Our rating of services improved. We rated it 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 have a systematic or timely approach to quality improvement. We identified concerns in some services that had not been acted upon or changes had not been embedded or sustained from previous inspections.
• 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 service 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 seven of the nine services at the hospital were below the trust target of 85%.
• Not all services provided care and treatment based on national guidance. There was variable participation and outcomes in local and national audit and we found action plans did not always address the effectiveness of the care and treatment patients received.
• 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.
• Services did not always manage and investigate concerns and complaints in line with the trust’s policy.
• Services at the hospital did all not 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. 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 Scunthorpe General 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, medicine fridge temperature recording 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.
• There was no assurance that safeguarding assessments had taken place in the ED.
• Sepsis pathways were not always completed or completed fully and antibiotics were not always given in a timely manner.
• Staff in the ED had not completed Paediatric Early Warning Scores (PEWS) in most records we reviewed.
• We had security concerns regarding the electronic medicine key system for controlled drugs.
• Entry to the resuscitation room in the ED remained a security risk.
• Actual staffing levels did not always match the planned staffing levels in maternity and the ED.
• The World Health Organisation (WHO) surgical safety checklist was not consistently embedded in maternity.
• We found inconsistencies in how staff in the maternity service recorded delays in patient care.
• 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;

• The ED was now visibly clean and tidy.
• Emergency equipment in maternity was now checked in line with trust policies.
• A new children’s waiting area and ambulance entrance had been opened in the ED.
• National early warning scores (NEWS) were recorded in all adult patients’ notes we checked.
• Clinical records in maternity were now completed in line with trust policy.
• New nursing documentation had been introduced in the ED.
• We observed staff in the ED offering patients food and drinks.
• 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.
• We found that the management of patients with mental health problems in the ED had improved. The room was ligature free and a standard operating procedure had been introduced.

Professor Ted Baker 

Chief Inspector of Hospitals

The inspection at Scunthorpe General Hospital was carried out to assess whether the trust had implemented actions in response to non-compliance found at the inspection in February 2013. This was in relation to patient care in the accident and emergency department (A&E), stroke care and supporting staff to receive appropriate training, professional development, supervision and appraisal. The inspection also included a review of maternity services.

We spoke with over 50 patients or their relatives and staff. The inspection team comprised CQC inspectors, doctors, nurses, and patient representatives. We received information from local bodies such as the clinical commissioning groups, Healthwatch, Monitor, NHS England, Health Education England and the Supervising Authority for midwives.

On the whole patients were positive about their care and treatment. Patients using services we inspected all said they had been treated with dignity and respect. They said they had received treatment quickly and staff had kept them informed about their plan of care.

Our review of the trust showed they had made progress in taking action to improve patient care and treatment in the areas we visited. We saw elements of good practice particularly in the treatment of patients suffering from a stroke. The trust acknowledged that there was still work to be done to ensure there was continuous and sustained improvement to maintain patient safety and welfare. There had been changes to medical leadership and new directorate structures were being introduced in January 2014. This would ensure greater accountability at Board and ward level for patient care and safety.

We found that patient's health, safety and welfare was protected when more than one provider was involved in their care and treatment, or when they moved between different services. This was because the trust worked in co-operation with others such as commissioners, GPs, other trusts, ambulance services and community services. There were systems in place to minimise the risk to patients care and treatment during their transfer and discharge.

There were enough qualified, skilled and experienced staff to meet patient's needs. The trust had management structures, systems and procedures which were followed, monitored and reviewed to enable the effective maintenance of staffing levels.

Patients were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard. Good progress had been made to ensure all staff received mandatory training and appraisal. Staff morale was noted to have improved in most areas.

The provider had an effective system to regularly assess and monitor the quality of service that patients received. There were structures in place to ensure governance arrangements were met at corporate and ward level. Complaints management was an area which the trust recognised required further improvement.

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.

