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West Suffolk Hospital

Overall: Requires improvement read more about inspection ratings

Hardwick Lane, Bury St Edmunds, Suffolk, IP33 2QZ (01284) 713050

Provided and run by:
West Suffolk NHS Foundation Trust

All Inspections

Other CQC inspections of services

Community & mental health inspection reports for West Suffolk Hospital can be found at West Suffolk NHS Foundation Trust. Each report covers findings for one service across multiple locations

13 April 2021

During an inspection looking at part of the service

West Suffolk NHS Foundation Trust (WSFT) provides hospital and community healthcare services and is an associate teaching hospital of the University of Cambridge. WSFT was awarded foundation trust status in December 2011.

WSFT serves a predominantly rural geographical area of roughly 600 square miles with a population of around 242,000. The main catchment area for the trust extends to Thetford in the north, Sudbury in the south, Newmarket to the west and Stowmarket to the east. Whilst mainly serving the population of Suffolk, WSFT also provides care for parts of the neighbouring counties of Essex, Cambridgeshire and Norfolk.

The maternity service at West Suffolk Hospital delivers approximately 2,500 babies per year and offers a choice of three birth settings: birth at home; the co-located low risk midwifery led birthing unit (MLBU); the consultant led labour suite.

The service is provided by a team of consultant obstetricians who provide consultant presence on labour suite, supported by training grade doctors and midwives who work across the inpatient areas. Community maternity services are provided by four teams of midwives, as well as three continuity of carer teams. The maternity service has a number of specialist midwives. A perinatal mental health midwife works in partnership with the perinatal team at the local mental health trust. The service has a midwife who leads on bereavement and offers ongoing support to women and partners who have suffered a pregnancy loss. The service also had two practice development midwifes to assist maternity staff with their mandatory training and competencies and a safeguarding midwife who staff can seek safeguarding advice from.

We last inspected the maternity service between 24 September 2019 and 30 October 2019. The report was published on 30 January 2020. The maternity service was rated requires improvement overall. Safe and effective were rated as requires improvement, caring and responsive were rated good and well led was rated inadequate. Due to the significant concerns within the maternity service we undertook enforcement to enable the improvement of safety within the service. We issued a warning notice under Section 29A of the Health and Social Care Act 2008 on the 14 November 2019 and told the trust it must improve.

We carried out this unannounced focused inspection to follow up on the issues we identified in our 2019 inspection. We have continued to monitor the trust closely and carried out this unannounced inspection to follow up on the actions taken by the trust to address the safety risks to patients. We found that the trust were now compliant with all aspects of the S29A warning notice.

Our rating of services stayed the same. We rated them as requires improvement because:

  • The service was frequently short staffed and had to rely on calling in staff from other areas to cover the labour suite and maternity ward. Staff told us that the shortages impacted their welfare and at times they didn’t feel listened to.
  • The service did not have a tool in place to triage women. Staff told us that they relied on their clinical decision making when triaging women and that this meant decisions could vary from clinician to clinician.
  • The service had improved their governance arrangements, however we had concerns about continued lack of compliance with the Maternity Incentive Scheme. Arrangements were not in place for oversight of local audits, two audits we saw did not have action plans assigned to them. The service did not always minute meetings or produced minutes that lacked in detail.

How we carried out the inspection

As part of our inspection we visited the following areas within the maternity service: labour suite, midwifery led birthing unit, F11 ward (the combined antenatal and postnatal ward) and the maternity day assessment unit. We spoke with 21 members of staff including medical and midwifery staff, maternity care assistants and service leads. We observed care, handovers/meetings and reviewed 11 sets of maternity records. We also looked at a wide range of documents including policies, standard operating procedures, meeting minutes, action plans, prescription charts, risk assessments and audit results. Before our inspection, we reviewed performance information about this service.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

24.09.2019 to 30.10.2019

During a routine inspection

Our rating of services went down. We rated them as requires improvement because:

  • We rated safe, responsive and well led as requires improvement and rated effective and caring as good.
  • Out of the five hospital services inspected we rated three as requires improvement and two as good. In rating the hospital overall, we took into account the current ratings of services not inspected this time.
  • The ratings for medical care and outpatients went down, whilst the ratings for urgent and emergency services and surgery stayed the same. Maternity was rated as requires improvement. We previously inspected maternity jointly with gynaecology so we cannot compare our new ratings directly with previous ratings.
  • There was limited assurance about safety across all five services we inspected. Processes for identifying, recording, escalating and managing risks across the organisation were not always fully effective or undertaken in a timely manner. Safety concerns included, but were not limited to, infection control, the timeliness of patient risk assessments, patient record keeping, recording and storing of medicines, emergency equipment checks, and mandatory training compliance rates for medical staff. Staff training and compliance in key skills fell below trust target, specifically for medical staff.
  • Within the maternity service there was a lack of consistency in the effectiveness of the care, treatment and support that people received.
  • Services did not always meet people’s needs. People could not always access services for assessment, diagnosis or treatment when they needed to.
  • The leadership, management and governance across the services did not always support high quality patient care. Arrangements for governance and performance management were not always effective. Clinical and internal audit processes were not fully utilised to improve services. Not all systems produced reliable information that supported staff to develop and improve performance.


