Executive summary
Overall, the trust has demonstrated a commitment to improving the training experience and made significant progress on areas outlined in their improvement plan. The hospital environment fosters a strong culture of teamwork and support.
Areas working well and good practice identified:
- All resident doctors reported the trust as welcoming, friendly, supportive and helpful, with a focus on finding solutions rather than criticism.
- A highly engaged faculty with a positive attitude towards training.
- Foundation resident doctors meeting with clinical supervisors, very early on, describing supervisors as “really good” and easily contactable.
- Foundation resident doctors have regular teaching sessions which are generally well attended and found to be useful.
- The rota co-ordinator should be commended for their work and approach to working with resident doctors.
- The trust’s postgraduate hub page included useful information about the induction programme. Video material was produced and shared with new resident doctors prior to them commencing with the trust.
- Foundation resident doctors advised clinic maps were in place and reported receiving a high quality generic educational work schedule, specifically written to aid on-boarding and provide signposting to educational opportunities.
- The internal medicine year 2 acting up week is a good initiative.
- Resident doctor forums appear to be functioning well with regular meetings taking place.
- College tutors and the foundation programme director have delivered a series of webinars to support and update educational supervisors and key educational topics.
High level areas for improvement:
- Foundation training: F1 doctors were undertaking follow-up jobs that were not suitable for their level of training; F1 resident doctors were no longer permitted to be resident medical officers (RMOs) receiving general practice calls, but some shifts had not been updated to reflect the change; foundation doctors reported it being a struggle to take a break while on-call due to service pressures.
- While the induction process at the hospital was largely effective, there is a need for improvement in several areas, particularly around providing better structure, clarity and support for new staff.
- Clinics: Some doctors reported being discouraged from attending off-ward clinics and procedural training, particularly in respiratory medicine; some doctors reported attending clinics in their personal time.
- Some doctors reported being deterred from completing exception reports by their supervisors.
- A lack of departmental teaching in the Acute Frailty Unit (AFU) was reported.
- The documentation for educational meetings could be improved, particularly in terms of documenting the conversations that take place around induction. Specifically, a need to include competencies-in-practice (CiPs) and general internal medicine (GIM) discussions, which should be reflected in the induction documentation and subsequent educational meetings.
- Out of hours facilities require attention, particularly in relation to the mess, and access to food.
Challenges remain, including a potential patient safety concern; however, we are assured that the trust will review and address the areas for improvement highlighted above, along with the additional recommendations in this report.
The intensive support framework category 2 rating for this concern will remain. The trust is asked to ensure that all outstanding issues shared within this report are addressed by implementing robust actions which are fully embedded within the department to deliver sustainable and measurable improvement at the pace required. The item will remain on the NHS England quality improvement register.
Review overview
Background to the review
A series of quality interventions have been held to address concerns in acute and general medicine at the organisation and in 2019, the trust was referred to the General Medical Council (GMC) for enhanced monitoring.
In June 2021, a learner educator meeting identified improvements, resulting in a reduction of the intensive support framework (ISF) category from 3 to 2, and the trust was removed from GMC enhanced monitoring.
Further reviews took place 2023 and in June 2024 the trust’s improvement plan was once again reviewed confirming progress. A follow-up quality intervention was organised for November 2024 to assess the current training environment.
Who we met with
Learners
- Foundation, general practice (GP), internal medicine training (IMT) and higher specialty training (HST) resident doctors in acute and general medicine.
Educators
- Supervisors 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 Murthy Narasimha, Foundation School Director – South, NHS England
- Training Programme Director – Quality – Dr Amie Burbridge, NHS England
- Specialty Expert (Observing) – Dr Zaki Gaballa, Deputy Foundation School Director, South NHS England
- Education Quality Representative – Deputy Quality Manager, Joycelyn Boyce, NHS England
Review findings
Induction
The departmental inductions were generally well received but some doctors felt they did not receive sufficient role specific guidance before starting, particularly in terms of shadowing or knowing what to expect.
Some foundation resident doctors reported feeling unsupported during the very early stages of their rotation. They also mentioned facing ongoing staffing shortages and communication issues during post-take shifts, particularly struggling with illegible handwritten plans that are difficult to understand, especially when the resident doctor has not previously treated the patient.
Higher specialty doctors reported the environment was generally good for training and felt the trust induction met basic needs describing it as “helpful but brief” and some felt it could have included more detail, especially for working on-call shifts in the hospital.
The senior team advised that video material was produced and shared with new resident doctors prior to them commencing with the trust.
Rotas
Foundation doctors valued the colour-coded rota documentation that was explained and shared with them early on in the rotation.
Foundation doctors reported that it was at times a struggle to take a break while on-call due to work pressures, although, they were encouraged to take breaks by senior staff who may not have taken one themselves.
It was confirmed that F1 resident doctors were no longer permitted to be resident medical officer (RMO), but some shifts had not been updated to reflect the change.
Educational and clinical supervision
Foundation doctors reported meeting with their clinical supervisors very early on, describing the supervisors as “really good” and easily contactable. They were made aware of how to manage and map the curriculum, and how to upload and download their certificates.
All agreed that workplace assessments were undertaken in a timely manner and that the quality of the ward feedback was to a good standard. The trust confirmed that generic work schedules were specifically written to aid on-boarding and provide signposting to educational opportunities.
There was some confusion about the IMS1 and IMS2 doctors’ educational and clinical expectations, particularly regarding their general internal medicine (GIM) training. While discussions were had with supervisors about what to expect, resident doctors felt these conversations were not clearly documented or outlined in their induction paperwork.
