The Ipswich Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. We also checked people’s liberty was protected where this was in their best interests and in line with legislation.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant people were not always safe and protected from avoidable harm. The service was in breach of legal regulation in relation to the safe care and treatment.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

We scored the service as 2 . The evidence showed some shortfalls. The service did not always have a proactive and positive culture of safety based on openness and honesty. Staff reported incidents in line with policy, however they were not reviewed in line with policy to ensure lessons were learnt. This prevented them identifying learning and taking timely mitigations to prevent future occurrence.

The service had a positive culture of safety . Staff reported incidents in line with policy and feedback was given at morning huddles or via email. Staff were informed of recently reported incidents within their area through daily huddles and monthly governance reports which were displayed on quality boards on wards. Staff we spoke to were able to give examples of recently reported incidents and how learning had been implemented to reduce future occurrence. For example, a nurse told us that there had been an increase in falls on the ward. Following this the Falls Lead Practitioner carried out some training for staff around falls prevention. Wards had also introduced a ‘tagging bay’ which meant that staff were required to closely monitor patients within the bay.

We reviewed the last 3 safety incident investigations and found that 2 early learning reviews were completed within the 7 day timeframe. This was in line with the trust Reporting and Management of Incidents, Patient Safety Incident Response Framework Policy Version 2.0. There was evidence that they tried to share the review with the patient and their family. Learning was identified in 1 of the completed reviews, with detail of who was responsible for completing the actions and date completed.

We reviewed the divisional quality report for August 2025 for the clinical delivery groups for specialist services and pathways for medical care. This showed that 22 early learning reviews and 5 patient safety reviews were overdue and not completed in line with trust policy. Delayed incident report reviews increase the risk of delayed or missed safety improvements, which can lead to recurring incidents and a higher potential for harm. When an incident is suspected to cause moderate or severe harm or death, healthcare organizations have a legal and contractual obligation to be open and transparent with patients and families, this is known as the Duty of Candour (DOC). The division’s DOC compliance improved from 48.3% in April 2025 to 88.2% in July 2025 but remained below the 100% target. Leadership teams were actively supporting staff in making these required calls.

Most staff we spoke to felt confident to deal with complaints made by patients or family and where necessary they would escalate to their seniors. Ward managers told us they had completed difficult conversations training to support with dealing with complaints and conflict .

The service had implemented ‘Every bay, every day’ which ensured service users had an opportunity each day to speak to senior nursing staff. The purpose of this was to improve opportunities for service users to raise concerns complaints and any questions they may have, Staff told us that they were required to complete a log of concerns raised and actions taken to demonstrate its effectiveness. However, they felt this was time consuming and had raised this with matrons who were escalating this on their behalf.

Each month ward managers held quality summit meetings. They reviewed safety audits and reviewed what mitigating actions were taken to reduce risks and encourage wider local learning within the division. For example, due to an increase in medication errors a manager had implemented a medication audit. This was shared with other wards.

Senior leaders reported learning was shared with Colchester Hospital staff to provide a forum for shared experiences. They told us this helped support a culture of continuous learning and improvement. This meeting was held twice a year and was well attended by ward managers and senior divisional directors and matrons.

A Quarterly Reflective Learning Forum had been established in July 2024 to promote reflection and learning within the trust. The forum encouraged input from front-line clinicians with a view to improving patient safety and quality of services. All colleagues were invited to attend the forum.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

During the previous inspection in January 2020, we found that staff did not always complete risk assessments for Venous Thromboembolism (VTE) for all patients. During our onsite visit we found 9 out of 11 records were not completed in line with policy. Following the inspection we requested 3 months of VTE compliance audit data. This showed 5 out of 12 wards failed to consistently meet the trust target of 95%. The trust informed us that the introduction of a new electronic system in October 2025 would ensure VTE assessments were completed for all service users. The service did not always perform well in audits focused on the management of risks to people. Pressure ulcer risk assessment audits completed in the 6 months prior to our assessment found an average compliance score above the trust target of 95%. However, some wards were not meeting the monthly trust standard of 95% for completion of body map on admission . For example, Haughley ward scored 80% for May, July and August 2025. Following a review of the cases the service identified various actions including reminding staff to complete pressure ulcer risk assessments, ensuring staff checked continence assessments on transfers and ensuring accurate recording of patient positioning preferences. A poster was also being developed as a visual prompt to remind staff and support previous training provided. We reviewed governance meeting minutes for the (MACIES) division. This identified a total number of 971 patient incidents reported for the Division.

