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

• We rated safe, effective, responsive and well led as requires improvement and caring and as good.
• At this inspection we saw improvements in some of the hospital’s services, but some services had deteriorated since our previous inspection.
• We rated two of the hospital’s nine services as good, six as requires improvement and one as inadequate.
• The hospital did not always have appropriate numbers of staff to ensure patients received safe care and treatment. The trust had introduced some additional staff and roles and used agency staff to provide cover and mitigate some of the risk to patients.
• There was limited evidence that services staff had the skills, training and experience to provide the right care and treatment. For example, appraisal rates for a number of staff groups were worse than the trust target and mandatory training rates in eight of the nine services at the hospital were below the trust target of 85%.
• Services at the hospital did not all manage medicines in line with trust policy or national and professional guidance.
• Not all services provided care and treatment based on national guidance. There was variable participation and outcomes in local audit and national audit and we found action plans did not always address the effectiveness of the care and treatment patients received.
• Staff did not always understand their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. Training compliance in relation to the Mental Capacity Act did not meet the trust target in some services.
• People could not always access services when they needed it. The total number of patients on outpatient waiting lists had increased since the previous inspection. Delayed transfers of care, outlying patients, bed moves at night remained a concern in medical care.
• Services did not always manage and investigate concerns and complaints in line with the trust’s policy.
• We had some concerns about the ability of staff at all levels in the hospital to recognise where and when improvements were required in their own services.
• Services at the hospital did not all have a vision, strategy or business plan. There was limited evidence of effective engagement with patients, staff, and the public to plan and manage services.

However:

• The trust had acted on most of the concerns in the Section 29A warning notice that was issued after the inspection in November 2016.
• Staff used appropriate tools for identifying deteriorating patients and patients with sepsis and audits showed good compliance with these tools and escalation processes. Nurses told us that medical response to patients they escalated was prompt.
• Staff worked together as a team to benefit patients. Doctors, nurses, porters, other healthcare professionals and non-clinical staff supported each other to provide good care.
• Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. Staff involved patients and those close to them in decisions about their care and treatment.
• Staff morale appeared to be improving and most staff reported feeling well-supported by their immediate line managers.

The Care Quality Commission (CQC) undertook an announced inspection of Northern Lincolnshire and Goole NHS Foundation Trust between the 22 and 25 November 2016 and an unannounced inspection on the 8 December 2016. Following these inspections, the CQC issued the trust with a Section 29A warning notice which stated that the quality of health care provided by the trust required significant improvement.

We had significant concerns relating to:

• Staffing shortages and a lack of escalation processes about the shortages was putting patients at risk.
• The lack of patient assessment and/or escalation of patients identified as being at risk was causing patients’ safety to be compromised.
• There was insufficient management oversight and governance of the identified risks.

We undertook an unannounced inspection on 15 June 2017. The purpose of this was to follow up on the actions the trust had told us they had taken in relation to the Section 29A warning notice issued in January 2017. At this inspection we found the trust had not taken sufficient, timely action to address all our concerns.

CQC will not be providing a rating to Diana Princess of Wales Hospital for this inspection. The reason for not providing a rating is because this was a very focused inspection carried out to assess whether the trust had made significant improvement to services within the required time frame. Therefore not all of the five domains: safe, effective, caring, responsive and well led were reviewed for each of the core services we inspected.

At this inspection we found:

• There were still gaps in resuscitation equipment and cleaning checklists in the emergency department (ED).
• The completion of patient records in the ED remained variable. We saw gaps in pain, nutrition and hydration, falls and pressure damage risk assessments.
• We saw limited evidence that staff in the ED performed comfort rounds.
• Staff in the ED recorded clinical observations for patients; however, the completion of National Early Warning Scores (NEWS) remained inconsistent.
• We had security concerns regarding the electronic medicine key system for controlled drugs.
• Actual staffing levels did not always match the planned staffing levels in maternity and the ED.
• We were not assured that changes in practice had been fully embedded in maternity following a further never event relating to a retained swab.
• We saw that new processes had been implemented to allow oversight of risks and governance including a nursing dashboard. However, the evidence we found was not always consistent with the information recorded on the nursing dashboard.
• The trust had improved its capacity and demand planning, however, this had not been embedded across all specialties.
• The trust had some significant challenges to deliver against the referral to treatment standards.

