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Provider: West Suffolk NHS Foundation Trust Requires improvement

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  • We have served two fixed penalty notices on West Suffolk NHS Foundation Trust for failing to meet fundamental standards at West Suffolk Hospital, Bury St Edmonds on 09 September 2021. Fines totalling £2500 have been paid as an alternative to prosecution.


Inspection carried out on 24.09.2019 to 30.10.2019

During a routine inspection

Our rating of the trust went down. We rated it as requires improvement because:

  • We rated safe, responsive and well led as requires improvement and effective and caring as good. Ratings for all five key questions, safe, effective, caring, responsive and well led had gone down. The rating for the well led question at trust level had gone down from outstanding to requires improvement.
  • We rated three of the trust’s five acute core services as requires improvement (maternity, medical care and outpatients) and two as good (urgent and emergency care and surgery). Overall ratings for urgent and emergency care and surgery had remained the same, medical care and outpatients had gone down. We previously inspected maternity jointly with gynaecology so we cannot compare our new ratings directly with previous ratings. In rating the trust, we took into account the current ratings of the three services not inspected this time. We rated all three community services as good overall, with safe, effective, caring, responsive and well led rated good. Community health services had not been rated previously.
  • Processes for identifying, recording, escalating and managing risks across the organisation were not always fully effective or undertaken in a timely manner . There were inconsistent approaches to managing safety. Not all services controlled infection risk well. Completion of patient risk assessments, documentation and record keeping varied. Medicines management, including security and storage of medicines was inconsistent. Staff training and compliance in key skills fell below trust target, specifically for medical staff. Clinical and internal audit processes were not always fully effective across all services.
  • Services do not always meet people’s needs. People could not always access services for assessment, diagnosis or treatment when they needed to. The trust continued to underperform across a large range of national access standards, in particular those related to the national 18 week referral to treatment (RTT) standard, the six week diagnostic standard and access standards related to suspected and confirmed cancer management. Action to address this were not effective and at a global trust level, the number of patients on the RTT waiting list was substantially higher than 12 months previously, reflecting a lack of systemic waiting list control.
  • Not all systems produced reliable information that supported staff to develop and improve performance. Ongoing issues with e-Care had impacted on the ability and accuracy to report service performance specifics, such as referral to treatment time and theatre utilisation.
  • Not all staff felt respected, supported and valued or felt that they could raise concerns without fear. Communication and collaboration to seek solutions had not always been effectively undertaken. An open culture was not always demonstrated
  • The style of executive leadership did not represent or demonstrate an open and empowering culture. There was an evident disconnect between the executive team and several consultant specialties. Whilst priorities and issues were known and understood these were not always managed in a consistent way.


  • Services had enough staff to care for patients. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives and supported them to make decisions about their care. Key services were available seven days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The trust had a vision for what it wanted to achieve and a strategy to turn it into action, developed with all relevant stakeholders. The vision and strategy were focused on sustainability of services and aligned to local plans within the wider health economy. Leaders and staff understood and knew how to apply them in their work.

Our full Inspection report summarising what we found and the supporting Evidence appendix containing detailed evidence and data about the trust is available on our website – .

CQC inspections of services

Service reports published 30 January 2020
Inspection carried out on 24.09.2019 to 30.10.2019 During an inspection of Community health services for adults Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 24.09.2019 to 30.10.2019 During an inspection of Community health services for children, young people and families Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 24.09.2019 to 30.10.2019 During an inspection of Community health inpatient services Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
See more service reports published 30 January 2020
Inspection carried out on 9th, 10th, 30th November and 1st December

During a routine inspection

See guidance note 5 then add your text after the standard text paragraph below (and delete this help text).

Our rating of the trust improved. We rated it as outstanding because:

Safe remained good, effective improved to outstanding, caring remained outstanding and responsive and well led were good. Trust level leadership was rated outstanding.

Our inspection of the core services covered West Suffolk Hospital. Our decisions on overall ratings take into account, for example, the relative size of services and we use our professional judgement to reach a fair and balanced rating.

  • End of life care improved to outstanding overall, with the effective rating improved from requires improvement to good and well led from good to outstanding. Staff had improved knowledge around the use and implementation of Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS). There were clear escalation plans and improved performance in audit. National guidance and best practice was embedded in the service and there was clear, strong leadership that was widely respected by staff.
  • Outpatients remained good overall. The trust had had difficulties in reporting some referral to treatment (RTT) times following the introduction of eCare. With support from stakeholders, this had been addressed and the trust were able to report accurate RTT data.
  • On this inspection we did not inspect urgent and emergency care, medicine, surgery, critical care, maternity or children’s and young people’s services. The ratings we gave to these services on the previous inspection in August 2016 are part of the overall rating awarded to the trust this time.

Inspection carried out on 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 and Rosemary ward at Newmarket Community 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.
  • Good planning and collaboration with Suffolk Community Healthcare had ensured a smooth transition when the Trust took over the contract for the service at Newmarket hospital.
  • At Newmarket there was effective multidisciplinary working, communication and an open and positive culture of wanting to promote the best for patients and for 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.
  • Lord Carter assessed the trust as the most efficient small acute provider and the 4th most efficient provider in the country. According to Carter if the Trust were of average efficiency their deficit would be £20m higher and quality considerably worse than it currently is.
  • The trust performs well in national audits and is routinely amongst the top 15 trusts in the country across several national quality audits and international benchmarking databases.

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.
  • Ensure a robust process for data management with regard to medical photography, comply with all information governance protocols including informed consent, data protection, tracking and tracing, and appropriate audit systems implemented to ensure quality improvement.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up.

Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.

Joint inspection reports with Ofsted

We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.

Organisation Review of Compliance