The trust audited falls risk assessment compliance for patients who had experienced a fall whilst an inpatient. Audit data for the last 6 months for completion of falls risk assessment within 6 hours of admission was 91%, with only 5 of the 12 wards meeting the trust target of 95%. This meant that there was a delay in identifying and mitigating risk of falls on wards. Actions taken to mitigate the identified risk of falling in line with trust policy was 94%, with 8 out of 12 wards meeting the trust target of 95%. This meant that when risk of falls was identified action was taken by most staff to reduce the risk of inpatient falls in line with trust policy. The care of the elderly wards had the highest number of falls per 1000 bed days. Following review of the incident logs where trust policy had not been followed, staff were reminded of the processes by ward managers to ensure that risk was identified and mitigated in a timely manner . This was supported by our onsite findings where we found 2 out of 5 records showed that falls risk assessments had not been reviewed or completed on admission.

We were not assured that staff were recognising and escalating deteriorating patients consistently in line with trust policy to keep people safe. Staff identified deteriorating patients using tools such as the national early warning score (NEWS). Sepsis audits were completed for a score of greater than or equal to 5 or where scoring 3 in one parameter. Average compliance was 85% across medical care wards against a trust target of 90%. There was a decline in August 2025 which was largely influenced by Debenham ward scoring 43 %. Actions taken to address poor compliance included focused audits on poorer performing wards, re-run of escalation training with an emphasis on NEWS2 thresholds and bi-weekly mini audits to facilitate real-time feedback. Audit data also reviewed Critical Care Outreach Team (CCOT) 60 minutes clinical response times where patients had NEWS2 scores of 5 and above. Data showed response rates were below the target of 90% for March and July 2025 where it scored 88% and 44% respectively. Senior leaders had oversight of compliance through governance forums to review compliance, however there was no action plan in plan to address the poor compliance within the data reviewed.

We reviewed 5 care records for completion of nutrition and hydration charts. We found 3 of these records were not completed fully during their admission to evidence sufficient intake and management. This meant there was a risk that staff could not adequately monitor, assess, and respond to the nutritional and hydration needs of these service users and potentially leading to avoidable harm.

We reviewed 7 care records for completion of daily intervention to demonstrate completed care over a 24-hour period. For example, risk assessments, checking for pressure damage and hygiene needs. We found that these were not completed fully for 4 out 7 records. This meant that staff could not be assured that care was managing risks identified or was tailored to meet their individual needs.

Healthwatch fed back that the service had 26 comments relating to poor communication between teams around discharge to support safe and effective continuity of care. For example, GPs had not been updated on medication changes which resulted in delays prescribing required medication. Another patient said departments worked in isolation and did not communicate effectively. This resulted in them having to repeat information multiple times. We requested to review audit data on the medical discharge summaries. At the time of inspection, the Trust did not have an audit plan in place for measuring the quality of medical discharge summaries. Therefore, there was a lack of governance around the quality of information being given to ensure continuity of care when people moved between services. We reviewed the incident reporting log for August to September 2025 and found 5 incidents relating to poor communication impacting on timely care for patients. For example, a patient was transferred to another ward but staff did not hand over the urgent need for follow up of test results. This meant that there was a delay in continuation of care for chest pain.

The hospital had a data sharing agreement with a local hospice. This enabled timely sharing of patient information, such as care and treatment plans supporting end of life patients . This meant that care was seamless when transitioning between services.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They did not always share concerns quickly and appropriately.
At the January 2020 inspection we found medical and nursing staff did not meet the trust target for mandatory training or for safeguarding adults training. During this assessment we found compliance for doctors was 63.72% for adults and 61% for Children against a trust target of 90%. However, the service was meeting this for nursing staff. Medical staff we spoke with told us that they would escalate safeguarding concerns to the ward manager, consultant or contact the safeguarding team.

Nursing staff we spoke to could give examples of the types of concerns they would raise and told us that they were informed of raised safety concerns at morning huddles. Staff we spoke to told us that the safeguarding team was responsive and visible on wards when concerns were raised.

