried out this comprehensive inspection at Norfolk and Norwich University Hospital NHS Trust as part of our comprehensive inspection programme.

This organisation has two main locations:

  • Norfolk and Norwich University Hospital, a large acute hospital comprising all acute services.
  • Cromer Hospital which offers surgical and outpatients’ services.

We also inspected Henderson unit as part of the unannounced inspection on 25 November 2015.

The hospital opened in late 2001, having been built under the private finance initiative (PFI). Cromer and District Hospital was rebuilt by the Trust in 2013.

The Trust provides a full range of acute clinical services plus further private and specialist services. The Trust has 1237 acute beds and It provides care for a tertiary catchment area of up to 822,500 people from Norfolk and neighbouring counties. The hospital also has an important role in the teaching and training of a wide range of health professionals in partnership with the University of East Anglia, University Campus Suffolk and City College Norwich.

Previous unannounced responsive inspection by the CQC took place between the 4th and 6th March 2015. The inspection focused specifically on accident and emergency services, capacity and demand, medical care and cancer services, surgery, and overall leadership of the trust. As this was a responsive inspection there are no ratings attached to our findings. However, concerns were raised about governance arrangements, Mattishall ward, the Fit and Proper Persons regulations and the bullying culture.

The trust had a relatively new executive team. The Chief Executive was appointed substantively in October 2015. At the time of inspection three other members of the team were interim positions; the Chief Operating Officer, Medical Director, and Director of Finance.

The comprehensive inspections result in a trust being assigned a rating of ‘outstanding’, ‘good’, ‘requires improvement’ or ‘inadequate’. Each section of the service receives an individual rating, which, in turn, informs an overall trust rating.

The inspection found that overall; the trust had a rating of requires improvement.

Our key findings were as follows:

  • Staff were overwhelmingly caring in delivering care to patients. We witnessed some outstanding examples of care being given to patients and their relatives.
  • There were shortages of nursing staff that impacted on care provided throughout the hospital.
  • There were some areas where there were medical vacancies which impacted on care. Most notably in the palliative care team and in the critical care complex.
  • Incident investigation and root cause analysis was not always completed by those with extended training.
  • The security on the children’s ward needed to be improved to ensure their safety.
  • There was a lack of understanding by staff around patients’ ability to consent to care and treatment.
  • The consultant body was cohesive, loyal to the hospital and proud to be working at the trust.
  • The service to patients having a heart attack was extremely good.
  • The communication with parents in the neonatal unit was very good. These included well written booklets.
  • The number of one stop clinics within the out patients department was responsive to the needs of patients.

We saw several areas of outstanding practice including:

  • A specialist, midwife-led ‘Birth reflections’ clinic was provided to support women who wanted to come to terms with their birth experiences.
  • Clinical reporting and scheduling system in cardiology (Intellect) has been developed locally allowing the service to be more coordinated and efficient.
  • There was an excellent primary percutaneous coronary intervention (PPCI) service which provided prompt, effective treatment in line with national guidance and demonstrated good working with other providers and professionals.
  • On Elsing ward we observed that the bays had been colour coded to assist patients moving around the ward and used single use knitted sensory bands were available. Holt ward had refurbished a room to 1950’s décor.
  • The nursing team within the emergency department demonstrated outstanding care, leadership and treatment of patients.
  • The innovation around trialling new ways and models of care including medicines administration within the emergency department, as well as the vision for the service was outstanding.
  • The outcomes for trauma were outstanding and the best in the region.
  • The local audit programme for nurses and medical staff within the emergency department was outstanding.
  • The governance risk management, learning arrangements and staff willingness to continually strive to be better for the patients in the emergency department was outstanding.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • Ensure that patient acuity is properly assessed and there are adequate medical, nursing and midwifery staff to care for patients in line with national guidance.
  • Follow infection control principles when cohorting patients.
  • Ensure that all children’s inpatient wards and units have adequate security measures in place to reduce the risk of children absconding and unauthorised adults gaining entry.
  • Ensure that incidents are investigated in a timely way by trained investigators, graded, and reported in line with current national guidance.
  • Ensure that the management of outliers on Cley ward are properly assessed and provided with safe care.
  • Ensure that the management of referrals into the organisation reflects national guidance in order that the backlog of patients on an 18 week pathway are seen.
  • Ensure that patient records are legible, accurate, complete and contemporaneous for each service user, taking into account the use of both hard and electronic records.
  • Review ‘do not attempt cardio-pulmonary resuscitation’ (DNACPR) forms to ensure they are completed fully and in line with trust policy and national guidance.
  • Review its Mental Capacity Assessment and Deprivation of Liberty Safeguarding (MCADOLS) process and the way this is documented within patients’ notes – Regulation 17(2) (c).
  • Ensure that staff within the radiology department have access to appropriate support, supervision and appraisal.
  • Ensure that compliance to mandatory training is met and ensure consistent compliance across all clinical staff groups. Ensure that training is relevant to meet the needs of those in specific roles such as staff in the mortuary.
  • Ensure that medicines are stored and administered in line with national guidance.
  • Review and improve the environment of the children’s emergency department to ensure that the environment is fit for purpose and safe for children to receive care.
  • Review the staffing of the children’s emergency department to ensure that there are sufficient numbers of registered children’s nurses on duty at all times.
  • Ensure that there is an increase awareness of the complexities of end of life care, including a defined strategy and vision, increased involvement and referrals to the specialist palliative care team (SPCT) and improvement in performance indicators specifically recognition of the dying patient.

In addition the trust should:

  • Closely monitor transfers to Mattishall ward and the environment should be improved in line with the development plan for the unit.
  • The trust should reconsider the ambulatory care pathway in the acute medical unit (AMU).
  • Review the availability of adequate equipment for patients to sit out of bed if clinically able to do so.
  • Review the permanent clinical leadership in AMU.
  • Ensure a robust process for checking of emergency equipment.
  • Review its risk management and escalation policies with respect to how clinical staff raise concerns and ensure these are acted upon appropriately.
  • Reduce readmission rates for children and young people with long-term conditions.
  • Review the provision of information technology for community midwifery teams
  • Review mechanisms for supervision and appraisal for all staff so that they are supported effectively.
  • Develop an action plan to address the lack of improvement in the completion of discharge information in the specific safeguarding children paperwork for use within the maternity departments.
  • Review the provision of adequate seating in the antenatal clinic.
  • Reduce the number of cancelled gynaecology clinics.
  • Review the ratified guidelines within the Obstetric Assessment Unit and ensure that it is located in an area where it can operate effectively.
  • Put procedures in place to reduce the number of closures of the obstetric unit.
  • Review the staff understanding of the vision and strategy for their areas.
  • Review fluoroscopy changing areas and process to ensure patient privacy and dignity is maintained.
  • Ensure that doctors within the emergency department adhere to bare below the elbow policy requirements.
  • Improve the culture amongst the consultant body within the emergency department.
  • Improve the culture of the organisation towards the emergency department to reduce the feeling of blame for targets not being achieved.
  • Review the bed management process and site management processes within the organisation to increase capacity and flow.
  • Improve systems and processes for the declaration of black alert to ensure that it contains tangible changes designed to improve the service, i.e. daily consultant or nurse led discharges.
  • Review the emergency department triage process to ensure that all patients are offered pain relief where it is required.
  • Review the plans for expanding the main emergency department and make a decision swiftly on the future expansion of the service. 