  • Services had enough staff to care for patients. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care.
  • Staff across all five services inspected treated patients with compassion, kindness, dignity and respect. Patients were involved as partners in their care.

9th, 10th, 30th November and 1st December

During a routine inspection

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

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

8- 10 March 2016 Unannounced inspection 23 March 2016

During a routine inspection

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

13 March 2014

During an inspection looking at part of the service

At our inspection in June 2013 we found that some staff were not aware of their requirements under that Mental Capacity Act 2005 (MCA). We also found examples of poor recording of consent and discussion regarding key decisions about people's care such as resuscitation.

At this inspection we found that the service was well-led as the provider had improved training arrangements, effectively raised staff awareness about consent and MCA, and there was evidence in people's care records that consent and capacity had been appropriately managed. We saw that the service was effective and caring because when we spoke with 27 people who used the service we found that people were well informed about their care and had been involved in key decisions. The service was being provided safely as staff we spoke with knew the procedures relating to MCA and we saw evidence in documentation that appropriate procedures were followed when people did not have capacity to make significant decisions.

13, 14 June 2013

During a routine inspection

Most people told us that they were satisfied with the service. We visited 11 wards and departments and spoke with 68 people receiving care and treatment, and 4 visiting relatives. One person said 'You wouldn't find better service in a hotel, I cannot fault them.' Some people described problems of staff not being able to attend to them quickly enough when needed. Staff told us there had been occasions when they felt that staff levels fell below what was needed to provide safe care. We saw that action had been taken and staff levels were set to improve.

We found that the provider had systems in place to maintain the safety and welfare of service users. Clinical leads and managers at all levels monitored the reports of any incidents such as falls or avoidable infections. There had been occasion when staff levels fell below what was needed to provide safe care. We saw that action had been taken and staff levels were set to improve.

The provider had good arrangements to promote effective performance of the service. We spoke with members of staff in all departments including nurses, ward managers, care coordinators, medical staff, porters and administration staff. Specialist staff told us about the initiatives and projects to improve the service such as dementia training for all staff and improved electronic recording and planning of care. Staff told us they were able to raise issues with their manager and gave examples of the incidents and concerns, such as staffing levels, that they had reported. Clinical leads and managers at all levels monitored the reports of any incidents such as falls or avoidable infections.

We spoke with executive and non-executive Trust Board members who told us about the framework for monitoring quality and safety of the service. We saw that managers showed clear leadership that all staff were expected to provide a high quality of care to people. The provider used surveys to gather the views of people who used the service. There was a 'patient panel' which meant that people who used the service were involved in planning and monitoring the service. Therefore executive managers were able to make decisions based on valid information about the experience of people.

We found that the provider had systems in place to monitor the condition and safety of the premises. We saw that clinical areas were kept clean and ordered.

2 August 2012

During a themed inspection looking at Dignity and Nutrition

People told us what it was like to be a patient in West Suffolk Hospital. They described how they were treated by staff and their involvement in making choices about their care. They also told us about the quality and choice of food and drink available. This was because this inspection was part of a themed inspection programme to assess whether older people in hospitals were treated with dignity and respect and whether their nutritional needs were met.

The inspection team included four Care Quality Commission (CQC) inspectors joined by a practising professional who was an experienced nurse manager.

We spoke with 19 people on six different wards. We spoke with 16 staff including ward managers and other staff in the nursing teams. We also spoke with a senior nurse and dietician in the trust. We did this to gain the views of people who received care and treatment, people who visited the hospital or worked there. We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

The three wards where we spent most of our time were chosen as they had a high proportion of older people, as this was the focus of the dignity and nutrition inspection (DANI). We visited three surgical wards to observe the support provided to people at the evening meal.

One person told us 'Staff treat me with respect and they talk to me politely. They speak discreetly with me behind a closed curtain.' Another person said about the staff 'They are wonderful.' People told us that staff answered call bells promptly and gave them the level of assistance they required. They told us that staff were easy to approach and that they felt able to raise concerns if needed.

People told us they were offered enough food and drink. One person said 'The food has been good. I have had a good choice offered to me.' We were told that specific requests for alternative foods were met by the catering service.

22 March 2012

During a themed inspection looking at Termination of Pregnancy Services

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

4 October 2011

During a routine inspection

Over forty people who use the services and some family members were spoken with during the visit to the hospital on 4 October 2011. Overall people spoken with were satisfied with the care received at the hospital

People we spoke with told us that they were well informed regarding their treatment and care. They told us that staff consulted them and that they were involved in decision making about their care needs.

Generally the people we spoke with said that the food was acceptable, however all courses were served together allowing some to go cold before it could be eaten. All people spoken with stated that they felt the hospital was clean.

People spoken with were all complimentary about the staff across the hospital. Whilst they said that the staff were busy at times, they did not get the impression that they were short staffed, however on occasions it would be a 'long time' before actions were completed by staff.