We spoke with 8 staff (registered nurses and healthcare assistants) and asked them to explain their understanding of Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS). Of these, 6 staff members had limited understanding or were inaccurate in how and when to carry out an MCA and / or DoLS. For example, staff were unsure of the purpose of a DoLS application for authorisation and thought it authorised all interventions. Therefore, we were not assured that if a service user was unable to give consent because they lack capacity to do so, staff would act in accordance with the Mental Capacity Act 2005 (MCA 2005).

The service did not have effective processes to implement the Mental Capacity Act (MCA) or Deprivation of Liberty Safeguards (DoLS) in care records when caring for those who may lack capacity to consent to make their own decisions, or who are subject to restrictions on their liberty.

We reviewed 10 medical records for evidence of best interest decision making where nursing staff were acting under the mental capacity act. We found that in 9 records there was no evidence of capacity assessment or best interest decision making processes in accordance with the Mental Capacity Act (MCA 2005). This meant that staff could not demonstrate they were legally compliant within the realms of the act.

During the assessment we reviewed 9 service user records where staff informed us there was a mental capacity assessment and/or DoLS application in place. We found 5 records failed to evidence documentation of an MCA assessment and/or DoLS in line with trust policy. Therefore, records did not demonstrate processes to reflect a legal framework to support specific care and treatment, administration of medication, or an individual’s deprivation of liberty.

Safeguarding concerns were raised in line with policy and investigated fully. Staff told us they received feedback on cases at morning huddles to cascade information to staff. For example, on Bramford ward staff were informed of a section 42 being implemented for a patient during the ward huddle. This ensured the patient was kept safe when being given medication.

We observed posters detailing how to contact the safeguarding team and how to raise a safeguarding. The trust had a safeguarding policy which was reviewed and version controlled. This was easily accessible for staff on the intranet.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

During the assessment we observed people receiving 1:1 or 2:1 supervision by 3rd party security staff due to acute confusion with challenging behaviour. These staff had appropriate training and were given the relevant information for the patient that they were supervising. For example, we spoke to security staff on Claydon ward that were trained in restraint and were aware the security was required due to detoxing and challenging behaviour. However, we found examples of staff not following the reducing restrictive intervention policy. For example, a patient with dementia was on extended 1:1 supervision and there was a lack of documentation and timely review to evidence the use of 1:1 supervision and support this decision. This had been escalated to senior leaders however no action had been taken.

In July 2025, the hospital had introduced the yellow socks and blankets falls prevention strategy to visually signify to staff, patients who were at a high risk of falls. Some staff reported that this was a pilot and other staff reported that this was embedded within the hospital. We reviewed 3 patients who had been identified as high risk of falls and observed yellow socks on 1 out of 3 patients meaning 2 patients were left at risk of falls. We escalated this to staff who ensured this was actioned.

Staff were able to access out of hours medical support via a bleep system. However, staff told us doctor reviews were not timely and often they had to escalate this to the site matron. Medical doctors we spoke to stated that there was insufficient cover for the medical wards at night. Although there had been no incidents relating to harm to patients at night due to staffing, they often felt stressed and overwhelmed. They had reported this to senior leaders but felt there was a lack of action to address concerns raised. We discussed this following our on site assessment with senior divisional leaders who reported that they were aware of the pressures and were in the process of recruiting a clinical support team. This would assist in reducing the burden of administrative duties for doctors. Leaders told us they would continue to seek feedback from doctors around this area.

There was a balanced and proportionate approach to risk that supported people and respected the choices they made about their care and enabled people to do the things that mattered to them. For example, the renal team met with patients to explain how their condition is progressing, what treatment options were available to them and the associated risk and planning required to facilitate their choice. However, staff did not always refer to My health passports on admission to understand and support people with learning disabilities or autism make choices and manage the associated risks.

Staff and patients were supported by specialist nurses or teams such as, but not limited to, diabetes, palliative and dementia to deliver individualised care and balance risk. For example, the palliative care team reviewed patients within the emergency department to discuss their care needs balanced with their wishes and avoid unnecessary admission.