However;

• We found that the medicines used by the streaming nurse in the ED were now securely stored in a locked cupboard.
• Emergency equipment in maternity was now checked in line with trust policies.
• Patient records in maternity were now completed to a high standard and had evidence of appropriate risk assessment and escalation when required.
• The maternity service had completed a review of staffing levels using the Birthrate Plus® midwifery workforce-planning tool.
• The trust had developed a maternity services escalation policy.

Professor Ted Baker 

Chief Inspector of Hospitals

Diana, Princess of Wales Hospital is one of three acute hospitals forming the Northern Lincolnshire and Goole NHS Foundation Trust. The trust provides acute hospital and community services to a population of more than 350,000 people across North and North East Lincolnshire and the East Riding of Yorkshire. In total the trust has 850 beds across three hospitals and employs around 6,500 staff. Diana, Princess of Wales Hospital has 439 beds.

Diana, Princess of Wales Hospital (DPOW) provides medical, surgical, critical care, maternity, children’s and young people’s services for people across North East Lincolnshire. The hospital also provides accident and emergency (A&E) and outpatients’ services.

We inspected Diana, Princess of Wales Hospital as part of the comprehensive inspection of Northern Lincolnshire and Goole NHS Foundation Trust, which included this hospital, Scunthorpe General Hospital (SGH) and Goole District Hospital (GDH). We inspected Diana, Princess of Wales Hospital on 24 April 2014.

We carried out this comprehensive inspection because the Northern Lincolnshire and Goole NHS Foundation Trust was placed in a high risk band 1 in CQC’s intelligent monitoring system.

Overall, we rated Diana, Princess of Wales Hospital as requires improvement. We rated it good for being caring but it requires improvement in providing safe care, being effective, responsive to patients’ needs and being well-led.

We rated accident and emergency, maternity, services for children and young people, end of life care and outpatients services as good. Medical and surgical services require improvement, and critical care services were rated as inadequate.

Our key findings were as follows:

• There were arrangements in place to manage and monitor the prevention and control of infection, with a dedicated team to support staff and ensure policies and procedures were implemented. We found all areas visited clean. MRSA and C. difficile rates were within an acceptable range for the size of the trust.
• There were significant vacancies with nursing and medical staff in some areas. The trust was actively recruiting into these posts. In the meantime, bank, agency and locum staff were used to fill any deficits in staff numbers. Staff could also work extra hours.
• Patients were able to access suitable nutrition and hydration including special diets. Patients reported that on the whole they were content with the quality and quantity of food provided.
• Mortality rates were improving.

Importantly, to improve quality and safety of care, the trust must:

• Ensure that there are sufficient qualified, skilled and experienced staff, particularly in A&E, medical and surgical wards. This is to include provision of staff out of hours, bank holidays and weekends.
• Review the skills and experience of staff working with children in the A&E department to meet national recommendations.
• Review the consistency of care and the level of consultant input, particularly out of hours and at weekends in the high dependency unit.
• Review care and treatment to ensure that it is keeping pace with National Institute of Health and Care Excellence guidance and best practice recommendations, particularly within the intensive therapy unit and high dependency units.
• Ensure that the intensive therapy unit uses nationally-recognised best-practice guidance in terms of consultant wards rounds and reviewing admissions to the unit.
• Review delayed discharges from intensive therapy unit in terms of the negative impact this can have on patients.
• Ensure that the designation of the specialty of some medical wards reflect the actual type of patients treated.
• Ensure that there is an improvement in the number of Fractured Neck of Femur patients who have surgery within 48 hours.
• Ensure there is appropriate care planning and a paediatric early warning scoring system on the neonatal intensive care unit and that there is consistent nutritional and tissue viability screening and assessment on paediatric wards.
• Ensure that all staff attend and complete mandatory training, particularly for safeguarding children and resuscitation.
• Ensure that staff have appropriate appraisal and supervision.
• Review the effectiveness of handovers, particularly in the medical services.
• Ensure that all patient documentation is appropriately updated and maintained including documentation for mental capacity assessments and risk assessments.
• Review access to soft diets outside of meal-times.
• Ensure that reasons for Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) are recorded and are in line with good practice and guidelines.
• Ensure that DNACPR orders confirm discussion with patients or family members and whether multidisciplinary teams are involved before an order is put in place.
• Review the effectiveness of handovers, particularly in the medical services.
• Ensure that all patient documentation is appropriately updated and maintained including documentation for mental capacity assessments and risk assessments.
• Ensure that reasons for Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) are recorded and are in line with good practice and guidelines.
• Review the ‘did not attend’ and waiting times in outpatients’ clinics and put in steps to address issues identified.

