All inspections: Norfolk and Norwich University Hospital

Pages 1 to 3 of this report relate to the hospital and the ratings of that location, from page 4 the ratings and information relate to maternity services based at Norfolk and Norwich University Hospital.

We inspected the maternity service at Norfolk and Norwich University Hospital (NNUH) as part of our national maternity inspection programme. The programme aims to give an up-to-date view of hospital maternity care across the country and help us understand what is working well to support learning and improvement at a local and national level.

Norfolk and Norwich University Hospital provides maternity services to the population of Norfolk, North Suffolk, and Waveney.

Maternity services include an early pregnancy unit, maternal and fetal medicine, antenatal clinics, maternity assessment unit, antenatal/gynaecology ward (Cley Obstetrics), delivery suite, midwifery led birthing centre, two maternity theatres, postnatal ward (Blakeney Ward) and ultrasound department. There were 5199 babies born at NNUH between April 2021 to Mar 2022.

We will publish a report of our overall findings when we have completed the national inspection programme.

We carried out a short notice announced focused inspection of the maternity service, looking only at the safe and well-led key questions.

Our rating for this service did not change. We rated the service Require Improvement; safe as Requires Improvement and well-led as Requires Improvement.

We rated safe as Good and well-led as Good for maternity services. Our rating of Good for maternity services did not change ratings for the hospital overall.

How we carried out the inspection

We provided the service with 2 working days’ notice of our inspection.

We visited triage/day assessment unit, delivery suite, the midwifery led unit, obstetric theatres, and the antenatal and postnatal wards.

We spoke with a wide range of staff. This included leaders, maternity safety champions, the Maternity and Neonatal Voice Partnership lead, obstetric and anaesthetic staff, midwives (band 5- 8) and maternity support workers. We did not speak with any women or birthing people. We received 3 responses to our give feedback on care posters which were in place during the inspection.

We reviewed 8 patient care records, 7 observation and escalation charts and 5 medicines records.

Following our onsite inspection, we spoke with senior leaders within the service; we also looked at a wide range of documents including standard operating procedures, guidelines, meeting minutes, risk assessments, recent reported incidents as well as audits and action plans. We then used this information to form our judgements.

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.

The Norfolk and Norwich University Hospital (NNUH) is a 1,200-bed teaching hospital. Medical care services provided by NNUH include the specialties of cardiology, respiratory medicine, gastroenterology, endocrinology, stroke, neurology, rheumatology, haematology, oncology, renal medicine, older people’s medicine, radiotherapy, palliative care and diabetes.

Medical care had 95,392 admissions between March 2021 and February 2022, including 28,488 emergency admissions. The specialties with the highest number of admissions were gastroenterology (23,202), clinical oncology (21,120), and general medicine (13,551).

We last inspected the service in February 2022 as part of a review of urgent and emergency care services in Norfolk and Waveney. No ratings were attached to this inspection.

We carried out this unannounced focused inspection because we received information giving us concerns about the safety and quality of the services of medical care and older people’s services. The information of concern related to nurse and healthcare assistant staffing shortages and the use of additional beds in bays impacting on patient care.

As this was a focused inspection, we only inspected parts of our five key questions. We inspected parts of safe, effective, caring, responsive, and well-led.

We did not inspect all the core services provided by the trust as this was a risk-based inspection. We continue to monitor all services as part of our ongoing engagement and will re-inspect them as appropriate.

The ratings for safe and effective were limited to requires improvement as we issued requirement notices. We did not rate responsive and well-led at this inspection as we only inspected part of the key question. We rated caring as good.

See the medical care (including older people’s services) section for what we found.

How we carried out the inspection

The inspection team comprised of a lead CQC inspector, an inspection manager, 1 other CQC inspector and an expert by experience.

During the inspection we spoke with 21 members of staff and carried off site interviews with the divisional leadership team, the trust falls lead, the lead matron for discharge and the operations director for urgent and emergency care. We spoke with 15 patients and relatives or carers. We observed care provided; attended site and staffing meetings, reviewed relevant policies and documents and reviewed 6 patient records.

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.

Norfolk and Norwich University Hospitals NHS Foundation Trust operates primarily across two sites:

Norfolk and Norwich University Hospital (NNUH) – this was built in 2001 and is based on the Norwich Research Park. Care is provided for a tertiary catchment area from Norfolk and neighbouring counties.
Cromer and District Hospital – this was rebuilt by the Trust in 2013. It has a minor injuries unit and provides a range of outpatient and day-case services.

We carried out an unannounced focused inspection of Cromer Minor Injuries Unit (MIU) and medical care services (including older people’s care) at Norfolk and Norwich University Hospital, on 16 February 2022. We also had an additional focus on the urgent and emergency care pathways across Norfolk and Waveney and carried out a number of inspections of services in a few weeks. This was to assess how patient risks were being managed across the health and social care services during increased and extreme capacity pressures.

As this was a focused inspection for Norfolk and Norwich University Hospitals NHS Foundation Trust, we only inspected parts of our five key questions. For both core services we inspected parts of safe, effective, responsive, caring and well-led.

Medical care was previously rated as requires improvement overall with caring and responsive rated as good.

For this inspection we considered information and data on performance for medical care. This inspection was partly undertaken due to the concerns this raised over how the organisation was responding to patient need and risk in the emergency care and the wider trust in times of high demand and pressure on capacity. We were concerned with the waiting times for patients, delays in their onward care, treatment and delayed discharges, as well as delayed and lengthy turnaround times for ambulance crews.

We looked at the experience of patients using medical care services in In Norfolk and Norwich University Hospitals NHS Foundation Trust. This included the medical wards and areas where patients in that pathway were cared for while waiting for treatment or admission. We also visited wards where patients from the emergency department were admitted for further care. This was to determine how the flow of patients who started their care and treatment in the emergency department and those cared for on medical wards, was managed by the wider hospital.

A summary of CQC findings on urgent and emergency care services in Norfolk and Waveney.