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas


Requires improvement

Updated 16 March 2016


Requires improvement

Updated 16 March 2016



Updated 16 March 2016


Requires improvement

Updated 16 March 2016


Requires improvement

Updated 16 March 2016

Checks on specific services

Maternity and gynaecology

Requires improvement

Updated 10 August 2017

We rated this service as requires improvement because:

  • Incidents were not always classified in line with trust policy.
  • Controlled medicines were not always checked and stored safely.
  • Patient records were not stored securely and records audits indicated continued poor compliance in some areas.
  • Resuscitation equipment was not always checked regularly in line with trust policy. 
  • Mandatory and safeguarding training were below the trust targets.
  • Electronic discharge letters were not always sent within 24 hours meaning women’s general practitioners were not informed of their hospital stay and outcome.
  • Community midwives did not have access to information technology, although this was in the process of being addressed there was no time schedule yet.
  • Patient outcomes were similar to the England average, but maternity dashboard outcomes such as the percentage of women breastfeeding at discharge, readmissions within 30 days and admissions to critical care unit consistently failed to meet targets.
  • The gynaecology service did not meet its referral to treatment (RTTs) waiting times. There were 2543 patients on the gynaecology 18 week RTT incomplete waiting list and a backlog of 617 patients waiting up to 45 weeks for treatment.
  • There was a lack of ownership at ward management level of issues such as checking resuscitation equipment, ward cleaning and medication checking.


  • There have been significant improvements in the investigation of incidents with staff given training and protected time to investigate.
  • Midwifery staffing had improved since the previous inspection, and hospital midwifery staff were over establishment to accommodate leave.
  • Staff provided care according to national guidance and evidence based practice and where they were not using guidance they risk assessed, reviewed and worked towards compliance.
  • Staff contributed to a number of national audits and performed a range of local audits to improve women’s care and shared results.
  • Women we spoke with were very positive about their treatment by all clinical staff and the standard of care they had received.
  • Women were involved in their choice of birth at booking and throughout the antenatal period. In antenatal clinics, women were given information regarding different birthing settings early on in their pregnancy, including the benefits and risks of home birth.
  • Services were planned, delivered and co-ordinated to take account of women with complex needs, there was access to specialist support and expertise from medical and nursing and midwifery staff.
  • There was strong leadership demonstrated from the senior management team, with a clear vision and strategy for the maternity service.
  • The senior management had oversight of clinical risks and there was evidence that risks were regularly reviewed and updated with named ownership of risks.
  • There was a strong drive to improve and develop with multiple innovations including the development of the IT system, and the Baby University scheme.

Medical care (including older people’s care)

Updated 10 August 2017

  • Medicines were not always stored safely in line with trust policy and the temperature of medication requiring refrigeration was not always checked.
  • Staff did not carry out routine checks on resuscitation equipment.
  • Staff compliance with mandatory training, including safeguarding was below the trust target.
  • Most of the wards we visited had vacancies for either registered nurses (RN) or health care assistants (HCA). The vacancy rate across medical wards was 14%. .
  • Staff raised concerns regarding the length of time the trust had been operating with two doctors in training positions rather than three within the medicine division. The trust informed us that the establishment was for two with a third booked to support. The third position was to become permanent in August 2017.
  • We spoke with a number of junior doctors, who were unhappy with the working shift rota and working hours.
  • For medical non-elective patients, the average length of stay was 7.2 days, which is higher than England average of 6.7 days.
  • The following specialties were above the England average for admitted Referral to Treatment Times (RTT) (percentage within 18 weeks), neurology, geriatric Medicine, rheumatology, and dermatology.
  • The majority of staff we spoke with on the wards were unaware of any local vision or strategy held by the trust in relation to the medical division.
  • Some staff felt there was a lack of senior leadership within the medical division.
  • The majority of staff we spoke with said they hardly ever saw the directors on the ward areas. Some staff said they saw them infrequently at bed meetings, but most agreed that the senior team members were not visible.
  • Not all medical and nursing staff we spoke with during our inspection knew medical division risks were held on the electronic system.
  • Some staff felt there was unnecessary pressure placed on them to take and discharge patients from the wards and that at times this was uncomfortable for them to manage.