Professor Sir Mike Richards

Chief Inspector of Hospitals

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.

We undertook a simultaneous review of two children's wards managed by Northern

Lincolnshire and Goole NHS Foundation Trust. We visited wards at Scunthorpe General Hospital and Diana Princess of Wales Hospital.

During our inspection we spoke with a number of people who use the service. People we talked with were generally positive about their care and experience in hospital. They told us they received sufficient information about the hospital and the proposed treatment or procedure. The options for their treatment or procedure were explained to them in a way they could understand and they were given opportunities to ask questions. They were told about the risk and benefits of the treatment or procedure, they felt included in decisions made about their care and were given time to consider their decision about the proposed treatment or procedure.

From our inspection across both sites we received comments such as: "The doctor explained everything to me in detail", "Staff always talk things through with us" and "I felt happy about what was happening with the tests, the doctor explained everything in lay terms. I had to sign the care plan."

The people we spoke with felt they could raise any concerns with staff and these would be acted upon. People we spoke with were complimentary about the staff who looked after them. They told us staff supported them in a friendly and supportive manner. Comments we received included:" Nurses have been fantastic, really helpful", "Staff are very nice" and "Staff are really good."

We received mixed comments about staffing levels on the wards. Some people felt that during certain shifts staff were very busy however they told us care continued to be good during these periods. Comments we received included: "Staffing levels are good" and "Staff were very busy one night, though the care was good."

We undertook a simultaneous review of all three hospitals managed by Northern Lincolnshire and Goole NHS Foundation Trust. As part of our review we conducted an unannounced inspection of Diana, Princess of Wales Hospital and Scunthorpe General Hospital.

During our inspection we spoke to a number of people who use the service. People we talked to were generally positive about their care and experience in hospital. They told us that they were treated with respect and received sufficient information about the hospital and the proposed treatment or procedure. The options for their treatment or procedure were explained to them in a way that they could understand and they were given opportunities to ask questions. They were told about the risk and benefits of the treatment or procedure, they felt included in decisions made about their care and were given time to consider their decision about the proposed treatment or procedure.

People told us that they felt the hospital staff communicated effectively with them, they received their test results in a timely manner and were kept up to date of their progress.

People we spoke to told us that they received pain medication when they asked for it although one person at Diana, Princess of Wales Hospital described a particular incident when they had to wait a long time however when they reminded the nurse they received it immediately.

From our inspection of Diana, Princess of Wales Hospital we received comments such as “the doctors told me what was happening at every stage”; “I couldn’t fault the care”, “I wasn’t sure about the surgery so the doctor gave me more time to think about it which was really good”, “I was offered a date for my treatment that was convenient to me, as well as having the whole procedure discussed with me” and “the staff are really good”.

Two patients commented that during their stay on the medical admissions unit their sleep was interrupted by noise and activity at night which was due to emergency admissions. One patient told us that the only improvement they could make would be for the doctors to routinely provide more technical detail about the treatment or procedure they had carried out. The person did go on to say that not everyone may want the technical detail and there were opportunities to ask questions.

From our inspection of Scunthorpe General Hospital we received comments such as “The ward is very clean and tidy”, “they clean every morning, dust and clean the chairs and everywhere”, “I’ve been given lots of information from the doctors and nurses, I’m waiting for the results from a test yesterday and the doctor is coming today to discuss the results and what happens next”, “They have informed me about everything, I understand about the treatment“, “The staff are very good with the ones who are confused, I lie here and watch them, they are very patient and always polite and kind”.

The trust carries out short patient experience surveys themed around a number of quality indicators identified by the trust which are attached to inpatients’ menu cards to enable them to obtain a real time view of the patient perspective. Between April 2010 and March 2011 the majority of patients who completed the surveys indicated they were treated with respect and dignity and satisfied with their care whilst in hospital.

The majority of responses from the Care Quality Commission 2010 in-patient survey were similar to expected which is comparative to other trusts and also some positive comments were made on the NHS Choices website.

We carried out a follow-up inspection of Northern Lincolnshire and Goole NHS Foundation Trust from 22 to 25 November 2016 to confirm whether the trust had made improvements to its services since our last inspection, in October 2015. We also undertook an unannounced inspection on 8 December 2016.

