Executive summary
The trust has made progress on the areas outlined in their improvement plan, resulting in an improved training experience within acute and general medicine.
Furthermore, there has been a positive change in the culture of the Acute Medical Unit (AMU) with clear and well understood processes for escalating concerns.
Resident doctors expressed satisfaction with the support they received at the trust. They felt well-supported, enjoyed working with the consultants and registrars, and valued the opportunities provided to them. They reported a willingness to raise concerns locally, before escalating formally.
Areas working well and good practice identified:
- There is a positive shift in the trust’s ethos at a high level, demonstrating a willingness to listen to concerns and act where necessary.
- A positive and well organised induction experience (trust, department and role) was highlighted. All relevant information was received about roles and responsibilities, and rotas were provided well in advance.
- Consultants and registrars were described as approachable and actively supportive, taking the time to explain things. As a result, the doctors felt well-supported. The trust was described as a friendly place to work.
- There was widespread awareness of the freedom to speak up guardian, and doctors felt comfortable raising concerns locally, before escalation to formal procedures.
- Educators remarked that it was a good department for teaching.
- On-call and night shifts were reported as being adequately staffed.
- There are sufficient facilities for resident doctors to store their belongings, and they have access to office space and computers.
- Registrars were reported to be a supportive group to other doctors.
High-level areas for improvement:
- Resident doctors can be rostered onto on-call duties without an on-call induction, resulting in confusion about departmental locations and their role.
- Some internal medicine stage 1 (IMS1) resident doctors expressed feeling undervalued, because they felt they were being asked to perform tasks more suited for foundation level doctors.
- Resident doctors indicated that the handover process does not address training needs and that no discussions take place regarding learning objectives or what they hope to achieve from the shift.
- Induction meetings with supervisors were reported as not being as effective as they did not always define the training experience and evidence needed to demonstrate curriculum objectives.
- The lack of signage to wards and departments posed additional challenges.
The trust has demonstrated a clear commitment to improving the training experience, and NHS England is assured that the areas for improvement highlighted above, along with the additional recommendations in this report, will be carefully reviewed and addressed.
Based on these assurances, it is recommended that the trust be de-escalated from intensive support framework (ISF) category 2 to ISF 1.
An improvement plan addressing the mandatory requirements outlined in this report will be necessary with progress monitored through the national education and training survey (NETS) GMC national training survey (NTS).
Review overview
Background to the review
A series of quality interventions have been held to address concerns in acute and general medicine. An initial meeting held in April 2021, identified several issues, including patient safety concerns, leading to the implementation of an improvement plan.
A follow-up meeting in November 2021 noted progress but found that solutions were not fully embedded.
Continued efforts were required, and another review took place on 25 November 2022. A subsequent revisit on 27 September 2024 was arranged to assess whether the improvements had been effectively implemented and sustained.
Who we met with
Learners
- GP and IMS1 resident doctors in acute and general medicine
- Registrars in acute and general medicine
- Foundation doctors in acute and general medicine
Educators
- Trainers of residents in acute and general medicine
Education team
- Educational leads
Review panel
- Quality Review Lead – Phil Bright, Head of Postgraduate School of Medicine, NHS England
- External Specialty Expert – Dr David Palmer, Head of Postgraduate School of General Practice, NHS England
- Training Programme Director Quality – Dr Amie Burbridge, NHS England
- Specialty Expert (Observing) – Dr Indu Lakshmi, Deputy Foundation School North Director, NHS England
- Training Programme Director (Observing) – Dr Sabina Moolla, NHS England
- Deputy Quality Manager – Joycelyn Boyce, NHS England
Review findings
Induction
All resident doctors reported having a well organised trust, department and role induction, which included general departmental and localised speciality inductions.
It was reported that doctors can be rostered onto on-call duties without an on-call induction, resulting in confusion about departmental locations and their role.
Foundation year 1 resident doctors were informed they would have a full week of shadowing before starting rotation; however, this only amounted to around 3 actual clinical days, with some not experiencing on-call duties.