Staff communicated with patients so that they understood their care and treatment. This included finding effective ways to communicate with patients with communication difficulties. For example, staff accessed language line for translation services, and a renal nurse booked a British sign language interpreter for a patient. This meant that patients were able to understand the care and treatment being offered.

Staff enabled patients to make advance decisions when appropriate. We saw evidence of this in medical records we reviewed. For example, there were discussions on admission with regards to refusing life sustaining treatment, such as resuscitation or antibiotics, even if it meant a shorter life. However, documentation to reflect the quality and aspects discussed were inconsistent . The palliative care team were available 7 days a week to facilitate discussions which supported and advocated their wishes.

We scored the service as 2. The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Ward access varied across medical wards we visited. Some had intercom access whilst others had access control measured to enter. During our assessment of 11 wards, we observed staff not challenging visitors to the ward, showing a lack of professional curiosity to challenge visitors on the wards.

There was clear signage for fire exits on wards identifying a fire escape route in the event of an emergency. However, on some wards, these were found to be obstructed by equipment such as drip stands and patient weighing scales. This was highlighted to staff who reported that due to the equipment being on wheels it could be easily moved in an emergency.

Staff disposed of clinical waste safely. Sharps bins were labelled correctly and not over-filled. Staff separated clinical waste and used the correct bins.

Equipment, including special or adaptive, was available and used to deliver care and treatment that was suitable for the intended purpose. During the on site assessment we observed air mattresses being delivered to the wards for patients. Staff told us that there was often a delay in receiving requested equipment due to only 2 staff allocating equipment across the hospital. We saw Grundisburgh ward reported 3 incidents in September 2025 relating to lack of air mattresses available for patients. This meant that risk was not always mitigated in a timely manner once identified .

Staff were able to explain how they would report faulty equipment. However, there were times when these were not reviewed by the maintenance team in a timely manner. For example, within endoscopy a specialist piece of equipment was faulty. Although it has been reported numerous times by nursing staff, action was only taken to repair it once a medical doctor escalated the issue.

The Joint Advisory Group on Gastrointestinal Endoscopy (JAG) accreditation quality assurance (QA) standards are designed to provide a framework of requirements to support the assessment of endoscopy services. The hospital Endoscopy service had lost their JAG accreditation due to layout of the recovery area prevented the service having single sex recovery bays. Senior leaders were aware and funds had been allocated by senior leadership team to address this with work due to commence in 2026.

Ward managers told us that new staff had a local induction for their area of work. However, not all staff knew how to use equipment on the ward. For example, some staff were unable to explain how they would adjust alarm settings on a cardiac monitor or what the parameters were for some monitored patients. We found a monitor that was silenced and staff were not aware of how to change the settings. Although there was always visual oversight of the monitors at the central nursing station, there was a risk of delayed recognition of a patient’s deterioration when machines are silenced. We also found a lack of documentation within medical notes for the desired heart rate range to support escalation of a patient. This was discussed with the ward manager who reported that some staff had knowledge of the equipment.

The hospital used ‘boarding’ and ‘outlying’ practice to maintain flow during periods of high demand to increase capacity. This meant that people were admitted to a ward where a bed was not immediately available or transferred to a clinical area outside of their speciality either from the emergency department or off a ward/department to another within the trust clinical areas. During assessment, we reviewed 4 care records for outlier and boarding patients and found that risk assessments were not completed in line with policy to support decision making. We also found that 3 patients who did not meet the criteria to outlie and were therefore not being cared for in environments suitable for their needs.

Staff told us that outlier beds would be placed in designated areas in bays. We observed 1 boarding care during our on-site assessment. There was no risk assessment completed in line with policy. The service informed us there were 2 incidents reported where the criteria for boarding had been breached in the last 6 months.

During our assessment the stroke ward gym area was being used as an escalation area to bed patients. Rehabilitation equipment had been temporarily moved into the main corridor outside ward entrances. Although this was on the trust risk register, there was no evidence of the risk review within the ward environmental risk assessment . This area had been used for 3 weeks following our onsite assessment and intermittently since COVID-19. The lack of risk assessment for the rehabilitation area meant that potential hazards to health and safety had not been assessed and mitigated. This was raised with senior leaders and we were told that this would be addressed.
We reviewed the environmental risk assessments for medical care wards and found that only 3 out of 10 wards had carried out a local fire drill. This had been escalated to estates, but had not been actioned. Therefore, we were not assured all risks were identified and actioned to ensure compliance with current Health and Safety Regulations. Claydon ward had reported a window restrictor needed replacing and this had been raised in April 2025. We saw evidence to show that this had been completed.

