Source · CQC inspection

West Suffolk Hospital

Type NHS Healthcare Organisation Region East Last inspected 22 Jun 2021

Overall rating: Requires Improvement View full CQC report

Domain ratings

Five CQC key questions

Safe

Requires Improvement

Effective

Requires Improvement

Caring

Good

Responsive

Good

Well-led

Requires Improvement

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 …