Urgent and emergency care services across England have been and continue to be under sustained pressure. In response, CQC is undertaking a series of coordinated inspections, monitoring calls and analysis of data to identify how services in a local area work together to ensure patients receive safe, effective and timely care. We have summarised our findings for Norfolk and Waveney below:

Norfolk and Waveney

Provision of urgent and emergency care in Norfolk and Waveney was supported by services, stakeholders, commissioners and the local authority. The health and care system in this area lies across a large, predominantly rural, geographical area with a large proportion of the population aged over 65 years.

Compliance with CQC regulations has historically been challenging across Norfolk and Waveney, particularly in Acute, Mental Health and Adult Social Care services, many of which have been rated Requires Improvement or Inadequate.

We spoke to staff in services across primary care, urgent care, acute, ambulance services, mental health and adult social care. Staff told us of increased pressure across urgent and emergency care pathways, staffing issues and a lack of capacity in key sectors including GP and Dental practices and social care. These issues were resulting in inappropriate calls to 999 and attendances in emergency departments. There were delays in discharge for patients who were medically fit but unable to access appropriate packages of care to enable them to leave hospital.

We previously inspected mental health services in the Norfolk and Waveney area in November and December 2021 and found, due to an increase in referrals and staffing shortages, patients in the community had long waits to be seen. This led, in some cases, to patients deteriorating and requiring urgent and emergency treatment. In addition to this, some inpatient services (such as CAMHS) did not have available beds within the area. Patients were kept in urgent and emergency care settings whilst a bed was found. During inspections of acute services, we found patients unable to access appropriate and timely care to meet their mental health needs.

We inspected a number of GP practices and found some concerns in relation to access for patients trying to see or speak to their GP. We found high levels of staff absence resulting in some staff working long hours and experiencing increased pressure on their services.

To try and alleviate the increasing demand on Emergency Departments, GP streaming services had been introduced in EDs in Norfolk and Waveney. Patients who presented at the ED with problems which were deemed suitable for a primary care appointment could be referred to a co-located primary care service. In some cases, streaming services helped to prevent up to 33% of patients attending the ED.

We inspected urgent care services in the Norfolk and Waveney area and found these to be well-run. However, an on-going shortage of out of hours and urgent care appointments, particularly for urgent dental care, meant patients couldn’t always be appropriately signposted by NHS111. This meant patients often presented to ED for treatment. NHS111 in Norfolk and Waveney had also experienced significant staff shortages, much of which has been due to the COVID-19 pandemic. Leaders in this service had a recovery plan in place; however, staff shortages and increased demand had resulted in significant delays in call answering and call-back times in comparison to the national targets and there was also a very high call abandonment rate, meaning people ended the call before speaking to an advisor. Whilst performance across Norfolk and Waveney did not meet national targets and people experienced significant delays, these delays were, on average, shorter than regional and national averages

We inspected emergency departments (ED) in Norfolk and Waveney between December 2021 and February 2022 and found lengthy delays for people accessing emergency care. A high number of patients were waiting over 12 hours in ED resulting in overcrowding. This impacted on ambulance handovers and further delays in releasing ambulance crews into the community to respond to 999 calls.

Staff shortages have had a significant impact on social care services across Norfolk and Waveney. In addition, the provision of domiciliary care services is challenging due to the rurality of the area. At the time of our inspections, a care hotel was being utilised in Norfolk and Waveney. We spoke to healthcare professionals who had provided services to people being cared for at the hotel and found them to be safe and generally well cared for. The number of people receiving care in the hotel was small and the aim was for them to only stay for a very short amount of time before going home. This service is commissioned until the 30 April 2022, a formal evaluation will take place before any future plans are agreed.

Some social care and learning disability services in Norfolk and Waveney have struggled to achieve compliance with CQC regulations and a rating of good. Some support has been established across Norfolk and Waveney to help services improve. However, the impact of any support to date has been limited.

Staff shortages and service quality has significantly reduced capacity across social care and learning disability services in Norfolk and Waveney. This has resulted in significant delays in transferring people from hospital to their own home or an appropriate place of care. This in turn meant people who were medically fit for discharge remained in hospital delaying the admission of new patients. These delays and poor flow resulted in overcrowded EDs and an inability to transfer patients from ambulances.

Strategic, system wide workforce planning and increased community provision of health and social care is needed to meet the needs of the local population. This is needed to reduce the pressure on urgent and emergency care services and to reduce the risk of harm to people living in Norfolk and Waveney.

Summary of Norfolk and Norwich University Hospitals NHS Foundation Trust – Norfolk and Norwich University Hospital

The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well.
Managers monitored the effectiveness of the service. Staff worked well together for the benefit of patients, supported them to be involved in decisions about their care, and had access to good information. 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 service planned care to meet the needs of local people, took account of patients’ individual needs.
Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff mostly felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities.

However:

The service did not always have enough staff to care for patients and keep them safe.
Although people could access the service when they needed it they did not always receive the right care promptly due to pressure on bed capacity. Arrangements to admit, treat and discharge patients were impacted due to significant numbers of patients that no longer met the criteria to reside in the hospital but were unable to leave as they were waiting for access to onward care packages.

How we carried out the inspection

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

During the inspection we observed care, spoke with 35 members of staff and carried off site interviews with the senior leadership team. We spoke with 15 patients and one carer. We observed care provided; attended site meetings, reviewed relevant policies and documents and reviewed ten patient records.

We carried out this unannounced focused inspection on the 1 June 2021 because at our last inspection on 8 December 2020, we identified a breach of the Health and Social Care Act (2008) Regulation 12, Safe Care and Treatment. Concerns were based on long waiting times for assessment, the uses or infection, prevention and control measures and staffing levels. We issued the provider with a warning notice served under Section 29A of the Health and Social Care Act 2008. Between January 2021 and 1 June 2021, the trust saw 22,870 children and 149,732 adults within its urgent and emergency care service.

At our inspection on 1 June 2021, we focused on the Care Quality Commission (CQC) domains of safe, responsive and well led. We rated the service as requires improvement for responsive and good for safe and well led. The overall rating has improved for urgent and emergency services from requires improvement to good.

We found:

The service-controlled infection risk well. Staff used equipment and control measures to protect patients, themselves and others from infection. They kept equipment and the premises visibly clean.