To get to the heart of patients’ experiences of care and treatment we always ask the same five questions of all services:are they safe, effective, caring, responsive to people’s needs, and well-led? Where we have a legal duty to do so, we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

When we last inspected this trust, in October 2015, we rated the trust overall as ’requires improvement’. We rated safe,effective, responsive, and well-led as ‘requires improvement’. We rated caring as ‘good’. Scunthorpe General Hospital was rated as ‘inadequate’ overall, Diana Princess of Wales Hospital was rated as ‘requires improvement’ overall and Goole District Hospital was rated ‘good’ overall. In community services community adult services was rated as ‘requires improvement’ overall, end of life care was rated as ‘requires improvement’ overall, children’s and young people’s services was rated as good overall with safe rated as ‘requires improvement’ and dental services was rated as ‘good’overall.

Following the inspection in October 2015 there were six breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations. These were in relation to staffing, safe care and treatment, dignity and respect, premises and equipment, good governance and need for consent.

The trust sent us an action plan telling us how it would ensure that it had made improvements required in relation to these breaches of regulation. At this inspection we checked whether these actions had been completed.

In November 2016 we inspected:

• Diana Princess of Wales Hospital

• Scunthorpe General Hospital

• Community Adult Services – safe and well led domains

• Community end of life care services – effective, responsive and well led domains

• Community children’s and young people’s services – safe domain

We did not inspect Goole District Hospital as the services provided at this hospital were rated as good in October 2015. We carried out a follow up inspection of community services and looked specifically at the domains that were rated as‘requires improvement’ following the October 2015 inspection.

We rated Northern Lincolnshire and Goole NHS Foundation Trust as Inadequate overall. Safe and well led were rated as‘inadequate’, effective and responsive were rated as ‘requires improvement’ and caring was rated as ‘good’.

We rated Diana Princess of Wales Hospital as requires improvement overall.

Key Findings:

• Nursing and medical staffing had improved in some areas since the last   inspection. However, there were still a number of nursing and medical staffing vacancies throughout the trust, staff turnover in some areas were particularly high especially in medical care, emergency departments, surgical services, and services for children and young people.
• The trust had systems in place to manage staffing shortfall as well as escalation processes to maintain safe patient care. However, a number of registered nurse shifts remained unfilled despite these escalation processes and we saw examples of wards not meeting planned staffing levels and high patient acuity not identified appropriately.
• There had been a lack of improvement since the inspection in 2015, areas of concern had not been fully addressed in a sustained way and there had been deterioration in a number of services. Safety processes were not always adhered to in some services.
• In 2015, we said that the trust must ensure there is an effective process for providing consistent feedback and learning from incidents. During this inspection learning from incidents remained inconsistent and variable between directorates. Staff we spoke to reported a varying standard of feedback and learning from incidents.
• Assessing and responding to patient was risk was inconsistent and did not support early identification of deterioration in maternity, surgery and urgent and emergency services. This was particularly evident in the Emergency Department (ED) at Diana Princess of Wales Hospital, where the national early warning scores (NEWS)were not recorded in the majority of records we reviewed.
• A Paediatric Early Warning Score (PEWS) was used in ED however there was inconsistent documentation of PEWS scores so we were unable to be sure that the identification and escalation of deterioration in a child’s condition would be recognised.
• The trust used the five steps to safer surgery procedures including the World Health Organisation (WHO) checklist.However, from a review of records and observations of procedures, it was apparent that this was not an embedded consistent process.
• Mandatory training rates in infection control were variable across the hospital.
• We found inconsistent practice with regard to resuscitation trolley checks, fridge temperature checks and medication checks across the hospital.
• We were not assured patients had adequate nutrition and hydration whilst they were in the emergency department for a long period of time.
• Patient flow through the hospital however remained an issue with a significant number of patients cared for on non-medical or non-speciality wards. A buddy ward system was in place, however there was still confusion regarding which consultant should review which patient. Patients who were moved more than once could be under the care of different consultants during their stay in hospital.
• Between December 2015 and September 2016 Diana, Princess of Wales (DPoW) hospital had 452 black breaches.However, since the introduction of the ambulance handover team there had been an improvement.
• Patients requiring pre-assessment prior to surgery were not always assessed according to an effective patient pathway. There remained a large number of ‘on the day’ cancellations for clinical reasons.
• Referral to treatment times across a number of services showed a deteriorating position and were significantly below the national indicator and slightly below the England average. Patients were not always able to access services for assessment, diagnosis or treatment when they needed them. There were long wait times within surgical services and overall the service was not meeting the national referral to treatment times (RTT) or all cancer performance standards.
• Emergency department performance was variable and between August 2015 and July 2016 the department did not achieve the target for 95% of patients to be treated, discharged or admitted within four hours.
• The neonatal intensive care unit (NICU) and Rainforest ward had been closed to admissions on a number of occasions due to capacity or staffing concerns. The paediatric assessment and observation unit (PAOU) was not always available to staff due to adult overflow patients from the emergency department.
• In 2015 we raised concerns regarding the numbers and reporting processes of mixed sex breaches. The trust had updated the policy for eliminating mixed sex accommodation, which was in line with Department of Health guidance(November 2010). However the trust has continued to report mixed sex breaches in a number of core services. Mixed sex breaches occurred twice in both November 2015 and December 2015 in AMU due to capacity issues and problems with patient flow.
• The trust participated in national and local audit programmes however trust performance against national performance was mixed across most of the core services with many showing performance that was worse than England averages. There was also variation in patient outcomes between the two hospital sites. Patient outcomes were overall slightly better at DPoW when compared to SGH. Mandatory training and appraisal targets had not been met by some staff groups. This included safeguarding training targets and not all staff had the required level of safeguarding training in place.
• The endoscopy unit had lost their Joint Accreditation Group (JAG) accreditation in August 2016 due to an audit that was not submitted within the necessary timescales and communication issues.
• In maternity services we had concerns regarding the completion of the K2 training package (an interactive computer based training system that covered CTG interpretation and fetal monitoring) for midwives and medical staff in maternity.
• We found poor leadership and oversight in a number of services, notably maternity services, outpatients, surgery and urgent and emergency care. In these services leaders had not led and managed required service improvements effectively or in a timely manner. In addition service leads had tolerated high levels of risks to quality and safety without taking appropriate and timely action to address them.
• There was variability in the quality of risk registers, not all risk registers accurately reflected the risks in the service and were not always updated and reviewed effectively.
• Concerns remained regarding the organisational culture. There were a number of themes that emerged from discussions with staff relating to a disconnection still between the executive team and staff, there was a sense of fear amongst some staff groups regarding repercussions of raising concerns and bullying and harassment. Feedback frommanagement teams had a more positive focus.