  • Staff knew how to report incidents and deal with complaints and there was a learning culture within the medicine division.
  • There were clear procedures for managing and referring safeguarding concerns in relation to children and adults who may be at risk of abuse. Staff we spoke with knew how to make a referral and who to refer their concerns to within the trust.
  • We reviewed 21 patient records and found all risk assessments were completed, early warning scores (EWS) and risk assessments clearly documented.
  • Staff adhered to the trust hand hygiene and ‘bare below the elbow’ policy, and wore personal protective equipment such as gloves and aprons during care.
  • Staff used early warning scores (EWS) on the medical wards to monitor and identify any deteriorating patients. All records we reviewed showed that staff routinely completed EWS and alerted senior staff to any patient that may be deteriorating.
  • Between November 2015 and October 2016, the average length of stay for medical elective patients at the trust was 2.9 days, which is lower than England average of 4.1 days.
  • We saw significant improvements in the Acute Medical Unit Men (AMUM) and Acute Medical Unit Ladies (AMUL) performance due to changes in the physical environment.
  • Patients living with dementia and those who had suffered a stroke had “This is me.” documentation in place. The division had a dementia strategy and delirium strategy in place and supported by a dedicated dementia team.
  • The speech and language therapy (SaLT) team saw patients who had had a stroke promptly to reduce the time patients spent nil by mouth.
  • If patients had complex needs or required additional family support, staff made special arrangements regarding visiting and access to patients outside of normal visiting hours
  • The trust had significantly invested in the recruitment of discharge co-coordinators who worked across the wards to promote the safe and timely discharge of patients.
  • All staff we spoke with knew how to report a complaint and that feedback from complaints would be shared on a one-to-one basis where necessary or via team meetings.
  • There were several established systems to ensure good clinical governance and monitor performance.
  • The majority of staff we spoke with felt supported and valued by their direct line manager.
  • Junior nurses we spoke with told us that the medical division was a good place to start their career.

Urgent and emergency services (A&E)


Updated 16 March 2016

We rated urgent and emergency services as good overall with safety rated as requires improvement, effective and caring rated as outstanding and responsive and well led as good.

Safety of the service required improvement because the children’s emergency department was not fit for purpose. The children’s department has two cubicles and a treatment area within the waiting room. The main emergency department was often overcrowded, the department was originally built to see 70,000 people per year but now sees upwards of 110,000 people per year. We observed that not all doctors adhered to the elbows infection control requirements. Some triage nurses were not able to offer pain relief to people while they were waiting. There was also a shortage of registered children’s nurses working within the children’s emergency department. However we also found that there was a good incident reporting and learning culture within the department. There were robust safeguarding procedures in place for both adults and children. Staffing levels for both nursing and medical staff in the adult department were safe. The department had effective streaming, triage, treatment and early warning systems in place to ensure patients received safe care.

The service was outstanding for being effective because the National Audit on Severe Trauma (Trauma Audit & Research Network, TARN) for 2014 showed that the trust performs better on trauma than any other trust in the East of England on survival rates, unexpected survival rates and data submissions. The fracture neck of femur pathway between the emergency department and the orthopaedic service was outstanding due to the reconfigured pathway in place which meant that consistent care was continually provided. The department also ran a series of improvement projects, chosen by staff, who support the completion of the projects to improve safety and patient care. The department was trialling new and innovative ways of managing pain and severe pain for patients within the department. The trust’s unplanned re-attendance rate within seven days at 3% was consistently below the 5% standard between January 2013 and October 2015. The department operates a range of admission avoidance programmes including diabetes, deep vein thrombosis (DVT), ulcers clinic, wound clinics and pain clinics.

The service was rated as outstanding for being caring because we consistently saw staff going above and beyond the call of duty to provide outstanding care to patients, relatives, families and other staff. All people we spoke with were overwhelmingly positive about the care and service they received. We spoke with paramedics who were all positive about the service and all expressed how they would choose to come to this emergency department over others in the area.

The service was rated as good for being responsive because there were plentiful leaflets and information sources available to support patients; the service had a dedicated area for relatives with three individual relative rooms for speaking with patients and their families and breaking bad news. Despite delays in admission to beds from the emergency department patients received care which ensured that their inpatient food, hydration and personal care needs were met. The majority of delays and breaches of the four hour target came due to a lack of bed availability, though there was still room for improvement.