The design, maintenance and use of facilities, premises and equipment kept people safe. Staff managed clinical waste well.

Staff completed risk assessments for each patient swiftly. They removed or minimised risks and updated the assessments. Staff identified and quickly acted upon patients at risk of deterioration.

The service had enough nursing staff and support staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed staffing levels and skill mix, and gave bank and agency staff a full induction.

The service had enough medical staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed staffing levels and skill mix and gave locum staff a full induction.

The service planned and provided care in a way that met the needs of local people and the communities served. It also worked with others in the wider system and local organisations to plan care.

Leaders had the skills and abilities to run the service. They understood and managed the priorities and issues the service faced. They were visible and approachable in the service for patients and staff.

The service 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 and monitor progress.

Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. The service had an open culture where patients, their families and staff could raise concerns without fear.

Leaders and teams used systems to manage performance effectively. They identified and escalated relevant risks and issues and identified actions to reduce their impact. They had plans to cope with unexpected events. Staff contributed to decision-making to help avoid financial pressures compromising the quality of care.

The service collected reliable data and analysed it. Staff could find the data they needed, in easily accessible formats, to understand performance, make decisions and improvements. The information systems were integrated and secure.

All staff were committed to continually learning and improving services. They had a good understanding of quality improvement methods and the skills to use them. Leaders encouraged innovation and participation in research.

However:

People could not always access the service when they needed it or receive the right care promptly. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were not always in line with national standards.

Access to support for patients who required support with their mental health remained a challenge within the trust.

We carried out this unannounced focused inspection because we had concerns about the quality of services. The emergency department (ED) had continued poor performance in the trust’s ability to meet national targets, which posed concerns about patients’ safety. The service was rated as requires improvement at our last inspection in December 2019. As this was a focused inspection, we did not inspect all key questions. Our priority was to identify if the service was safe and well led. 

We did not inspect any of the trust’s other core services. This included surgery, outpatients and end of life care previously rated requires improvement, good and outstanding, respectively. This was because our inspection was part of the urgent and emergency care focused inspection programme. We are monitoring the progress of improvements to services and will re-inspect them as appropriate.

During our inspection we identified a breach of regulation 12, Safe Care and Treatment. We took action under our enforcement powers, by issuing the provider a Warning Notice served under Section 29A of the Health and Social Care Act 2008.

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

Patient risk assessments were not always timely and there was not effective prioritisation and triage of patients. We saw seven patients triage delayed over one hour which included one patient waiting in physical discomfort with clear abdominal pain.

The service did not always control infection risk well. Staff did not always use equipment and control measures to protect patients, themselves, and others from infection.

Equipment checks were not always recorded. There were omissions in the daily checks of emergency equipment and life critical equipment.

The service did not have enough nursing and medical staff with the right qualifications, skills, training, and experience. However, the trust took mitigating actions to address the staffing shortfalls.

People could not access the service when they needed it and did not receive the right care promptly. Waiting times and arrangements to admit, treat and discharge patients were not in line with national standards. Some patients waited for long periods to get care and treatment.

Triage and prioritisation of patients was not embedded. We identified several patients whose triage was delayed.

There were gaps in audit results in response to issues with IT connectivity. This resulted in gaps in information, reducing the ability to monitor performance.

There was a stable leadership team in place however, we found that leaders had failed to adequately address risk to performance and sure this was effectively managed.

Leaders and teams used systems to manage risk, however performance issues remained that impacted on the quality and safety of care.

However; 

The ED design was suitable and met national standards. 

Most staff felt respected, supported, and valued. They were focused on the needs of patients receiving care.

Leaders operated governance processes. Staff at all levels were clear about their roles and accountabilities and had regular opportunities to meet, discuss and learn from the performance of the service.

How we carried out the inspection.

We spoke with 28 staff across a range of disciplines including lead nurses, senior nurses, healthcare assistants, emergency department (ED) consultants, a trust grade doctor, a junior doctor, a matron, the hospital ambulance liaison officer (HALO), the divisional nurse director, and the divisional associate medical director. We attended two ED safety huddles and a patient flow meeting.

As part of the inspection, we observed care and treatment and looked at ten care records. We analysed information about the service which was provided by the trust.

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

Our rating of services stayed the same. 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 four hospital services we looked at we rated two as requires improvement, one as good and one as outstanding.
The ratings for end of life care improved whilst the ratings for urgent and emergency care, surgery and outpatients remained the same.
Capacity and patient flow continued to impact services at the trust including the ongoing use of escalation areas.
Culture continued to improve but there remained pockets of a negative challenging culture that the trust continued to work on.
There were medicines management issues across the core services.

However;

Staff across all services we inspected treated patients with compassion, kindness, dignity and respect. We saw people actively involved with their care.
There was improved divisional leadership and nursing leadership in the emergency department.
There was improved knowledge of the Mental Capacity Act 2005 in the core services we inspected.

Records were not always stored securely and medicines were not always stored appropriately in outpatient areas, which were both raised at our previous inspection.
Data on waiting times was not formally recorded and therefore efficiency and areas for improvement could not be monitored and identified. This was raised at our previous inspection.
People could not always access the service when they needed it. Waiting times from referral to treatment were not in line with national guidance.
Clinics continued to run behind time. We observed, and patients told us, that clinics frequently ran late, however the trust did not monitor clinic waiting times formally to enable oversight and improvement.
An average of 18.8% of clinics were cancelled at short notice (under six weeks).
The service was not always managing information effectively. Staffing related information held by the trust, such as training, appraisals and vacancy numbers, did not always clearly identify compliance for outpatient medical staff. Therefore, we were not assured there was sufficient oversight of medical staffing of the service.

However:

The service controlled infection risk well. Staff kept themselves, equipment and the premises clean.
There was an appropriate process for responding to risk for patients that were waiting for appointments.
Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
Staff understood their roles and responsibilities under the Mental Capacity Act 2005. They knew how to support patients who lacked the capacity to make decisions about their care.
Staff cared for patients with compassion, involved them in decisions about their care and treatment and provided them with emotional support to minimise their distress.
Outpatient specialties offered some out-of-hours appointments, one-stop clinics, community based appointments, and telephone appointments, which provided patients with flexibility and choice.
The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with all staff.
Managers promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
The service engaged well with patients and staff to plan and manage appropriate services.

