The Ipswich Hospital

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of people who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement.

This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to the governance of the service.

We have not awarded this service a score for Well-led.

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

We scored the service as 3. The service had a shared vision , strategy and culture which was underpinned by the trust strategic objectives. The ambition was to offer the best care and experience and to increase equality in health outcomes. The new strategy was developed in collaboration with people who use the service, staff and external partners. The aim was to deliver on the strategic objectives over the next 5 years and there were key initiatives that focussed on personalising care and empowering people to care for themselves, increase the integration and standardisation of services, have sustainable care, develop a greater skill-mix and make the most of technology opportunities.

Divisional leaders understood the need for the aligned working with community partners to address flow and admission avoidance to meet the current bed deficit as well as having a strong focus on providing harm-free, high-quality care. There was a shared vision for the progression of the division and divisional leaders were aware of the challenges. For example, they told us that they were aware of the bed capacity ahead of the winter pressures and the importance of getting people into the right bed to optimise care. This was being impacted on due to the loss of an escalation area within medical care.

The divisional triumvirate were proud of the compassionate staff and felt that there was a culture and focus from staff on patient experience. They understood that things could be improved such as communication, discharges and staffing and felt confident that the new structure of the division allowed them to be able to effectively engage with teams to achieve the overall vision and strategy.

The trust values were optimism, appreciation and kindness (OAK). Most staff that we spoke to during the onsite assessment were aware of these. However, they were unsure of the vision and strategy but knew these could be accessed on the intranet.

The last NHS staff survey took place between September and November 2024, with a 42.7% response rate for medicine and community Ipswich and East Suffolk (MACIES) division at Ipswich Hospital against the average trust response of 48.1%. The lowest responses were from Haughley ward and stroke services at 15%. There was no action plan for 2024. New Staff survey for 2025 was in progress and senior leaders told us that actions would follow the results. Areas where medicine at Ipswich scored lower compared to the trust were morale, we are recognised and rewarded, we are safe and healthy and we work flexibly. This was supported by staff we spoke to and data we reviewed .

We scored the service as 2 . The evidence showed some shortfalls. Leaders understood the context in which the service delivered care, treatment and support. Leaders had the skills and knowledge to lead effectively . However, they did not always embody the culture and values of their workforce and organisation.

The DMT was formed of divisional directors, divisional director of nursing, divisional director of operations and a vacant associate director of nursing post. This team had oversight of 4 clinical delivery groups (CDG): CDG 1 urgent and emergency care; CDG 2 and 3 Specialist services /pathways which covered the medical care and older peoples services and CDG 4 community. Each CDG 3 and 4 comprised of a Head of Therapies, general managers and senior matrons who reported directly to the DMT. Senior leaders had the qualifications and experience in leadership for the roles.

The DMT and CDG leadership had a good understanding of the services they managed, for example, they were aware of the issues that had been identified during our onsite assessment such as mental capacity assessments, medical staffing and the use of MSKAU area for outlier patients. They acknowledged that action taken to address mental capacity assessments had been started prior to the on site assessment but more training was required. They were hopeful that the new electronic system would improve the efficiency of working to address the concerns staff raised regarding the medical staffing cover at night and this would need to be reviewed. They had taken action following the assessment and told us that the MSK AU area had not been used since the assessment and a speciality review of the bed base was being conducted.

Senior leadership were open and honest about the risks and challenges the service faced. For example, they were aware that the service was delivering a robust induction for staff as well as flow within the hospital. They acknowledged that although the formation of the MACIES division was positive there was more progress to be made to ensure delivery of the strategic objectives to provide the best care and experience and to increase equality in health outcomes, alongside a happy workforce.

The last NHS staff survey results in 2024 for the medicine division scored lower for compassionate leadership across all 4 areas, with ‘my immediate manager works together with me to come to an understanding of problems’ declining the most. Staff we spoke to felt that leaders were not responsive to concerns they raised. For example, concerns around staffing which impacted staff speaking up again. Some staff felt that senior leadership were not visible.

The division significantly scored lower in ‘How often, if at all, do you find your work emotionally exhausting’, this increased by 7.2% compared to 2023. There was no action plan provided to address changes in the NHS staff survey. We were told that the next NHS staff survey was underway following our onsite assessment and actions would follow the results. Therefore, we were not assured that the senior leadership embodied the culture and values they expected of their workforce and organisation. Although we saw evidence of staff well being within some of the monthly ward governance reports, we did not see any evidence of action to address stress and burnout. The May 2025 board report reported the agreed focus following the results of the 2024 staff survey were advocacy, raising concerns and appraisal. This meant that the division were not focussed on actions relating to the feedback by their staff.