We reviewed evidence to ensure all equipment was tested and serviced for its intended purpose. We found all equipment was serviced and within date. We reviewed 15 items across medical care wards and found all were labelled and tested in line with health and safety executive (HSE) guidelines.

We observed that call bells were accessible to patients if they needed support. However, staff told us there had been complaints from patients and relatives regarding the time they waited for staff to respond to call bells.

Although doors to sluices or storage rooms were not always locked, cupboards containing hazardous substances were locked securely with a digital code. This ensured hazardous substances were locked away safely from reach. Codes were changed every 3 months by housekeepers and evidenced on wards.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

Nursing staffing numbers were lower than planned in all areas. The trust used an electronic system to calculate the number and grade of nurses and healthcare assistants required to manage the acuity of the patients on the ward. This was reviewed twice daily to support the matron to make decisions regarding safe staffing across the division and organisation. When staffing issues were escalated in particular areas, managers told us they moved staff to where they were most needed within the division. However, some staff told us that they did not always have staff deployed to them when numbers were low. Staff we spoke to told us that movement had a negative impact on morale. Managers logged staff movement to prevent the same staff being moved on a regular basis. However, they recognised at times this was unavoidable due to the skill mix requirements for the wards. For example, a review of the staff movement log showed, on 12 September 2025, 4 staff were moved from Claydon ward to other wards due to low staffing. We saw the same staff member moved multiple times within a 2 month period on Debenham ward to other speciality areas. A ward manager from a specialist ward told us that the impact on some staff being moved was that they were not available to complete their ward-based competencies for their specialism sooner, as they were moved to another area to work, delaying their own development. Some staff within escalation areas told us they did not have orientation to the area they had been moved to work in. This meant that they were unprepared for local procedures and systems, impacting patient safety and the quality of patient care.

We reviewed redeployment data for the last 6 months that showed that nursing staff were moved more than health care assistants. The trust reported 18 incidents in the last 6 months where staffing was not safe and impacted the ability to mitigate risk around patient acuity and dependency. It was acknowledged by wards that staffing deficit and challenges impacted on the ward’s governance performance as well as the ward sister’s capacity to complete the tasks in a timely manner. For example, ward managers were asked to document completion of ‘Every Bay, Every Day’ booklet to evidence completion on a daily basis and record areas of concern. Staff told us that this was already documented in patient records and was duplication which added to their workloads.

During our on-site assessment, we saw wards did not always have the planned number of staff on duty. We reviewed national safer staffing data and found between March and May 2025 staffing was not consistently compliant across all the wards with only 2 consistently having above 85% compliment. April 2025 had the most instances (11) across the wards of shifts having less than 85% of staff. However, March had the highest number of shifts where qualified staff were on average less than 85% staffed. We requested staffing rosters for the last 4 weeks prior to the onsite assessment for all medical wards. Data showed that overall fill rate for nursing shifts were 91.59% with the lowest being 81.93% on Debenham ward. Therefore we were not assured that there were sufficient numbers of staffing across all wards during the day and night.

During assessment we asked speciality wards if they had a competency programme to ensure staff had received effective support, supervision and development to deliver specialist care. We found not all wards had a specific training competency checklist. For example, on Claydon ward there was no formal cardiology training for junior nurses. This was raised with the ward manager who told us that they were going to work on putting together a competency pack specific to cardiology. Therefore, we were not assured that staff had the necessary skills to deliver quality cardiac care.

During the previous inspection in January 2020, we found inconsistent record keeping around staff competencies by ward. During this assessment we were told all training competencies were held electronically by the education team. Some ward managers were able to identify appropriately trained staff using the electronic staffing roster and other wards could not visually demonstrate staff skill mix. This meant ward managers did not always know which nurses were competent to complete which task.

