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Inspection Summary

Overall summary & rating


Updated 4 August 2016

The Care Quality Commission (CQC) carried out a comprehensive inspection between 8 and 10 March 2016. We also carried out an unannounced inspection on 23 March 2016. We carried out this comprehensive inspection as part of our regular inspection programme.

The West Suffolk Hospital site, in Bury St Edmunds, is where the majority of the services offered by West Suffolk NHSFT occur. The trust also offers outpatient and community services at Newmarket Community Hospital, Haverhill Health Centre, Thetford Healthy Living Centre, Stowmarket Health Centre, Sudbury Health Centre, Botesdale Health Clinic and Mildenhall Clinic.

During this inspection we inspected the trust’s sites at Bury St Edmunds and Newmarket Community Hospital. We did not inspect at the other locations as they only offer outpatient services at these sites. West Suffolk Hospital serves a population of approximately 275,000 people, over an area of roughly 600 square miles.

During this inspection it was evident that the trust had an established staff base that was proud to work at the hospital. Many staff had worked at this location for a long time. This meant that challenges were addressed quickly and efficiently. However, documentation of recorded actions was not consistent but this did not impact on the care of patients. The trust and its staff placed the patient at the centre of care provided and strove on a daily basis to enhance the patient experience of healthcare.

Our key findings were as follows:

  • All staff were helpful, open and dynamic. They were aware of what good looks like and were striving to implement this in daily practice. Staff were proud to work at West Suffolk Hospital.
  • Staff felt well supported by their managers and were impressed at the visibility of the chief executive.
  • Feedback from patients, relatives and carers was extremely positive throughout the hospital and at the listening event.
  • There were some excellent leaders in a number of areas, especially in the gynaecology and post-natal wards. The interim head of midwifery was providing good support to her team; however they would benefit from further support.
  • Staff were overwhelmingly caring in delivering care to patients. We witnessed some examples of excellent compassion and all staff we met put patients at the center of the care provided.
  • Many good ideas for improvement and innovation were from the junior, ward level staff.
  • Staff awareness and understanding of the Mental Capacity Act and Deprivation of Liberty Safeguards was not consistent.
  • Medical cover at night was not consistent and was not in line with good practice guidelines.
  • In the maternity service there had been a previous bullying culture that was beginning to decline. However pockets of this still existed.
  • Staff could not adequately explain the governance arrangements.
  • Information governance and data protection within medical photography was not assured. Systems for audit and documentation records and consent were not embedded or monitored effectively.

We saw several areas of outstanding practice including:

  • The porters’ display of respect for the transport of the deceased to the mortuary especially in respect of baby deaths.
  • The virtual fracture team who were dedicated to ensuring diagnosis of fractures was not missed in the emergency department (ED).
  • The receptionist in ED providing CPR to a collapsed patient and summoning immediate assistance.
  • Two consultant pediatricians learnt hypnosis to reduce the need for sedation in children requiring MRI or CT scanning.
  • Trust performance against national audits was outstanding especially in the Sentinel Stroke National Audit Programme (SSNAP) and Myocardial Ischaemia National Audit (MINAP).
  • Consultant paediatricians worked to provide access for patients. They set up outreach clinics in GP premises and held telephone clinics so that patients could stay in their own surroundings
  • Staff who went the extra mile to drop off take-home medications or provide decaffeinated tea bags for a patient.
  • The arrangement of a linked funeral service for the wife of the deceased who could not leave the hospital.
  • The pharmacy service was excellent in providing take-home medications for patients.
  • Additional support for critical care patients was provided by a follow-up nurse and a critical care outreach team, who also provided a cross-department education programme.
  • In critical care, staff were encouraged and supported to undertake novel research projects, which they were able to present at national conferences as a knowledge-sharing strategy.
  • Senior critical care staff had developed a robust five-year service plan in collaboration with unit staff, which was further evidence of the cohesive and supportive work culture we found.

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

Importantly, the trust must:

  • Review and ensure robust processes are in place to provide compliance with mixed sex accommodation regulations especially within CDU, critical care (in relation to level one patients) and recovery when it is utilised for stepdown from critical care.
  • Review its ‘Escalation Plan and Resuscitation Status’ (EPARS) forms to ensure, specifically, that the Mental Capacity Act and Deprivation of Liberty Safeguards aspects are appropriate.
  • Review its Mental Capacity Assessment, Deprivation of Liberty Safeguards and EPARS policies to ensure they are compliant with law and reflect good practice.
  • Ensure a robust process for data management with regard to medical photography and comply with all information governance protocols including informed consent, data protection, tracking and tracing and appropriate audit systems implemented to ensure quality improvement.

In addition the trust should:

  • The trust should review the reporting of mortality and morbidity (M&M) discussions and learnings in surgery services to ensure consistent and effective documentation across the service.
  • The trust should ensure staff compliance, across all staff groups, with mandatory and statutory training requirements.
  • The trust should review referral to treatment times and aim to improve to ensure that surgical patients receive care within 18 weeks.
  • The trust should ensure robust oversight of cancelled clinics and review theatre utilisation to support access to services and reduce patient treatment delays.
  • The trust should ensure that the nutrition, hydration and toileting needs of patients are met when recovery is utilised as a step down area from CCU.
  • The trust should ensure the principles of infection control are appropriate and monitored within the critical care unit for caring for potentially infectious patients.
  • The trust should ensure appropriate senior staffing support to promote patient safety, including midwifery support in the management of complex cases on labour ward, appropriate supervision for high dependency patients and appropriate level of supervision within outpatients.
  • The trust should consider quality measurements such as local targets for induction of labour, assisted deliveries and return of women with perineal problems.
  • The trust should have action plans where it is not reaching national standards in maternity.
  • The antenatal and postnatal ward F11 should review the practice of overnight stays for all partners on the ward.
  • The trust should review the succession planning and development for staff in seconded or interim roles within the maternity service.
  • The trust should consider developing strategic planning arrangements including action plans to achieve service goals, a performance dashboard for children’s services and a comprehensive transition policy to help all teenage patients adjust to adult health services.
  • The trust should review the availability of staff with play specialist skills.
  • The trust should review the options and nutritional value of food offered within the children’s service.
  • The trust should review medical staffing, particularly within end of life care services to ensure consultant cover meets recommended national guideline levels.
  • The trust should ensure that nurse staffing levels for children meet recommended national guideline levels.
  • The trust should include sepsis monitoring on the maternity dashboard for inpatient areas.
  • The trust should consider midwifery staffing and specialist midwives roles to support vulnerable groups.
  • The trust should review the way patients in the last days or hours of life have their needs holistically assessed and how this is documented.
  • The trust should review it’s specialist palliative care service for medical staffing and provision of a seven day service
  • The trust should ensure that records management is secure and appropriate in all areas
  • The trust should ensure a robust process for oversight and management of all policies and procedures.
  • The service should ensure that risk scrutiny in governance meetings is robust and recorded so that there is assurance of management of risk.
  • The trust should ensure dissemination of outcomes from audits and meetings is robust across all services.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas



Updated 4 August 2016



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Updated 4 August 2016

Checks on specific services

Maternity and gynaecology


Updated 4 August 2016

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Medical care (including older people’s care)


Updated 4 August 2016

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

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

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

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

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

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

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

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

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

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

Urgent and emergency services (A&E)


Updated 4 August 2016

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

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

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

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

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

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

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

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

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

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



Updated 4 August 2016

Surgery services at West Suffolk Hospital were good overall.

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

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

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

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

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

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

Intensive/critical care


Updated 4 August 2016

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

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

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

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

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

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

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

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

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

Services for children & young people


Updated 4 August 2016

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

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

Management and storage of medicines was appropriate and safe.

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

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

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

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

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

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

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

End of life care


Updated 4 August 2016

End of life care at West Suffolk NHS Foundation Trust was rated good overall. Safe, responsive and well led were all rated as good and caring as outstanding, with effective rated as requires improvement.

Staff knew how to report incidents involving patients at the end of life and evidence of this was seen throughout the inspection.

Staff adhered to infection control practices, particularly within the mortuary. The specialist palliative care team (SPCT), mortuary, chaplaincy and bereavement staff had all completed 100% of their required mandatory training. Patient records were accurate and completed in a timely manner.

Patients were able to access food and drink when they required it, and were assisted to eat if needed. Pain relief was prescribed and administered in a timely manner and in accordance with trust policy. The trust scored well in the March 2016 National Care of the Dying Audit, meeting four out of the five clinical outcomes. The trust’s policies around the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) were ambiguous and left staff confused about how to interpret the MCA and when to apply for a DoLS. The completion of the trust Escalation Plan and Resuscitation Status (EPARS) was inconsistent and often did not reflect the patient’s medical notes.

Patients and their families were cared for with dignity, compassion and in a respectful way throughout the inspection. Staff gave examples of exceptional practice that enhanced patients’ physical and emotional wellbeing. Staff used their initiative in often difficult situations to ensure patients and their families received the care they required.

There was a mixture of patients with and without cancer referred to the SPCT. We saw care planning was documented and implemented across all clinical areas inspected.

The chaplaincy was able to contact religious leaders of other faiths; however this was limited and rarely used.

The trust had a clear strategy and vision for end of life care. Although no substantive medical leadership was in place, the SPCT practice development matron met weekly with the executive lead for end of life care for senior guidance and support. The trust demonstrated multiple initiatives to improve and ensure sustainability within the service. Formal staff and public engagement was lacking, however informal feedback was sought from staff on a regular basis through discussions within ward areas.



Updated 4 August 2016

Overall we rated the diagnostic and outpatient services at West Suffolk Hospital as good.

Staff were safety and risk aware, knew how to ensure provision of a safe service and could describe how to escalate incidents and learning from these when things had previously gone wrong.

Cleanliness was good. The trust monitored this through audits, for example for hand hygiene.

There was a process for maintenance of equipment within the departments and the trust had plans for replacement, maintenance or service interruption through major incidents.

Medicines were securely stored and monitored, and information was available for patients regarding potential side effects. The trust used evidence-based guidance to treat patients and monitored outcomes.

Staff were aware of their responsibilities to protect patients from abuse or harm and could describe how to escalate concerns or seek help. Staff could describe appropriate processes for protecting people who were vulnerable through intellectual disabilities such as dementia.

Caring was good as staff were able to describe how they go ‘the extra mile’ for their patients and we observed staff interact with patients, relatives and their colleagues respectfully and treat them with dignity. Patient feedback showed that people were very happy with the care they received.

We saw that staff from different professional disciplines worked well together to provide the most appropriate care for their patients. The trust was achieving target times for referral to treatment for most services.

There were governance processes and risk management for most of the services. Risks were appropriately captured and documented.

Staff were universally positive about local and trust wide leadership. The executive team supported staff, encouraged them to suggest and make changes to improve patients’ experience, and supported implementation of these.

However there were gaps in mandatory training and appraisal for some groups of staff such as nursing staff in radiology. We could not be confident that outpatient clinics were appropriately staff by skilled and qualified staff, for example paediatric dermatology.

Some outpatient areas, for example audiology, were very cramped.

Policy making in the outpatients department lacked timeliness, trust-led scrutiny or endorsement.