Senior managers told us they visited clinical areas, supported on wards when required and met with matrons weekly. Matrons met with senior nurses weekly to discuss quality and safety audits. Ward staff told us that they did not see matrons and senior leaders frequently and did not feel that action was taken to address concerns that were raised. The 2024 NHS staff survey results for the division scored below the trust average for both burnout and morale. This meant that the actions taken by leaders were not effective to meet the needs of their staff.

We scored the service as 2. The evidence showed some shortfalls. People did not always feel they could speak up and that their voice would be heard.

People felt that they could speak up but they did not always feel that their voice would be heard. For example, staff escalated concerns regarding staffing levels but they continued to occur, and staff did not see any action taken to address the concerns raised. Staff, therefore, did not feel confident that their concerns were always listened to.
Some staff reported raising concerns around working in wards outside of their skillset. They raised this with the ward manager but said they did not receive any feedback on action taken. Some staff felt that they were not consulted or had an option to speak to senior leaders regarding changes being made to their department that directly affected them. Some staff reported that they felt that not all staff were confident to speak up for fear of retribution and loss of job if they were international recruits. Not all staff we spoke to during our assessment were aware of the freedom to speak up (FTSU) service.

There were 2 FTSU guardians for Ipswich Hospital and 5 assistants. They provided 6 monthly reports to the board and raised concerns brought to them via the FTSU steering group which was established in 2024. The steering group was put in place to offer strategic direction to the FTSU Guardian and assistants, and to act as a focal point to encourage and monitor how the trust improved the mechanisms and culture for ‘speaking up’.

The Freedom to Speak Up report for April 2025 to September 2025 showed a reduction in concerns being raised , there had been no concerns raised within the medicine division. There was direct communication between FTSU and the board and had experience of raising concerns in a timely manner with them. There was an acknowledgement that there had not been any concerns raised within the medical care division and that this may be staff are scared or disengaged. The FTSU guardians were planning on visiting all clinical staff areas to promote the staff and encourage staff to use the service.

Training was due to commence for well being ambassadors to encourage staff in their understanding and use of FTSU services.

Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs.

Managers and staff had access to the feedback from patients, carers and staff and used it to make improvements. This was evidenced within via monthly governance meeting minutes. We saw action had been taken to address disabled toilet access at the entrance of the hospital following complaints raised via Patient Advice and Liaison Services.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We scored the service as 2 . The evidence showed some shortfalls. The service had clear responsibilities, roles and systems of accountability. However, they did not always act on the best information about risk, performance and outcomes.

The service had a clearly defined governance structure to enable the flow of information from frontline staff to senior managers and the trust board . Matrons met with senior nurses weekly and reported to the monthly Clinical Divisional Group level meeting which fed into monthly Divisional Governance and Quality Board Meeting which ultimately had oversight from Executive Management Committee who reported to trust board. However, we were not assured that information was communicated effectively due to concerns identified during the assessment and review of internal audits.

There was a clear framework of what must be discussed at a ward, team or directorate level in team meetings to ensure that essential information, such as learning from incidents and complaints, was shared and discussed. However, meeting minutes we reviewed did not always demonstrate that this was effective. For example, there were repeated themes around poor discharge and communication.

Team managers had access to information to support them with their management role. This included information on the performance of the service, staffing and patient care. Key information covered areas such as audit compliance, achievements, friends and family feedback and emerging risks and actions taken to address them. This was summarised in a monthly ‘2 at the top’ (2@T) document, emailed to all ward staff, in an accessible format and was timely, accurate and identified areas for improvement. We saw evidence of 2@T on wards we visited during our onsite assessment. We reviewed the August 2@T for all medical care wards and there was evidence of items being escalated to senior leaders. For example, Grundisburgh ward had escalated wellbeing for staff and review of acuity and dependency of ward as staff were struggling to adhere to wards compliance as acuity had increased.

We were told that matrons met with ward managers on a monthly basis to discuss performance within the 2@T. We requested the last 3 months meeting minutes but were provided with May, August and September 2025. This may have been due to meetings being cancelled due to operational pressures.