We requested to review current mandatory training compliance for nursing and medical staff. Data showed that medical staff had an overall compliance rate of 65% against a trust target of 90%. They did not meet compliance in any of the 31 mandatory training topics, which included learning disability and autism level 2 (66%), Resuscitation level 2 (38.6%) or MCA, DoLS and Domestic violence and abuse (50%). Nursing staff had an overall compliance rate of 96%. Three out of 30 topics did not meet compliance which included conflict resolution level 2 (87%), MCA DoLS and Domestic violence and abuse (89%) and Resuscitation level 2 (75.8%). We were not assured that staff were completing mandatory training in line with policy to ensure they had the necessary skills and knowledge whilst providing care and treatment.

Substantive staff members received a full trust induction which was role specific and monitored and held electronically. As Ipswich ward layouts were the same, with the exception of Waldringfield ward, staff moving between areas would receive an informal orientation where required, though this was not formally documented. We were provided with a sample of formal induction checklists completed for new Waldringfield staff. This meant that staff could work efficiently, integrate with the team, and understand their roles, which directly impacts a safe and effective working environment for both staff and patients.

Some staff told us low staffing was a regular occurrence and was having a direct impact on morale and they could not always meet the demands placed on them in a timely manner. This was evidenced in a complaint from a family member relating to long waits to answer call bells. However, during assessment we found staff attending to patients when they requested assistance. Where able, managers used bank staff to cover gaps in roster for registered nurses rather than agency staff. Senior leaders told us that bank staff were a mix of substantive trust staff (fully inducted) or regular bank workers who were familiar with the ward environments. For any bank staff that were new to the ward, an informal orientation or formal induction was completed. There was no formal method for tracking the completion of formal inductions . We were provided with a sample of completed induction forms for staff on Washbrook ward.

There was an inconsistent process for safety checks and induction procedures across the medical division. For example, some wards did not use a checklist to demonstrate safety checks and induction for agency and bank staff. The checklist we reviewed lacked a thorough process to check the identification of all new agency staff on arrival. This meant that there was a risk of individuals with false qualification or identities gaining access to sensitive areas which may result in patient safety incidents. Following the onsite assessment, we were provided with a standard operating procedure for new and reassigned staff which included an identity check as an action to be completed on arrival to the ward. This was not dated or version controlled, therefore we were not assured if this was in place at the time of our onsite assessment.

Agency staff were provided by NHS Professionals (NHSP). NHSP had confirmed with the trust that a worker could not book any shifts unless they were fully compliant with all mandatory training. As soon as a training module was out of date the worker became restricted.

Nursing vacancy and sickness rates were 7.3% and 5.1% against the trust target of 3.5% and 4% respectively. Whereas medical staff were lower for vacancy (1.2%) and sickness (0.11%). This meant risk was reduced as staff were familiar with working on the ward. Data provided showed a bank use of 12% and 4.6% for medical staff for medical care wards.

Dementia, delirium and DOLS training was provided for all new band 5 to7 clinical staff. This educated staff on the basics of dementia care and how the Dementia Specialists could be used to support the wards. There had been an ad hoc training with the endoscopy dementia champion June 2025. This was due to an increase in patients with Dementia. The training audit showed an increase in confidence of 30% around the assessment and observation and communication of dementia and delirium patients.

There was a 7 day service for therapy and palliative care for the hospital to support patients and staff. There was an on call respiratory therapy service throughout the year and on call consultants were available for all specialist areas to support out of hours medical staff. There were vacancies for stroke consultants which meant that staff were rostered every 3 weekends to provide adequate cover. Senior divisional leaders told us that they are aware of staffing gaps and this was being recruited into.

We scored the service as 2. The evidence showed some shortfalls. The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

During the January 2020 inspection, we found staff did not label monitoring equipment or hoists after cleaning. During this assessment we found staff were not using ‘I am clean’ stickers to identify when equipment had been cleaned. This was not in line with policy.

Staff we spoke to were able to explain the process for cleaning and isolating patients during infection outbreaks. The infection prevention and control (IPC ) team were visible when there was an outbreak and would complete audits around IPC principles in line with trust policy. Staff told us that following a deep clean of an area a matron was required to approve a patient admission into the area post clean. This resulted in a delay in admitting patients to ward areas.