The service was rated as good for being well led because the culture of the nursing workforce was outstanding with a well-established nursing team. The nursing leadership within the service, particularly at matron level, was outstanding.  There was a strong culture of governance and risk management within the service. The service had a defined vision and strategy for the future, and this included the staff who contributed to the vision of the service. However there were some areas that could be improved including the attitude of medical staff and the culture of the consultant body in relation to how they work with the nursing staff and respond to the leadership team. We observed some disrespectful interactions between nursing and medical staff at times though the trust did take action to improve this throughout the inspection and there was a notable improvement by the time we undertook the unannounced inspection.


Updated 10 August 2017

  • The trust reported four never events between February 2016 and January 2017.
  • There were no local observational audits or measurement of the quality of the World Health Organisation (WHO) five steps to safer surgery checklists.
  • Staff did not follow infection prevention and control procedures. Staff, on Gissing and Earsham ward, left side room doors open when they should have been closed to prevent the spread of infection.
  • Medicine management was not in line with trust policy.
  • There were examples of poor storage and security of patient medical records.
  • Nurse staffing did not reflect the acuity of patients on some of the surgical wards. There was a high number of nursing vacancies and gaps in working rotas were frequently filled with healthcare assistant hours. We were concerned that staffing shortfalls could impact on patient care.
  • Resuscitation equipment on the wards and was not adequately checked and maintained. 
  • Staff compliance with some aspects of mandatory training such as safeguarding were well below trust target. 
  • Patients were frequently delayed in theatre and the number of bays available in recovery was not in line with guidance from the Department of Health. Health building note (HBN) 26 Facilities for Surgical Procedures states there should be two recovery bays for every theatre. We saw there were 16 adult bays for 17 theatres.
  • The trust had cancelled 2,647 procedures between quarter 4 2014/ 15 and quarter 3 2016/17, 20% of these patients were not treated within 28 days.
  • Staff morale was low within the surgery division with staffing and clinical pressures contributing factors. A shortage of medical beds throughout the hospital meant that ward staff felt pressurised to take patients who were not suitable for their ward areas and there was a lack of communication between the ward and the board.


  • Staff reported incidents and were knowledgeable about the incident reporting process.
  • The trust had clear processes and procedures in place for safeguarding.
  • Ward areas were visibly clean, with appropriate equipment and facilities for hygiene and infection control. Staff accessed equipment such as hoists and scales that were serviced and checked in line with policy.
  • Staff completed patient care records legibly and signed and dated entries.
  • There had been an improvement in referral to treatment times in the division since the beginning of 2017. 
  • One stop clinics were available for hand and cystoscopy surgery patients and the day patient unit (DPU) was proactive in reducing patient admissions.
  • Translation services were available and patient information leaflets were available in different languages and formats.
  • There was evidence of learning from complaints in the form of “you said we did” posters.
  • Staff we spoke with knew the vision and values of the trust and junior staff felt supported by their ward managers. Most ward staff felt they had a good team.
  • Ward managers and surgical matrons attended monthly surgical governance meetings. There was evidence that the ward team discussed their performance around the quality indicators used at the trust.
  • The trust had a plan to develop, refurbish and expand the high dependency unit and develop level one beds on Gissing ward. Staff we spoke with knew about the plan and how it would impact them.

Intensive/critical care


Updated 16 March 2016

The safety of critical care at Norfolk and Norwich University Hospital required improvement. The effective, caring, responsive and well-led domains were good.

Patients and their relatives were treated with respect and dignity by competent staff who were passionate and provided treatment in line with national standards and benchmarks. Staff were proactive in reporting incidents and senior staff on the unit conducted thorough investigations that had led to improvements in practice. The critical care complex (CCC) was clean and well-maintained and staff demonstrated an acute understanding of how to provide person-centred care that met the treatment needs of individuals and also considered their wellbeing and social needs.