The Norfolk and Norwich University Hospital is an established 1237 bedded NHS Foundation Trust which provides acute hospital care for a tertiary catchment area of up to 1,016,000 people. The trust provides a full range of acute clinical services and operates from a large purpose built site on the edge of Norwich and from a smaller satellite at Cromer in North Norfolk. The emergency department at the Norfolk and Norwich University Hospital is a type one major injuries unit, which had 133,073 attendances between July 2017 and June 2018.

We last inspected the urgent and emergency service in October 2017. The service was rated inadequate overall; safe and well-led were rated inadequate, effective and responsive were rated requires improvement, and caring was rated good. During the 2017 inspection, we identified significant concerns regarding staff understanding and application of the Mental Capacity Act (2005), the systems and processes for preventing and controlling the spread of infections, the healthcare records of service users, and the emergency department premises. Concerns regarding the premises included the layout and size of the department, the size of the children’s emergency department and the lack of safe environments for those living with mental health concerns. As a result, we issued a Section 29A warning notice to the trust in October 2017. The warning notice informed the trust that significant improvements were required by 1 January 2018, and we requested an action plan from the trust, outlining steps that had been taken to address the concerns raised in the warning notice.

We carried out a focussed inspection on 6 November 2018 to follow up on the concerns raised in the Section 29A warning notice.

Our inspection was unannounced (staff did not know we were coming) to enable us to observe routine activity. We carried out a focused inspection which did not include all key lines of enquiry (KLOEs). We did not rate the service as a result of this inspection.

During this inspection we visited the emergency department (ED), children’s ED, older people’s emergency department (OPED), clinical decisions unit (CDU) and the urgent care centre (UCC). During the inspection visit, the inspection team spoke to 24 members of staff, including nurses, doctors, support workers and senior managers. We reviewed 10 paper healthcare records and seven electronic healthcare records.

Before and after the inspection visit, we reviewed information that we held about these services and information requested from the trust.

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

We found the following issues that the service provider needs to improve:

Patients at high risk of deliberate self-harm continued to be cared for in the CDU, which remained an unsafe and inappropriate environment for these patients.
Risk assessments for patients with mental health concerns had not always been completed appropriately. Mental capacity assessments had not always been completed when required, despite concerns raised at the time of our last inspection.

We were not assured that staff understanding of isolation procedures was consistent or that implementation and monitoring of compliance was fully effective. Results from cannula insertion, commode and bed pan audits showed mixed compliance.
There was a lack of evidence that progress against concerns raised at our last inspection were being regularly monitored at a local level. There was a lack of progress in developing and implementing effective governance systems within the department.
The level of scrutiny and oversight that the mental health board was providing could be improved.
Information was not always collected, analysed, managed and used well to support all the service’s activities.
The emergency department strategy had not been reviewed or developed since our inspection in 2017.

However, we also found the following areas where improvement had been made:

Environmental changes had positively impacted on infection prevention and control. We observed staff using personal protective equipment appropriately and adhering to bare below the elbows standards. Area specific cleaning records had been implemented.
The emergency department premises had been re-configured to increase the number of patients that could be accommodated at any one time. The service had increased the environments which were safe, and secure where necessary, for those living with mental health concerns.
There had been a reduction in the number of areas that were inappropriately being used as an extension to the majors area due to a lack of capacity. Whilst patients were still being cared for in the corridor at times of peak pressure, the trust had improved their processes to ensure that all patients were clinically assessed before a decision was made about whether their condition was appropriate for them to be cared for in the corridor.
Staff had become more aware of the need to carry out a risk assessment to review whether patients could pose a risk of harm to themselves or others. Staff understanding of the Mental Capacity Act (MCA) and compliance rates for MCA and Deprivation of Liberty Safeguards (DoLS) training had significantly improved.
Significant progress had been made in the development of the urgent and emergency service and senior staff were able to describe plans to further develop the service.
The establishment of the mental health board had improved the focus on mental health care within the organisation.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve. We also issued the provider with two requirement notices that affected urgent and emergency services. Details are at the end of the report.

Amanda Stanford

Deputy Chief Inspector of Hospitals

Diagnostic imaging staff were not always trained to the appropriate level for safeguarding children and there was low compliance in some areas of mandatory training.
Equipment was ageing and there was no capital replacement programme in place. Specialised personal protective equipment was not always being checked on a regular basis. Resuscitation trolleys were not always being checked on a regular basis.
Security and access to controlled areas was not consistent.
Contrast media was not stored appropriately, in a temperature monitored and secure area, within the diagnostic imaging service areas.
The emergency call bell system within nuclear medicine had not been fit for purpose since 2015.
The diagnostic imaging service was not always meeting NHS England Seven Day Services Clinical Standards.
Recommended changes to practice as a result of audit findings did not always identify the individual responsible for implementing changes or the date by which the change should have been implemented.
Written consent for radiological procedures was not consistently undertaken in line with the trust’s standard operating procedure.
The diagnostic imaging environment did not always afford patients with privacy and dignity.
Friends and Family Test scores were below the national average, and there were low response rates.
Reporting times were not meeting targets in the majority of diagnostic imaging areas.
Managers had not identified or put in place actions to address a number of the concerns that were identified during our inspection and action had not been taken to address some of the concerns identified at our previous inspection. Risks were not always resolved or acted upon in a timely manner and the risk register did not reflect all of the risks identified during this inspection.

However:

There had been improvements in staff understanding of the incident process and training provided for those undertaking incident investigation and root cause analysis..
Progress had been made in the recruitment of new staff to address previously high vacancy levels.
Appraisal rates were in line with trust targets and the service offered staff the opportunity for development and progression in their roles.
The service was regularly reviewing the effectiveness of care and treatment through a comprehensive range of audits.
Staff cared for patients with compassion, involved patients in decisions and provided emotional support to minimise distress. Feedback from patients confirmed that staff treated them well and with kindness.
The service took account of patients’ individual needs and offered out of hours, walk-in and one stop services to provide flexibility and choice. The service gathered the views of patients to ensure that services were being provided in a way that met their needs.
Staff said that they felt proud to work in the organisation and described supportive relationships with colleagues. Staff said that their managers were approachable and supportive. None of the staff spoken to on this inspection raised concerns about bullying or harassment.