It was suggested that including rota information for all levels during the induction process would be helpful in reducing confusion, as doctors were aware of an app, but not a rota for checking shift schedules.
Rota
Generally, rotas were provided up to 6 weeks before the start of each rotation; however, some gaps in the rota were only identified after doctors had already been in post for a period of time.
In addition, foundation doctors reported a lack of access to rotas on weekends and night shifts, making it difficult to determine who else was on shift during those times.
Education and training
Resident doctors reported being assigned a named educational supervisor and having an initial meeting to discuss their training plan for the forthcoming year.
During acute medical unit (AMU) and emergency department (ED) shifts, doctors were not often able to discuss patients they had clerked. This was viewed as a loss of a valuable learning opportunity.
Only some doctors received helpful feedback via supervised learning events (SLEs). On night shifts, they generally felt supported by more senior doctors and were able to access assistance when needed.
Clinics
Resident doctors reported being unable to attend clinic sessions due to work pressures, with some mentioning ‘trust policy’ requiring a minimum number of doctors on the ward. Space in clinics to see patients on their own was reported as challenging.
Support and supervision
All resident doctors have a named educational supervisor, whom they have already met. They have also attended initial educational meetings where portfolios were discussed, and most doctors had follow-up meetings scheduled.
Handover
Handover practices vary depending on the circumstances, with some registrars and consultants providing detailed updates, while others focus primarily on service delivery. In-depth handovers can sometimes be lengthy, taking up to an hour.
While handover should provide valuable learning opportunities, doctors reported not having time to discuss their own learning needs.
Registrars mentioned they were not given clear guidance on what was expected of them when leading the handover.
The process for handover does not include identifying the training needs of junior staff nor does it include a discussion on individual learning objectives which was felt to be a missed educational opportunity.
Workload and workflow
The wards are adequately staffed, and the workload is manageable.
Interdepartmental relationships/referrals
Referrals are effective and doctors are allowed to post-take patients with consultants.
Facilities
Registered doctors have designated areas to store their belongings and typically find space to complete paperwork. They can access shared computers in a busy mess room but often struggle to find an available workstation on a ward due to a lack of computers.
The elderly care ward was reported as having insufficient space, and the overall number of computers is inadequate.
Furthermore, the continued reliance on a paper-based system for recording patient information has been seen by doctors as a hindrance to productivity.
Teaching
F1s and F2s reported being unable to attend teaching sessions, particularly during busy periods on the ward and periods of staff shortages. Generally, doctors feel pressured to remain on the ward to complete ward duties with no option to catch up on missed teaching.
Foundation doctors reported that while the teaching content is generally relevant, some sessions were perceived as unnecessarily lengthy and could be shortened.
Culture and behaviours
Doctors described the trust as friendly and consultants and registrars as approachable, with one doctor labelling the trust as an excellent place to work. Senior management are open to listening and addressing concerns where necessary.
Colleagues were reported as being supportive and resident doctors were directed to appropriate resources for issues relating to harassment and bullying. They felt confident attempting to resolve matters locally before resorting to formal channels.
However, not all doctors were aware of the sexual safety policy and some resident doctors reported being discouraged from exception reporting.
Resident doctors reported that consultants and registrars proactively check with them to see how things are going and to offer any assistance they may need.