The mortality rate of the CCC was consistently lower than the national average for similar units, at 15%. Staff used care bundles appropriately and audited these regularly. Multidisciplinary input into patient treatment plans was available but significant short staffing meant that the unit did not have a full time pharmacist and that the presence of physiotherapists and microbiologists on ward rounds was inconsistent.

Medical staffing out of hours did not meet the requirements of the Intensive Care Society (ICS). Nurse staffing levels did not meet the recommended requirements of the Royal College of Nursing (RCN) or the Faculty of Intensive Care Medicine (FICM), with each shift regularly short of up to four nurses. A supernumerary senior nurse coordinator was not always available out of hours on the intensive care unit.

In 2014/15, 63.6% of patients experienced a delayed discharge of four hours or more. Introduction of a more robust escalation process had started to reduce delayed discharges through more effective clinical and operational governance. Staff were encouraged to contribute to the development and improvement of the service.

Staff were not always listened to or engaged with appropriately by the trust’s senior leadership team when they had escalated areas of concern or risk.

In the year prior to our inspection the unit had experienced significant disruption to its staff team, including the departure of two matrons. We found that staff had established a coherent, mutually supportive working environment and culture and were positive about the changes that had been implemented by a new matron and operational manager.

Services for children & young people

Updated 10 August 2017

  • Patient care records were clear, detailed, and contained all necessary information.
  • Additional security measures had been introduced throughout the children and young people’s service. All areas were found to be secure during our inspection. This addressed concerns raised during our previous inspection.
  • Staff were knowledgeable about the incident reporting process. There was evidence of learning and communication to staff regarding outcomes of investigations.
  • Staff across the children and young people’s service were knowledgeable about the complaints process. Staff gave us examples of complaints that had led to changes in practice.
  • The service was planned and delivered to meet the needs of local people. For example, accommodation was available for parents to stay on the neonatal unit and an outreach team supported the discharge process.
  • The service met the individual needs of patients, including those in vulnerable circumstances. For example, there were support groups and a family care coordinator for parents on the neonatal unit.
  • An electronic bed booking system had been introduced on the children’s day ward to improve list utilisation.
  • A paediatric flow coordinator role was introduced in April 2017. This role would support patient flow throughout the children and young people’s service.
  • A child and adolescent mental health service (CAMHS) was introduced in April 2017 and was available seven days a week, meaning that children and young people suffering from mental health problems could be assessed on the same day as their admission.
  • Staff described a positive and open culture with approachable and visible local leadership in the children and young people’s service.
  • The majority of staff demonstrated an awareness of the trust vision and values.
  • Action had been taken to address some of the concerns that were identified on our last inspection. For example, additional security measures had been introduced across the service, cytotoxic waste was now being segregated and disposed of appropriately, and a bank healthcare assistant was being used on the children’s day ward.
  • Senior leaders were well sighted on the risks in the division. There was a clear strategy in place for the development of services.
  • There were regular governance and quality meetings within the division with good attendance form staff.
  • Staff were increasingly given an opportunity to contribute to the direction and strategy of the division.


