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West Suffolk Hospital

Type NHS Healthcare Organisation Region East Last inspected 22 Jun 2021

Location rating: Requires Improvement  View location on CQC

Location ratings by domain

Five CQC key questions

Ratings held for this CQC location under the inspection framework, last inspected 22 June 2021. Ratings extracted from individual reports are shown separately below.

Safe
Requires Improvement
Effective
Requires Improvement
Caring
Good
Responsive
Good
Well-led
Requires Improvement

Most recent report indexed for actions

The date and rating here are from an individual report, not necessarily the location's latest assessment. Report ratings are extracted with AI; verify the original PDF.

Type: Location
Date: 22 June 2021
Rating extracted from this report: Requires Improvement
Actions indexed: 6 must-do 3 should-do

Read this inspection PDF

AI-extracted 3 Jun 2026

Earlier inspection findings

pre-2024 framework · 6 must-do 3 should-do

Must-do actions (6)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 6
Must do
Safe
The trust must ensure that medical and anaesthetic staff meet mandatory training compliance levels.
Regulation: Regulation 12 (1)(2)(c)
⚠ Medical staff did not always keep up-to-date with their mandatory training. Overall mandatory training rates for medical staff were 84%, this was below the 90% trust target, Obstetric medical staff missed the trusts target for PROMPT (89.7%), Growth Assessment Protocol training (GAP) (80%) and safeguarding children training (85%). PROMPT training …
Must-do action 2 of 6
Must do
Safe
The service must ensure they complete emergency drills in a baby abduction scenario.
Regulation: Regulation 12 (1)(2)(a)(b)(c)
⚠ The service did not have a baby abduction policy and had not conducted any abduction drills despite this being raised in our previous inspection report in 2019. We found the service had not conducted any baby abduction drills in the intervening 15 months between inspections. We were concerned that in …
Must-do action 3 of 6
Must do
Safe
The service must ensure equipment is serviced within its due date.
Regulation: Regulation 12 (1)(2)(e)
⚠ The maintenance of equipment was not always timely. We reviewed five pieces of equipment including bladder scanners, SPO monitors and Cardiotocography machines (CTG) on F11 ward. We saw that four out of the five pieces of equipment had missed their service due date. Three of the pieces of equipment had …
Must-do action 4 of 6
Must do
Safe
The service must ensure it implements a tool to safely triage women in the maternity day assessment unit and labour suite triage.
Regulation: Regulation 12 (1)(2)(a)(b)
⚠ At the time of our inspection the service did not use a tool to triage women. Staff completed risk assessments for each woman on admission/arrival to either the maternity day assessment unit (MDAU) or labour suite triage, however they didn’t use a recognised tool to triage women. This meant midwives …
Must-do action 5 of 6
Must do
Safe
The service must ensure its staffing levels meet acuity levels within the service.
Regulation: Regulation 18 (1)
⚠ The service didn’t always have enough maternity staff to keep women safe from avoidable harm and to provide the right care and treatment. From January to April 2021 the trust’s acuity data showed that the service’s staffing levels only met acuity 62.7% of the time.
Must-do action 6 of 6
Must do
Well-led
The service must ensure governance arrangements establish timely compliance with national recommendations and ensure oversight of local audits.
Regulation: Regulation 17 (1)(2)(a)(b)(f)
⚠ There was a lack of oversight with local audit action plans and a slow pace of improvement in relation to compliance with national recommendations. The service was slow to implement national recommendations from the Maternity Incentive Scheme and the Ockenden report. The service had six amber actions for the Maternity …

Should-do actions (3)

Recommended improvements to enhance service quality.

Should-do action 1 of 3
Should do
Effective
The trust should improve appraisal rates for midwifery staff.
Should-do action 2 of 3
Should do
Well-led
The trust should consider minuting triumvirate meetings.
Should-do action 3 of 3
Should do
Well-led
The trust should consider improving the quality of perinatal mortality and morbidity meeting minutes.