However:

• The trust had taken action in some areas since the 2015 inspection, for example the trust had stopped using band 4 nurses awaiting professional registration numbers within the registered nurse establishment.
• There were improvements in critical care services. The management team were able to articulate a clear vision and governance processes were effective.
• Infection control processes and cleanliness was satisfactory in the ED.
• There was a new management team in surgery that were able to demonstrate an understanding of the challenges and the areas that required further improvement. They had only recently come into post and had not had sufficient time to implement the changes required to address the ongoing concerns.
• An acute physician model had been established on the acute admissions ward, short stay ward and ambulatory care.One of the benefits of this was to improve the four-hour standard in ED by improving patient flow.
• There was evidence of good multidisciplinary working in most of the services.
• In critical care patient outcomes, for example, mortality, early re-admissions, delayed and out of hours discharges had improved and were in line with similar units.
• There were improvements in the ophthalmology service specifically with regard to the cancellation of clinics and clinical oversight of this process.
• Overall we observed staff treating patients with dignity and respect. Patients told us staff were caring, attentive and helpful. Staff responded compassionately to pain, discomfort, and emotional distress in a timely and appropriate way.

We saw several areas of good practice including:

• An ambulance handover team, to see ambulance patients and provide an initial assessment, had been introduced and was providing a positive impact on the ambulance turnaround times.
• An acute physician model had been established on the acute admissions ward, short stay ward and ambulatory care.One of the benefits of this was to improve the four-hour standard in ED by improving patient flow.
• An online call service run by the infant feeding co-ordinator was being offered to support breast feeding mothers within the community setting.
• The trust had held 'Dying Matters' roadshows at a number of local venues in May 2016, including supermarkets and community centres. These had been advertised as events to provide advice and sign-posting to members of the public on all aspects of planning end of life care, bereavement, dying, organ donation, and will-writing.The introduction of the domiciliary non-invasive ventilation service by the respiratory nurse team. This allowed patients to be monitored at home and reduces the need for hospital admissions. Home assessments could be completed and information could be downloaded onto computer software.
• The development of advanced midwifery practitioners and advanced nurse practitioners in gynaecology.
• The paediatric service used a ‘pants and tops’ system to allow children to feed back on the care they received.Children filled out ‘pants’ templates and said what they did not like, or filled in ‘tops’ templates to say what they did like.However, there were also areas of poor practice where the trust needs to make improvements.