The Care Quality Commission (CQC) carried out this inspection on 4th, 5th and 20th April 2017. We undertook this inspection due to a number of whistle blowing contacts from staff in relation to regular movement of staff between wards to fill gaps in rotas, insufficient staff in some areas including medical wards, maternity and children’s services and allegations of bullying. At this inspection we found that some of these concerns remained amongst some staff groups we spoke with. However, progress had been made by the trust in recruiting additional nursing staff and used other staff to mitigate risks to patients. Information also showed a poor performance in some referral to treatment times and 5 never events reported between February 2016 and January 2017.

This inspection examined the key questions of safe, responsive and well led in medicine, surgery and children’s and young people services. We looked at all key questions (including effective and caring) in maternity and gynaecology.

We carried out a comprehensive inspection at Norfolk and Norwich University Hospital NHS Trust in November 2015 when the trust was rated as requires improvement.

The hospital opened in late 2001, having been built under the private finance initiative (PFI). Cromer and District Hospital was rebuilt by the Trust in 2012.

The trust provides a full range of acute clinical services plus further private and specialist services. The Trust has 913 acute beds, 210 day case beds and provides care for a tertiary catchment area of up to 1,024,000 people from Norfolk and neighbouring counties. The hospital also has an important role in the teaching and training of a wide range of health professionals in partnership with the University of East Anglia, University Campus Suffolk and City College Norwich.

Since our last inspection the trust had recruited further substantive executives and had no interim executives on the board. Whilst we found the trust had met our previous requirement notices for some concerns we had previously raised, they had failed to meet the requirement notices or make significant progress in the management of medicines and staff mandatory training.

Our key findings were as follows:

There had been a change in the operational structure at the hospital since our last inspection. There were now 4 divisions, the clinical divisions being headed by a chief of division, operations director and nurse director.
The attitude of staff remained excellent. All staff were helpful, open and caring in their manner. We found staff to be very ‘upbeat’ locally within ward and clinical teams.
There were examples of excellent leadership in the areas we inspected. Some had an excellent understanding of their area and were driven and committed in leading their teams to provide excellent care.
Whilst we only inspected effectiveness in maternity, we saw good examples of multidisciplinary working between clinical and non clinical staff in ward areas.
We have seen good overall improvements in maternity services.
Some good examples of record keeping were seen through ward and clinical areas.
Staff demonstrated a good knowledge of safeguarding principles though training levels for staff were well below trust target in some areas.
Mandatory training compliance was variable across the trust but in most of the areas we inspected, compliance was well below trust target.
Staff told us that concerns or positive ideas for improvement are reported to senior managers but whilst they felt these were listened to by their immediate managers it was lost in the ether above those managers.
Staffing at night remained a challenge with wards having less nursing cover than planned and frequent of movement of staff between wards to manage shortfalls of shifts. Staff also raised concerns regarding skill mix particularly when staff were moved to other wards at night.
A number of staff told us that they felt “bullied” to take patients that they felt were not appropriate for their area. This was predominantly out of hours. Matrons were able to advocate for junior staff during the day but when not available, staff felt under increased pressure to take these patients. We had a positive discussion about this with the trust and what they were doing to address these issues. The site team felt under pressure themselves from ward staff.
We found that staff were not always following policies, for example we found that emergency resuscitation equipment was not always checked daily and that fridge temperatures including those in theatres were not always checked and recorded. There was ongoing poor mandatory training compliance across the areas we inspected.
Almost all staff we spoke with were unaware of the speak up guardians at the trust. Some had used the whistleblowing/ speak up policy but experience of it was variable. Some felt it had worked and supported them others that it had not.
Ward staff report the executive team as not being visible in ward or clinical areas.
We found that quality checks on the WHO surgical safety checklist were not being completed; this despite there being four never events within the surgery service.

We saw several areas of outstanding practice including:

The children and young people’s service was proactive in clinical research. There were a large number of active research studies being undertaken throughout the children and young people’s service. This meant that the service was at the forefront of clinical innovation.
The hospital received funding January 2017 following a successful bid to the Department of Health’s Maternity Innovation Fund and the Maternity Safety Training Fund to provide additional training for staff. The Maternity Innovation Funding was for a new piece of simulation technology called ‘CTGi’ which replicates a baby’s heart rate pattern during labour. This piece of training technology will be used within clinical areas for both the midwifery and medical teams and supplement more traditional class room tutorials and e-learning programs.
The trust was about to launch the ‘Baby University’ scheme. Every new or expectant mum that signs up for the scheme will receive a Baby Box made from a very thick cardboard, a firm foam mattress, waterproof mattress cover and a cotton sheet. The scheme replaces the need for a traditional Moses basket or cot, and it is thought the small size of the Baby Box helps to prevent sudden infant death syndrome.
Cley gynaecology ward had a bereavement baby memento bag/box for parents, which contained a form to acknowledge the existence of a foetus born before it was viable (as a birth certificate could not be issued) and tiny hand knitted garments for stillborn babies to have photographs for parents.

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

Importantly, the trust must:

The trust must ensure that medication is stored in line with trust policy and that staff record medication refrigeration temperatures to ensure the safe storage of refrigerated medication.
The trust must ensure that resuscitation equipment in wards, theatres and other areas is checked in accordance with trust policy.
The trust must ensure that patient records are stored securely.

The provider must ensure staff complete appropriate mandatory training including safeguarding training to an level appropriate to their job role.