Patients we spoke with were mostly very positive about their experiences of care and treatment. They told us they were happy with the way staff cared for them and we received comments describing staff as “really good” and “they make time for me”. They also told us that staff respond quickly to their needs and were respectful.

Patients told us that they enjoyed mealtimes and were generally complimentary about their experience of mealtimes at the hospital and quality of food provided and we received comments such as “I can order what I like” and “it is nice and hot”. We received one negative comment from a patient who told us that they regularly missed a meal when they had to attend for treatment off the ward and when they returned they were only offered a sandwich.

We also used information provided by patients on NHS Choices website, complaints that we have been sent, Patient Environment Action Team assessment and patient survey results. The results have shown that the responses were about the same or better in comparison to other similar trusts.

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 17 October 2016 and 08 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 (SGH) was rated as inadequate overall, Diana Princess of Wales Hospital (DPoW) 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 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 Scunthorpe General Hospital as inadequate 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 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 Scunthorpe General Hospital (SGH), where the national early warning scores (NEWS) were not recorded in the majority of records we reviewed.
• A Paediatric Early Warning Score (PEWS) was not used in the Emergency Department, 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.
• The standard of documentation was variable, for example in the ED at SGH; documentation was variable and at times inadequate to ensure delivery of safe care.
• During our inspection, the ED at SGH was overcrowded with no resuscitation bays or trolleys available. Patients were queuing with paramedics waiting for a cubicle and we saw and heard evidence of patients put at risk due to unavailable space.
• There were poor infection prevention and control processes and standards of cleanliness in the ED at SGH. Mandatory training rates in infection control were variable across the hospital with low rates in the areas where concerns were identified.
• 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 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.
• There was a high number of black breaches (ambulances waiting for over one hour) at this trust between December 2015 and September 2016, there were 694 black breaches.
• 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 was 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.
• In 2015, we raised concerns regarding the numbers and reporting processes of mixed sex accommodation 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. For example in medicine at SGH, 14 mixed sex breaches had been reported.
• 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 worse at SGH than DPoW.
• 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.
• At the 2015 inspection we were told that were plans to introduce a seven day 24 hour gastro-intestinal (GI) bleed rota. At this inspection we found that this was still not in place. Agreement had been reached for consultant rota cover however further work was being undertaken to agree the nursing rota.
• 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 from management 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.
• 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.
• At SGH the Ambulatory Care Unit (ACU), which opened in September 2015, had a positive impact on patient flow.
• There was evidence of good multidisciplinary working in most of the services. A frail elderly assessment team (FEAST) attended ED liaising with the community teams and the service offered hyper acute stroke services with acute stroke nurses attending ED.
• In critical care patient outcomes, for example, mortality, early readmissions, 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
• All radiology staff had received training regarding the ionising radiation (medical exposure) regulations (IR (ME) R 2000).
• 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.
• There was a new initiative called the virtual ward. Two health care assistants were available all day Sunday to Friday and half days on Saturdays. They were deployed to an elderly medical ward at the start of their shift, and then re-deployed to any area with short notice absence or where one to one patient care was required.
• The Ambulatory Care Unit (ACU) opened in September 2015 and had a positive impact on patient flow at the Scunthorpe General Hospital site. This had resulted in a significant reduction in length of stay of almost 2 days, an increase in zero length of stay patients and a significant reduction in medical outliers.
• A 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 Macmillan end of life care clinical coordinator had been in post for ten months. During that time, 400 staff had attended educational sessions and the new end of life care plan had been implemented on 11 wards. An end of life care facilitator had also been appointed recently.
• The diagnostic imaging departments had begun a pilot in conjunction with primary care for radiologists to refer patients straight to CT following an abnormal chest x-ray. When patients were seen in clinic as a two-week wait, they already had CT scans and results available for the clinician at their first appointments. This potentially reduces lung cancer patients’ length of pathway.

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

• The trust must ensure that 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.
• 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 there are the appropriate systems in place to maintain the cleanliness of the ED at SGH to prevent the spread of infections.
• 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 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.

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 of the 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, is 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 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 were 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