  • Only 16% of incidents were reported to the National Reporting and Learning System (NRLS) within 60 days.
  • Checks of resuscitation equipment were inconsistent.
  • Mandatory training compliance was below the trust target of 95% in February 2017. Compliance rates for medical staff (67.1%) were much lower than for nursing staff (86.9%).
  • Registered nursing staffing levels regularly fell below basic levels on Buxton ward and healthcare assistants were used to increase staffing numbers when this occurred.
  • There were insufficient numbers of qualified staff to fill the rota to the recommended levels for the four paediatric high dependency unit (HDU) beds on Buxton ward. In the interim, practice educators, the ward sister and staff with relevant experience but no HDU qualification were used to support the rota.
  • Consultant cover in the children’s assessment unit did not meet national guidance. However, consultant cover had been increased from previous levels and a CAU improvement project was underway at the time of our inspection, which included a review of the level of consultant cover.
  • Cohort nursing, where infectious patients are treated together in one area away from other patients, was practiced on the children’s assessment unit due to the lack of side room availability. This presented an increased risk of cross infection. However, an integrated performance report showed that daily audits were undertaken as a monitoring precaution.
  • Paediatric surgery and neonatal mortality and morbidity meeting minutes lacked detail and this limited the opportunity for shared learning with those unable to attend. It was not clear who attended meetings as only initials were recorded and the minutes for the February 2017 surgery meeting appeared to indicate that only one person was in attendance.
  • The children and young people’s service had lost access to four transitional beds for young people aged 16 to 18.
  • There were increased admission times on the children’s assessment unit (CAU) due to an increasing number of attendees with no increase in bed spaces.
  • Referral to treatment time (RTT) was not met consistently across all sub-specialties, meaning that children were not always treated within 18 weeks of referral.
  • Staff said that they rarely or never saw the director of nursing or the executive team.
  • Staff said that there was a lack of out-of-hours management support on Buxton ward.
  • The risk register did not reflect all of the risks identified on our inspection. For example, the inconsistent checks of resuscitation equipment and children being admitted onto non-paediatric wards where staff were not always appropriately trained in safeguarding or paediatric resuscitation.
  • A number of the concerns identified during our previous inspection had not been addressed. For example, mandatory training compliance levels, inconsistent checks of emergency resuscitation equipment, and nursing staffing levels.

End of life care

Requires improvement

Updated 16 March 2016

End of life services at Norfolk and Norwich University Hospital required improvement overall. Safety, effectiveness, responsiveness and well led were all rated as requires improvement. Caring was rated as good for the service.

‘Do not attempt cardio-pulmonary resuscitation’ (DNACPR) forms were not always completed fully or accurately. The trusts DNACPR forms did not conform to national standards. No standardised documentation pathway had fully replaced the Liverpool Care Pathway (LCP) which had been phased out. The trust was using care-rounding forms to assess patients hourly for pain, comfort and hydration, and other key aspects of care. There was an incident reporting system in place however, this did not specifically capture incidents concerning patients at the end of their lives.

The trust did not have systems in place to make effective assessment of the quality of end of life care. The trust scored significantly worse than the national average in the latest national care of the dying audit, meeting only 47% of the key performance indicators.

There was no on-site seven-day specialist palliative care service at the trust. Out-of-hours staff across the trust were unsure of who to contact should advice be needed.

The specialist palliative care team (SPCT) had the vision to create a seven-day service however the current staffing was not sufficient to support this.

Patients at the end of life and their relatives were cared for with respect and compassion and in a way that considered their dignity.


Requires improvement

Updated 16 March 2016

Outpatient and diagnostic services were rated as requires improvement with caring, and well led rated as good, but safety and responsive were rated as requires improvement, which gives a rating of requires improvement overall.

Incident reporting and correct identification of harm were not robust in either outpatients or radiology services. There had been three ophthalmic never events in the trust in last three years and two in dermatology in the last two years. The consistency of incident reporting was not robust; there was a limited number of staff trained to undertake root cause analysis; and reporting responsibility sat with senior staff members, with little individual feedback or learning. Incidents were not always classified correctly which resulted in under-reporting. There had been three dermatology incidents that we raised with the trust as potentially meeting the never event criteria. The trust held a serious incident meeting at the end of November 2015 to review the incidents and two were raised retrospectively as never events.

The trust was not meeting two of its referral to treatment targets for cancer patients.

The Cromer site was potentially underutilised given the appointment waiting lists at the main Norwich site.

There was effective patient focused care provided by ‘one-stop clinics’ and innovative nurse led clinics. The venous-thromboembolism (VTE) clinic had been recognised nationally winning the British Nursing Journal award for 2015.

Patients and relatives gave high praise for the care received within the trust. Clinics collected patient feedback to improve services. Initiatives were trialled, audited and monitored to improve the safety and experience of patients.

It was evident that there was a strong teamwork ethos with a large number of staff employed for many years within the trust. Staff were very passionate and proud of the services they offered to patients.