In addition the trust should:

Ensure that there are adequate medical and nursing staff and an appropriate skill mix to care for patients in line with national guidance.
The provider should ensure they regularly undertake observational audits or measurement of the quality of the World Health Organisation (WHO) five steps to safer surgery checklists and action any lessons learnt.
The trust should ensure it meets the referral to treatment time for specialities that do not meet the England average such s gynaecology.
Ensure staff follow infection prevention and control procedures and do not leave side room doors open when they should be kept closed to minimise the spread of infection.
The trust should ensure that maternity electronic discharge information is sent to general practitioners within 24 hours of discharge.
The trust should consider how they provide community midwives with access to information technology.
Review access to transitional beds for young people aged 16 to 18.
Ensure clinical staff receive training in sepsis protocols and procedures.
Ensure that staff caring for children in non-paediatric areas have appropriate safeguarding and resuscitation training.
Ensure morbidity and mortality meeting minutes include sufficient detail of background information, discussions and those in attendance.
Review the children’s assessment unit to address admission times, infection control concerns, and distance to transfer acutely unwell children from the emergency department.
The trust should ensure that it contributes to the national Maternity Safety Thermometer.
Review and ensure the effective management of community midwifery staff.

Professor Edward Baker

Chief Inspector of Hospitals

The Care Quality Commission (CQC) carried out a comprehensive inspection between 10 and 13 November 2015. We also carried out unannounced inspections on 20 and 25 November 2015. We carried out this comprehensive inspection at Norfolk and Norwich University Hospital NHS Trust as part of our comprehensive inspection programme.

This organisation has two main locations:

Norfolk and Norwich University Hospital, a large acute hospital comprising all acute services.
Cromer Hospital which offers surgical and outpatients’ services.

We also inspected Henderson unit as part of the unannounced inspection on 25 November 2015.

The hospital opened in late 2001, having been built under the private finance initiative (PFI). Cromer and District Hospital was rebuilt by the Trust in 2013.

The Trust provides a full range of acute clinical services plus further private and specialist services. The Trust has 1237 acute beds and It provides care for a tertiary catchment area of up to 822,500 people from Norfolk and neighbouring counties. The hospital also has an important role in the teaching and training of a wide range of health professionals in partnership with the University of East Anglia, University Campus Suffolk and City College Norwich.

Previous unannounced responsive inspection by the CQC took place between the 4th and 6th March 2015. The inspection focused specifically on accident and emergency services, capacity and demand, medical care and cancer services, surgery, and overall leadership of the trust. As this was a responsive inspection there are no ratings attached to our findings. However, concerns were raised about governance arrangements, Mattishall ward, the Fit and Proper Persons regulations and the bullying culture.

The trust had a relatively new executive team. The Chief Executive was appointed substantively in October 2015. At the time of inspection three other members of the team were interim positions; the Chief Operating Officer, Medical Director, and Director of Finance.

The comprehensive inspections result in a trust being assigned a rating of ‘outstanding’, ‘good’, ‘requires improvement’ or ‘inadequate’. Each section of the service receives an individual rating, which, in turn, informs an overall trust rating.

The inspection found that overall; the trust had a rating of requires improvement.

Our key findings were as follows:

Staff were overwhelmingly caring in delivering care to patients. We witnessed some outstanding examples of care being given to patients and their relatives.
There were shortages of nursing staff that impacted on care provided throughout the hospital.
There were some areas where there were medical vacancies which impacted on care. Most notably in the palliative care team and in the critical care complex.
Incident investigation and root cause analysis was not always completed by those with extended training.
The security on the children’s ward needed to be improved to ensure their safety.
There was a lack of understanding by staff around patients’ ability to consent to care and treatment.
The consultant body was cohesive, loyal to the hospital and proud to be working at the trust.
The service to patients having a heart attack was extremely good.
The communication with parents in the neonatal unit was very good. These included well written booklets.
The number of one stop clinics within the out patients department was responsive to the needs of patients.

We saw several areas of outstanding practice including:

A specialist, midwife-led ‘Birth reflections’ clinic was provided to support women who wanted to come to terms with their birth experiences.
Clinical reporting and scheduling system in cardiology (Intellect) has been developed locally allowing the service to be more coordinated and efficient.
There was an excellent primary percutaneous coronary intervention (PPCI) service which provided prompt, effective treatment in line with national guidance and demonstrated good working with other providers and professionals.
On Elsing ward we observed that the bays had been colour coded to assist patients moving around the ward and used single use knitted sensory bands were available. Holt ward had refurbished a room to 1950’s décor.
The nursing team within the emergency department demonstrated outstanding care, leadership and treatment of patients.
The innovation around trialling new ways and models of care including medicines administration within the emergency department, as well as the vision for the service was outstanding.
The outcomes for trauma were outstanding and the best in the region.
The local audit programme for nurses and medical staff within the emergency department was outstanding.
The governance risk management, learning arrangements and staff willingness to continually strive to be better for the patients in the emergency department was outstanding.

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

Importantly, the trust must:

Ensure that patient acuity is properly assessed and there are adequate medical, nursing and midwifery staff to care for patients in line with national guidance.
Follow infection control principles when cohorting patients.
Ensure that all children’s inpatient wards and units have adequate security measures in place to reduce the risk of children absconding and unauthorised adults gaining entry.
Ensure that incidents are investigated in a timely way by trained investigators, graded, and reported in line with current national guidance.
Ensure that the management of outliers on Cley ward are properly assessed and provided with safe care.
Ensure that the management of referrals into the organisation reflects national guidance in order that the backlog of patients on an 18 week pathway are seen.
Ensure that patient records are legible, accurate, complete and contemporaneous for each service user, taking into account the use of both hard and electronic records.
Review ‘do not attempt cardio-pulmonary resuscitation’ (DNACPR) forms to ensure they are completed fully and in line with trust policy and national guidance.
Review its Mental Capacity Assessment and Deprivation of Liberty Safeguarding (MCADOLS) process and the way this is documented within patients’ notes – Regulation 17(2) (c).
Ensure that staff within the radiology department have access to appropriate support, supervision and appraisal.
Ensure that compliance to mandatory training is met and ensure consistent compliance across all clinical staff groups. Ensure that training is relevant to meet the needs of those in specific roles such as staff in the mortuary.
Ensure that medicines are stored and administered in line with national guidance.
Review and improve the environment of the children’s emergency department to ensure that the environment is fit for purpose and safe for children to receive care.
Review the staffing of the children’s emergency department to ensure that there are sufficient numbers of registered children’s nurses on duty at all times.
Ensure that there is an increase awareness of the complexities of end of life care, including a defined strategy and vision, increased involvement and referrals to the specialist palliative care team (SPCT) and improvement in performance indicators specifically recognition of the dying patient.