Importantly:

• The trust must ensure that the service risk registers are regularly reviewed, updated and include all relevant risks to the service.
• The trust must monitor and address mixed sex accommodation breaches.
• The trust must continue to improve its paediatric early warning score (PEWS) system to ensure timely assessment and response for children and young people using services.
• The trust must ensure that, following serious incidents or never events, root causes and lessons learned are identified and shared with staff, especially within maternity and surgery.
• The trust must ensure that effective processes are in place to enable access to theatres out of hours, including obstetric theatres, and that all cases are clinically prioritised appropriately.
• The trust must ensure that the five steps to safer surgery including the World Health Organisation (WHO) safety checklist is implemented consistently within surgical services.
• The trust must ensure there are effective planning, management oversight and governance processes in place,especially within maternity, ED and outpatients. This includes ensuring effective systems to implement, record and monitor the flow of patients through ED, outpatients and diagnostic services.
• The trust must ensure the proper and safe management of medicines including: checking that fridge temperatures used for the storage of medication are checked on a daily basis in line with the trust’s policy.
• The trust must ensure that there are effective processes in place to support staff and that staff are trained in the recognition of safeguarding concerns including all staff caring for children and young people receiving the appropriate level of safeguarding training and in outpatient services.
• The trust must ensure that actions are taken to enable staff to raise concerns without fear of negative repercussions.
• The trust must ensure that a patient’s capacity is clearly documented and where a patient is deemed to lack capacity this is assessed and managed appropriately in line with the Mental Capacity Act (2005).
• The trust must ensure that policies and guidelines in use within clinical areas are compliant with NICE or other clinical bodies.

Emergency and Urgent Care

• The trust must ensure that effective timely assessment and/or escalation processes are in place, including the use of the National Early Warning Score (NEWS), so that patients’ safety and care is not put at risk, especially within ED.

• The trust must ensure that timely initial assessment of patients arriving at ED takes place and that the related nationally reported data is accurate.

• The trust must ensure that ambulance staff are able to promptly register and handover patients on arrival at the ED.

• The trust must ensure that patients are assessed for pain relief; appropriate action is taken and recorded within the patients’ notes.

• The trust must ensure that patients in ED receive the appropriate nursing care to meet their basic needs, such as pressure area care and being offered adequate nutrition and hydration and, that this is audited.

• The trust must ensure the checking of controlled drugs and the safe storage of medications used by the ‘streaming’nurse in ED at DPoW hospital are in line with trust policy.

​

Critical Care

• The trust must audit compliance with NICE CG83 rehabilitation after critical illness and act on the results.

• The trust must review and reduce the number of non-clinical transfers from ICU.

Maternity

• The trust must ensure that effective timely assessment and/or escalation processes are in place, including the use ofthe Modified Early Obstetric Warning Score (MEOWS).

• The trust must continue to improve obstetric skills and drills training among medical staff working in obstetrics.

• The trust must continue to improve midwifery and medical staff competencies in the recognition and timely response to abnormalities in cardiotocography (CTGs) including the use of ‘Fresh eyes’.

Children and Young People’s Service

• The trust must ensure the number of staff who have received training in advanced paediatric life support in line with national guidance and the trust’s own target.

Outpatients and diagnostic imaging

• The trust must complete the clinical validation of all outpatient backlogs and continue to address those backlogs, prioritised according to clinical need.

• The trust must continue to take action to reduce the rates of patients who do not attend (DNA).

• The trust must continue to take action to reduce the numbers of cancelled clinics.

• The trust must continue to strengthen the oversight, monitoring and management of outpatient bookings and waiting lists to protect patients from the risks of delayed or inappropriate care and treatment.

• The trust must continue to work with partners to address referral to treatment times and improve capacity and demand planning to ensure services meet the needs of the local population.

There are also areas of poor practice where the trust should make improvements which are detailed at the end of this report.

On the basis of this inspection, I have recommended that the trust be placed into special measures.

Professor Sir Mike Richards

Chief Inspector of Hospitals