We reviewed the last 3 months CDG 2 and 3 meeting minutes and agenda. Agenda items were highlighted for areas of focus during the virtual meeting. Meetings were not always effective in managing the risks identified. For example, we found that in June 2025 there was an increase in incidents relating to falls and aggressive patients, escalation areas were in use due to a deficit of medical care beds. Incident rates for pressure ulcers and falls were not reviewed in the July or August 2025 meeting, nor were there actions on how senior leaders would monitor or address these within the MACIES CDG 2 and 3 board action log. Agenda items that had been highlighted were not all covered or minuted within records we reviewed. Therefore, we were not assured that areas of risk and concern were being discussed with senior leadership to take timely action .

We reviewed divisional quality board meeting minutes. This covered 3 months of MACIES quality board meeting minutes and CDG 2 highlight report for June and July 2025. The meeting minutes showed that relevant topics were discussed, including audits, complaints, incidents and risks. We requested the last 3 months performance dashboards for medical care and were provided with MACIES accountability framework for performance from April to June 2025.

Governance processes were not always effective in managing the risks identified. For example, audit data showed consistent poor performance for completion of mental capacity act (MCA) assessments, falls risk and pressure ulcer risk assessments. MCA assessment compliance was 33.3% in April and 25% in June 2025, against a trust target of 85%. Diagnostic wait times for more than 6 weeks were reported at 10.43% in April 2025 and increased to 20% in June 2025 against a target of 5%. The MACIES CDG 2 & 3 board action log did not reference the increase in incidents or pressure ulcer and falls data. Therefore, there was a lack of senior leadership ownership to address the ongoing failure of compliance and drive positive improvement within the division.

Endoscopy had bimonthly governance meetings within the surgical division. We reviewed the last 3 meeting minutes to ensure essential information, such as learning from incidents and complaints was discussed. There was evidence of action taken in response to feedback from staff. For example, action was taken to ensure referrals had all information required to support the team to triage and optimise bookings due to increased frustration from ward teams.

Staff maintained and had access to the risk register at ward or directorate level. Staff concerns matched those on the risk register, for example staffing, lack of suitable stroke rehabilitation area and ability to safely review medical outliers. Risks such as poor risk assessment completion and mitigation, and falls were overseen by senior leadership teams through the Trusts Accountability Framework and Divisional Meetings for mitigation planning. However, action taken by leaders was not effective to ensure a sustained improvement of compliance in all areas in line with trust policy.

We found repeated breaches of regulations in relation to mandatory training compliance, the labelling of equipment after cleaning, the completion of food and fluid balance charts, and the completion of VTE risk assessments. This meant that governance processes were not robust in addressing known risks identified at the previous inspection.
Staff did not always have access to the equipment and information technology needed to do their work. For example, air mattresses were not always available for patients on wards which was supported by 2@T report for Kirton ward and the current incident log provided. The new change in electronic system meant that the Diabetic team would no longer be on a system with community partners which could potentially delay information sharing for other healthcare professionals.

There were policies and standard operating procedures (SOP) in place to support staff. However, there were 4 policies identified as being overdue for review within governance meeting minutes. We also found that staffing for the overnight bedding of patients within the Heart Centre was not in line with the current Heart Centre Escalation Ipswich Hospital standard operating procedure v3.0. Leaders told us that this was to be reviewed and amended.

Various policies and procedures were in place to cope with unexpected events. Business continuity plans were in place for all areas of the division which detailed strategic arrangement and activities undertaken within the trust to support the emergency preparedness.

We scored the service as 3. The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The division held patient/family engagement where they share their experiences with the clinical teams for wider shared learning and guide improvements for medication management, training and spot checks, communication, infection prevention and control training and audit and breaking bad news.

Directorate leaders engaged with external stakeholders, such as Suffolk Constabulary, commissioners and Healthwatch to improve services and seek feedback, and work in partnership so that they could improve services for people. For example, there was a system response to the Healthwatch Suffolk research into waiting for treatment. Themes included communication, protection from the impacts of waiting as well as offering choices. The division took action to address these such as informing patients of wait times at the point of referral and their rights whilst they wait, with a proactive communication to ensure people knew of the choices they can make at all stages whilst they wait. All agreed actions to address the themes within the report were supported with an action plan detailing the rationale, named lead with the ICB and timeframes. Upon review of the action plan the division was on track to deliver these .

Specialist teams worked closely with partner agencies to ensure that services worked seamlessly. For example, the local GP practices could call the palliative care team consultant for direct advice, the community butterfly volunteer scheme supported the completion of Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) forms in the community. The renal team had outreach nurses that supported GPs with chronic kidney disease patient management.