Domestic cleaning was provided by an external company which had changed since July 2025. Cleaning logs were kept on wards to evidence completion of daily tasks such as restocking gloves, aprons and wipes, cleaning computers and telephones and ensuring equipment was clean, such as drip stands and weighing scales. We checked the cleaning log on Claydon from 15 to 19 September 2025 and found it had not been completed as the housekeeper was on leave. We were told by staff that there was no cover when housekeeping staff were on annual leave or sick leave.

A monitoring team carried out audits to ensure compliance against trust policy. We requested cleaning audits for all medical care wards for the last 6 months. We found in August only 5 out of 13 wards met the trust target of 95%. The worst performing ward was Debenham which failed to meet the trust target from May to August 2025. Safety huddle topics covered non compliance with IPC and in the last 6 months items such as handwashing, reminding staff around the use of gloves and the importance of checking the electronic system for patients with known infections admitted to wards had been discussed.

There was evidence of the IPC team supporting wards that were not performing in line with trust target. This included weekly audits where actions were taken to address non-compliance such as escalating concerns as needed

We reviewed 7 patients cannulas on Saxmundam and Shotley ward for compliance with trust cannula policy. We found that care was inconsistent across these wards. For example, dates of insertion were written on dressings or on visual infusion phlebitis (VIP) charts attached to the patients drug chart. We also found that cannulas were not always managed in line with trust policy. For example, we found a cannula secured with micropore tape and a lack of review if a cannula was still required. This was escalated to the ward sister who reviewed the cannulated patients on the ward.

On Woodbridge ward we observed patients placed in side rooms to reduce the risk of spreading infection to staff and other patients. However, we found examples of the doors being left open due to the patients being a high falls risk. These were patients isolated for covid, Carbapenemase-Producing Enterobacteriaceae (CPE) and a patient that had been in contact with another infectious patient. This meant there was potentially an increased risk of spreading air borne infections such as covid due to leaving doors open.

We saw evidence of testing water outlets for preventing healthcare-associated infections in vulnerable patients by identifying and controlling harmful microorganisms like Legionella and Pseudomonas aeruginosa. For August 2025 we found two examples within endoscopy where the result was borderline. The levels were not high enough to trigger the need for intervention.

We observed staff washing hands after patient contact and wearing personal protective equipment (PPE), such as gloves and aprons where indicated in line with national guidance and trust policy.

We scored the service as 3 . The evidence showed a good standard. The service made sure that medicines met people’s needs, capacities and preferences. They involved people in planning, including when changes happen. However, they did not always ensure and treatments were safely stored to reduce potential safety risks.
Patients consistently received their medicines as prescribed, with administration accurately documented on prescribing charts. Patients told us they were given information about their medicines especially when there are changes.

We reviewed 9 prescription charts and found allergy status was clearly documented in patient records. Additionally, patients were issued colour-coded wristbands to visually alert staff to any allergies, enhancing safety during care delivery.

Staff received medicines training and are assessed as competent to provide medicines support to people. Staff told us that a pharmacist was available to support some wards (apart from the MSKAU) and that they were responsive to queries. They were also contactable out of hours via an on call service. Staff understood how to access relevant local medicines policies, procedures, and guidelines.

We found 16 drug related incidents reported between August 2025 and September 2025. There was evidence of learning and actions such as reflection and shared learning to be shared at huddles and consultant meetings to prevent future occurrence. There was no harm attributed to any of the 16 incidents reviewed.

Staff told us that medication incidents are sometimes discussed within departmental meetings but we did not see evidence of learning shared trust wide with support from trust Medication Safety Officer (MSO) and pharmacists.
Medicines and controlled drugs were not always stored, recorded, administered, and disposed of safely in accordance with national guidance across all wards. Within MSKAU, we found prescription only medicines such as antibiotics were easily accessible for patients in unlocked cupboards . We found 5 oxygen cylinders not stored securely within the discharge lounge. This was escalated during assessment and items were immediately secured to prevent potential safety risk.

Emergency medications were available and subject to daily audits to verify tray contents. However, the resuscitation trolley in MSKAU was found to be unlocked with emergency medication left accessible. This was escalated and action was taken to address the concern.

People receiving their medicines covertly were safely supported in line with the Mental Capacity Act 2005. We observed this during our assessment where staff discussed this at morning handover and a MCA and DoLS was in place to support this practice.