In addition the trust should:

Closely monitor transfers to Mattishall ward and the environment should be improved in line with the development plan for the unit.
The trust should reconsider the ambulatory care pathway in the acute medical unit (AMU).
Review the availability of adequate equipment for patients to sit out of bed if clinically able to do so.
Review the permanent clinical leadership in AMU.
Ensure a robust process for checking of emergency equipment.
Review its risk management and escalation policies with respect to how clinical staff raise concerns and ensure these are acted upon appropriately.
Reduce readmission rates for children and young people with long-term conditions.
Review the provision of information technology for community midwifery teams
Review mechanisms for supervision and appraisal for all staff so that they are supported effectively.
Develop an action plan to address the lack of improvement in the completion of discharge information in the specific safeguarding children paperwork for use within the maternity departments.
Review the provision of adequate seating in the antenatal clinic.
Reduce the number of cancelled gynaecology clinics.
Review the ratified guidelines within the Obstetric Assessment Unit and ensure that it is located in an area where it can operate effectively.
Put procedures in place to reduce the number of closures of the obstetric unit.
Review the staff understanding of the vision and strategy for their areas.
Review fluoroscopy changing areas and process to ensure patient privacy and dignity is maintained.
Ensure that doctors within the emergency department adhere to bare below the elbow policy requirements.
Improve the culture amongst the consultant body within the emergency department.
Improve the culture of the organisation towards the emergency department to reduce the feeling of blame for targets not being achieved.
Review the bed management process and site management processes within the organisation to increase capacity and flow.
Improve systems and processes for the declaration of black alert to ensure that it contains tangible changes designed to improve the service, i.e. daily consultant or nurse led discharges.
Review the emergency department triage process to ensure that all patients are offered pain relief where it is required.
Review the plans for expanding the main emergency department and make a decision swiftly on the future expansion of the service.

Professor Sir Mike Richards

Chief Inspector of Hospitals

The Care Quality Commission (CQC) undertook an unannounced responsive inspection between 4th and 6th March 2015. The inspection rationale related to an increase throughout 2014 of negative intelligence regarding various areas within the Trust. Therefore the inspection focused specifically on accident and emergency services, capacity and demand, medical care and cancer services, surgery, and overall leadership of the trust. As this was a responsive inspection there are no ratings attached to our findings.

The hospital was opened in late 2001 having been built under the private finance initiative (PFI). The Trust provides a full range of acute clinical services plus further private and specialist services. The Trust has 1099 acute beds and It provides care for a tertiary catchment area of up to 822,500 people from Norfolk and neighbouring counties. The hospital also has an important role in the teaching and training of a wide range of health professionals in partnership with the University of East Anglia, University Campus Suffolk and City College Norwich.

Previous inspection by the CQC took place on the 2nd and 3rd December 2013 and had resulted in one compliance action in respect of Regulation 17 HSCA 2008 (Regulated Activities) Regulations

2010 Respecting and involving people who use services.

Since Qu2, 2014 the Trust has been breaching on national targets, ED waiting times, Cancer services and referral to treatment time. This has increased pressure on the leadership and staff teams to meet targets and raised concerns that patient care may be affected.

Our key findings were as follows:

Capacity and demand was an issue for the Trust and there were a high number of delayed transfers of care. It was evident that the lack of community provision was a contributing factor. Escalation areas had been opened in response to capacity demands however plans were not yet well established in terms of ensuring a longer term improvement strategy for capacity and demand.
The trust had taken action in respect of capacity management in the emergency department on a day to day basis however a cohesive strategic plan for access and flow of patients was lacking.
Leadership within the Trust is fragmented and the capacity and target pressures have led to the Board being too operationally focussed and reactive resulting in an inconsistent management approach to staff at a local level
On the Acute Medical Unit (AMU) staff were unclear regarding best interest decisions and of their responsibilities under the Mental Capacity Act 2005.
At the time of our inspection, there was no evidence to demonstrate that any patients had suffered an adverse clinical outcome due to breaching cancer waiting times. However, there was a significant risk of emotional impact for those people not receiving treatment within specified guidelines. An improvement in performance had been forecast but we were not assured sufficient plans were in place to ensure sustainable improvement.

There were areas of improved practice:

The trust had completed and implemented an action plan with regard to the compliance action and significant improvements had been made. We judged that the Trust was now meeting this requirement and therefore have removed this compliance action.
Following a serious incident in 2014 regarding VTE risk assessment and treatment in patients undergoing day surgery the trust had put an action plan in place to address concerns arising from this incident. We found that this action plan had been completed appropriately and that learning and improvement had taken place.

The trust needs to make the following improvements:

The trust should ensure that there is a clear strategy to improve patient access and flow through the emergency department and that there is a consistent management approach in response to high demand pressures.
The trust should ensure that all staff receives training on the mental capacity act and that this is continuously monitored.
The trust should consider how it can demonstrate clinical decision making in those patients records who are admitted to Mattishall Ward.
The trust should consider how it can demonstrate and provide assurance that improvement to cancer services and demand for services will be sustainable.

Professor Sir Mike Richards

Chief Inspector of Hospitals

This inspection had a variety of intentions. Firstly, we looked to see that the hospital had made improvements following our previous inspection undertaken in March and May 2013. During that inspection we found that the hospital was not ensuring the safe and timely discharge of people in their care. We also found that the hospital was not co-operating effectively with other providers to protect service users from potential harms. The provider was responsive to our concerns and forwarded us a report detailing the actions they were going to take in order to make improvements.

During this inspection our enquiries into these improvements demonstrated that the hospital had taken the necessary steps to safeguard people using the service. These systems were in their infancy but we were confident that the hospital would continue to make advances to better the service they provided.