Areas that are working well
| Description | Reference number and/or domain(s) and standard(s) |
|---|---|
Culture There is a positive shift in ethos at a high level at the trust, with the trust demonstrating a willingness to listen to concerns and issues and take the relevant action where necessary. There was widespread awareness of the freedom to speak up guardian, and resident doctors felt comfortable raising concerns locally before resorting to formal procedures. | 1.1, 1.4 |
Induction Resident doctors generally reported having a positive induction experience, noting it was well organised. They received all relevant information about roles and responsibilities and were given their rotas well in advance. | 3.9 |
Support and supervision Resident doctors described the trust was a friendly place to work and consultants and registrars were described as actively supportive, approachable and took time to explain things. As a result, resident doctors felt well-supported. | 1.1, 3.6, 3.7 |
Workload and workflow Resident doctors reported that both on call and the night shifts are adequately staffed. | 1.1 |
Facilities There are adequate facilities for resident doctors to store their belongings, and they access to office space and computers to complete documentation. | 1.11 |
Areas for improvement
Immediate mandatory requirements
| Review findings | Required action | Reference number and/or domain(s) and standard(s) |
|---|---|---|
Potential patient safety concern Ongoing issues with GP and urgent treatment centre referrals. Not consistently processed when patients are transferred to AMU. The standard procedure requires the medical registrar to enter the patient’s name onto a list; however, this step is sometimes missed if the registrar is occupied with other tasks. As a result, patients can remain in AMU for several hours, leading to delays in investigation/treatment for those with urgent diagnoses, or unnecessary hospital stays, for those who could have been discharged. The primary concern appears to involve GP referrals arriving via the ED, as well as patients referred from the ED. Additionally, there are concerns that patients passing through the ED for AMU are not being assessed by the medical team while in the ED. | Trust response to immediate mandatory requirement requested and received. | IMR1 |
Mandatory requirements
| Review findings | Required action | Reference number and/or domain(s) and standard(s) |
|---|---|---|
Induction It was understood that doctors can be rostered onto on-call duties without an on-call induction, resulting in confusion about departmental locations and roles. | Ensure that all doctors receive an appropriate induction to the on-call environment prior to commencing their first on-call shift. | MR1 |
Recommendations
| Recommendation | Reference number and/or domain(s) and standard(s) |
|---|---|
Supervisor training Supervisor training for stage one speciality in internal medicine and general internal medicine needs to be strengthened. Sessions with supervisors should be documented more thoroughly. Additional training for educational supervisors on writing effective induction/year plans, educational meetings and end-of-year reports should be considered. Develop internal monitoring mechanisms. Group 1 HST must have an appraisal that coves GIM and their specialty programme. | 4.3 |
Clinics and teaching Resident doctors reported they sometimes struggle to get released from wards to attend clinics as well as in-trust teaching. | 3.7 |
Resident doctors should be actively encouraged to attend clinic and teaching sessions and provided the time and support to do so. They should also be made aware of the clinic map. Consider timetable for clinic attendance and non-attendance should be an exception that should be investigated. Review available clinic space capacity. | 3.6 |
Induction Offer all resident doctors a hospital site tour either before or during induction and improve sign posting to wards and departments. This will help doctors familiarise themselves with the building. | 3.9 |
Feedback To support resident doctor growth and development, trainers should establish regular development goals to offer feedback, and if needed, receive training on how to give effective constructive feedback. For example, the use of the Acute Care Assessment Tool (ACAT) for Medical Registrar non-clinical development feedback. | 1.4 |
Weeklong shadowing Enable foundation year 1 resident doctors to attend and benefit from scheduled weeklong shadowing opportunities. | 1.1 |
Handover Improve the quality of the handover as an educational opportunity including teaching doctors (registrars in particular), what is expected of them. This will also reduce the likelihood of the potential for “loosing patients” during the handover process. Ref: Guidance on Clinical handover Review the structure and process of handover and consider training Registrars in leading handover. | 3.7 |
Workload and workflow Trainers could better engage with doctors and actively seek their input on task assignments to reinforce their value. Trainers should also regularly review and assess tasks assigned, to ensure they match the doctor’s roles, responsibilities and experience levels. | 4.5 |
Facilities The trust should explore better provision of good quality out-of-hours food. | 1.11 |
Report approval
Report completed by: Deputy Quality Manager, Joycelyn Boyce, NHS England
Review lead: Prof. Phil Bright, Head of Postgraduate School of Medicine, NHS England
Date approved by review lead: 6 December 2024
NHS England authorised signature: Prof. Andy Whallett, West Midlands Postgraduate Dean
Date authorised: 11 March 2025
Final report submitted to organisation: 4 April 2025