The division had specialist collaboration with many local networks such as cancer, cardiology, respiratory and Neurology. Leaders told us collaborative working with networks had benefited the division and patients using services within Ipswich hospital. For example, within respiratory a consultant respiratory physician attended the regional multidisciplinary team with the tertiary specialist heart and lung centre for patients with pulmonary fibrosis. By working with the tertiary centre and attending the MDT they were able to get patients access to antifibrotic drugs. This reduced the need for many patients to travel to Cambridge in order to access treatment and follow up.

The division also worked closely with local services to support and facilitate more timely discharges such as non-profit organisations who support with decluttering/cleaning a patients property where this work has been identified as ‘essential for discharge’ and where there were no family/friends to do this.

The hospital’s Butterfly volunteers service was set up in partnership with the Anne Robson Trust Home. They provided company support to hospital patients in the last days and hours of their lives. All volunteers were trained to undertake the role and give time to engage with patients who have no visitors to engage in activities such as reading, listening to music or support family or friends if they were struggling, provide breaks for visitors, liaise with staff on behalf of the patient and ensure patients are not alone.

We scored the service as 2. The evidence showed some shortfalls. The service did not always focus on continuous learning, innovation and improvement across the organisation and local system.

At our last inspection in January 2020, we found breaches in regulation to staffing, infection prevention control, staff training and competence, venous thromboembolism (VTE) risk assessments and medicines management. During this assessment, we found repeated breaches of regulations in relation to mandatory training compliance, the labelling of equipment after cleaning, the completion of food and fluid balance charts, and the completion of VTE risk assessments.

The service did not always learn from reported incidents to embed good practice to reduce future risks. For example, in July 2025 there were 936 patient safety incidents reported relating to pressure and skin damage. There was also an increase in the number of section 42 safeguarding raised requiring local authorities to investigate potential abuse or neglect of adults. There was no evidence in the action log provided to demonstrate the divisional leadership team were responding to ensure that this was being addressed.

The division had 173 incidents awaiting review, worsening mental capacity act assessments completed and increase in percentage of patients awaiting diagnostics for more than 6 weeks against trust target. This meant that the division were not taking timely action to make improvements and prevent repeated harm.

Audits were preformed but this was not being used to drive improvement. For example, the trust carried out a range of audits to evidence fundamentals of care. We found that nutrition and hydration charts and ReSPECT forms were not completed in line with policy. Trust data supported our findings and although action had been taken this had not been effective to drive improvement to meet the trust standard of 95%. Therefore, we were not assured that the systems in place were effective in driving improvement.

Staff were able to report some positive changes to practice as a result of incidents. For example, bay tagging in response to increased falls across the division and the introduction of the yellow sock scheme. Despite the service introducing initiatives to reduce falls, these were not always being implemented, for example we found some patients not wearing the yellow socks. We also observed patients within the tagging bay not being observed as staff were required to deliver personal care behind a curtain and the staffing on the ward did not allow for another member of staff to monitor those at high risk of falls. Therefore systems in place were not effective as a result of resource.

We saw medical staffing mandatory compliance was below the trust target of 90% for all topics.

Training was not always effective in supporting the delivery of safe and effective care. For example, there had been a focus on staff receiving mental capacity act training, however, we found there to be a lack of completion and documentation to demonstrate ethical and legal compliance of decision about future care and treatment of confused patients on medical wards.

Staff were given the time and support to develop opportunities for improvements and innovation and this led to changes in care delivery. Staff used quality improvement (QI) methods to improve the services. Staff participated in national audits relevant to the service and learned from them. For example, Investigating the appropriateness of CT head requests in inpatient falls. The audit showed that Sub-optimal use of the adult post- falls flow chart (only used correctly in 30% of cases). Neuro observations and GCS were missed from the post fall assessments in 14 out of 30 cases on Washbrook, Woodbridge and Shotley wards. Learning was identified but there had not been a repeat audit to measure the effectiveness of the QI work.

Patients and carers were involved in decision-making about changes to the service. For example, diabetes specialist nurses had undertaken a trial of patients administering their own insulin on admission to wards as a result of feedback from patients felt disempowered whilst on wards to manage their own condition. Diabetic patients between 18- 25 years old expressed a wish to have continuity in nursing contact and the service changed it’s multidisciplinary model to ensure that a named nurse or clinician to offer continuity in their care for outpatient appointments.

Wards participated in accreditation schemes relevant to the service and learned from them. At the time of the inspection there were 2 wards with Silver accreditation and 2 with Bronze awards within the MACIES division. Ward governance reports showed that other wards were working towards a bronze accreditation to focus on engaging staff and empower leaders to improve standards and quality on medical care wards.