In addition, following a review of information that we had received or gathered since January 2013, we identified other areas where we had concerns. We therefore undertook a detailed inspection into these areas. This included looking at how people and their representatives were kept informed about their care and treatment. We looked at how people’s dignity was maintained. We also assessed the availability of some equipment within the hospital and looked at the systems in place to demonstrate the hospital worked effectively.

We found that, in general, safe care was provided to the people using this service. Equipment (such as pressure mattresses) was usually available and where this was not staff within the hospital took necessary steps to ensure it was provided to the people who needed it as soon as possible. Quality assurance systems demonstrated that effective processes were in place to identify and deal with risks associated with the running of the service.

As part of this inspection we also looked at the quality of care provided to support patients with dementia to maintain their physical and mental health and wellbeing as part of a themed inspection programme. This programme looked at how providers worked together to provide care to people with dementia and at people’s experiences of moving between care homes and hospital. The evidence collected was used to inform the judgements we made in this inspection report. In addition we have produced a separate (annex) report summarising the evidence we collected that related to dementia care at the hospital.

We received information that people had arrived by ambulance at the A&E department of the hospital and had remained in the ambulances for long periods of time before being treated in the A&E department. A visit was carried out between 6pm and 8pm on Friday 15 March 2013 to see if delays in people remaining in the ambulance had any effect on their safety, care and welfare.

We found that the hospital was managing the risk presented due to the higher than expected demand on the A&E department and that people were cared for safely and appropriately by the ambulance crew and designated assessment nurse whilst waiting to be treated in the A&E department.

A further visit was carried out on 3 May 2013 to look at how the hospital was working with other providers and stakeholders to ensure that people were being discharged from hospital in a timely manner. At the time of this visit we found that people were not always discharged from the hospital in a timely manner. We were told that the reasons why people were being delayed were being looked at by the hospital staff, commissioners and other providers of services and that action had already started to ensure people did not remain in hospital when they did not need to be there.

People who were waiting to move out of the hospital told us, 'I have been well looked after and told regularly where I am going and when.' 'I know I am late in leaving but my family have been looking for the best place for me.' 'I have had lots of support about my discharge from the staff on the ward.'

During this inspection visit we spoke with 14 people who were able to answer our questions on the care, treatment and support provided to them during there stay in hospital. We looked at care plans that showed us individual records of consent to treatment signed by the person and care plans that were personalised for the individuals. These records included assessed potential risks and the action required to minimise those risks.

Those people we spoke with who used the service and visitors said they were very impressed with the cleanliness and hygiene standards they had witnessed. People said staff always cleaned their hands before and after they attended to anyone.

The areas we saw had been cleaned regularly, and a cleaning schedule was available at the entrance to the ward which demonstrated to visitors the frequency and type of cleaning.

We were told staff were quick to answer call bells so that people were attended to when required. The only time there may be a delay was when an emergency arose.

People who were attending the hospital through the accident and emergency department (A&E) and were kept waiting were supported by staff who regularly attended and assessed those waiting, ensuring people with high level needs were prioritised.

During mealtimes, staff were allocated to serving and assisting with meals. This ensured that there were sufficient staff to provide people who required assistance with a relaxed and comfortable mealtime.

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.

During this visit we only spoke with people admitted to the wards about their care plan records and how they were involved in completing their records.

The people we spoke with told us they had been asked about the amount of food and drink they had consumed and that staff had explained to them why it was important to keep accurate records of what they had consumed.

We did not ask direct questions about other records during this visit.

During our visit on 07 October 2011 people told us that staff were good at promoting their privacy and dignity. They told us that they had been kept well informed about their health and had been involved in any decisions made about their treatment. They told us that they had been given good information about what will happen when they leave hospital.

We were told by people on the maternity ward that they could not fault the support the hospital had given them during their stay. They told us that they knew exactly what was happening, why it was happening and what the plans were for their stay and then their discharge home. They said 'I feel fully involved and not at all awkward when asking questions.'

People on one ward with whom we spoke told us that staff were very good and responded to their needs well. They said that 'staff can't do enough for you'. They also told us that staff were very busy and they had to sometimes wait for up to ten minutes for a response to a call bell. Yet another person accommodated in a side room told us 'I can ring the bell at anytime and get the help I need. I never have to wait long.'

People we spoke with after the lunch meal had been served told us 'The food is alright most of the time but sometimes it is not very good' and 'The food is pretty fair, we get a choice from the menu and it is hot.' People told us that they got enough to eat and one person stated 'When my food got cold because I was called away for a treatment my meal was replaced with a hot meal.' On the maternity ward we were told how pleasantly surprised people were by the quality and choice of the food provided which was hot and tasty.

We were told that although staff were very busy they were very caring. One person told us, from their own observations, how staff spent time with people who were very poorly and could not communicate. She said that staff would spend time sitting with people, perhaps stroking their hand or cheek to offer reassurance and try to connect with them.

New mothers on the maternity ward had nothing but praise for the staff. They gave us good examples of how staff had spent time guiding and explaining how to care for their baby. We were told, 'I was anxious but am now reassured.' One mother said that she had been offered an extended stay to ensure she was confident in managing breast feeding before she was discharged.

People staying in the hospital told us that they were asked if they were satisfied with the nursing care and support they received. They also said 'I have been given a questionnaire to fill in mostly about the food but also about the care I have received.'

The people with whom we spoke told us that they were listened to and were given the opportunity to express their views about their care, support and treatment. Some people were complimentary about the medical staff, they said that staff were always kind and made comments such as ‘I am very happy with the care I am given’ and ‘I have no complaints at all’. One person told us that staff called them by their first name, which they preferred and that they had been fully informed of any care, treatment or action that was to take place.

When we asked people using the service about the food they were provided with during their stay they told us that there was a choice of food and that the meals were served hot. One person told us ‘I am so well known by the ward staff that all my meal requirements are met without question.’ and ‘The mealtimes are pleasant and there is plenty of choice’. However, we were also told by one person they required a soft diet but were given hard carrots. Two other people said that ‘too much mince is used’ and ‘not enough fish offered’.

This section was not completed for this inspection. More information about what we found during the inspection is available in the report below.

All Inspections

Amanda Stanford

Professor Sir Mike Richards

Professor Sir Mike Richards