The foundation doctors had some guidance on specific CIPs in areas like respiratory care, but felt there was no clear direction on how to demonstrate these skills or show evidence of proficiency, especially for generic GIM skills.
While HST and IMS1s held regular meetings with supervisors, documentation of these discussions is lacking, particularly regarding how to meet specific competency requirements.
The trust reported that there is an ongoing effort to improve the educational experience of resident doctors with educators working on a more structured approach to skill maintenance, ensuring more feedback is available, and making the training environment more navigable for new doctors.
The trust reported that college tutors and the foundation programme director have delivered a series of webinars to support and update educational supervisors to help highlight the requirements for introductory meetings, end-of-year reports and a session on ARCP decisions. These sessions were well attended and remain an available resource for supervisors on the Postgraduate Medical Education Hub.
Clinics
HST and IMS1 doctors felt there was a lack of time allocated for clinic attendance and developing procedural skills. Despite these challenges, the positive aspects were acknowledged with doctors feeling supported by consultants who maintained an “open-door” policy in some departments.
IMS1 doctors reported being discouraged from attending off ward training clinics and procedures, particularly in respiratory medicine. In addition, some doctors reported attending clinics in their personal time.
Higher specialty doctors reported that attending clinics in different specialities was not easy. Although some flexibility exists in gastroenterology, other specialities have barriers to access clinics. They felt that attending ad hoc clinics does not provide meaningful learning opportunities, and there is a need for more tailored educational plans.
Handover
Most foundation and IMS1 resident doctors felt they were not given the opportunity to express their objectives or expectations for the shift during the registrar-led handover.
GP and IMT doctors expressed valuing educational content during handover but noted that overall, the handover process can be rushed.
Higher specialty doctors felt the handover process lacked structure, making it difficult to use the time for learning or observation. They had no guidance as to how to lead handover. The registrars were required to handle the day shift handover without any training as to what was expected.
Workload
Resident doctors experienced a pressure to stay beyond shift hours to complete tasks, often resulting in feeling obligated to remain after their shifts, which could lead to fatigue and burnout.
In addition, the doctors said they struggled with understanding how to raise concerns regarding excessive work hours.
There were challenges with access to the appropriate tools for exception reporting and a lack of encouragement from senior doctors.
While there is a general sense of support from senior colleagues, the working environment and training provisions are seen as inconsistent, and self-development opportunities are limited.
It was reported that the trust is in the process of recruiting additional medical staff to support with the post-take shift and share the workload to make things easier.
Facilities
The mess is located in an outside portacabin, this was initially intended as a temporary solution but has become permanent. All doctor groups reported that while the space is functional, it is not ideal.
Additionally, the vending machine has been out of order for a long time. Outside of regular hours, the vending machine is the only food option, and there is no designated area to eat food. A lack of adequate workspace was also reported, with insufficient access to computers and desk space.
Teaching and training
Foundation resident doctors have regular teaching sessions which are generally well attended and found useful. Local departmental teaching also takes place, although frailty teaching is often missed due to workload pressures.
It was revealed that self-development time, is not regularly provided, with only limited opportunities available. Simulation training was seen as valuable for procedural skills, but sporadic.
Clinical and educational supervisors raised concerns about educators’ ability to balance their clinical duties with educational responsibilities due to limited time allocation. This often results in clinical priorities taking precedence over educational ones.
Challenges in delivering the general internal medicine (GIM) curriculum and ensuring that resident doctors are able to attend relevant clinics or receive exposure to key aspects of their training was reported. There is a sense that GIM is sometimes considered secondary to other specialities, leading to gaps in training.
A lack of departmental teaching in the Acute Frailty Unit (AFU) was reported.
Patient safety
Concerns were raised around patient safety, particularly in terms of patient tracking across wards and the lack of clear systems for identifying medical patients. The hospital has introduced new systems that have caused some temporary issues, but it was anticipated this would improve over time.
Culture and behaviours
F1s and F2s reported generally feeling comfortable in raising concerns in the resident doctors’ forum. Regular meetings took place where staff were updated on progress of concerns raised which generally happens within a week.
While the residents felt supported in personal matters like managing shifts for family events, work-life balance remains a challenge, and there is concern about the culture of working beyond rostered hours.
The GP and IMT doctors described the hospital as friendly. They were aware of various support systems including knowing the identities of the foundation programme director and freedom to speak up guardian.
Higher specialty doctors described the culture in the trust as supportive and helpful with a focus on finding solutions rather than criticism.
In instances where resident doctors have witnessed or experienced difficulties, such as concerns over bullying or inappropriate behaviour, they expressed feeling comfortable approaching certain individuals within the department to raise these concerns.
Areas that are working well
| Description | Reference number and/or domain(s) and standard(s) |
|---|---|
Culture and behaviours Overall, doctors reported the trust as welcoming, friendly, and supportive with a focus on finding solutions rather than criticism. Resident doctors also felt supported in personal matters. They were aware of various support systems including the foundation programme director and freedom to speak up guardian. The resident doctors’ forum appears to be functioning well with regular meetings taking place. The rota co-ordinator should be commended for their work and approach to working with resident doctors. | 1.1, 1.7 |
Education and clinical supervision Foundation doctors were meeting with clinical supervisors, very early on, describing supervisors as “really good” and easily contactable. Foundation resident doctors reported that workplace assessments were undertaken in a timely manner and that the quality of the ward feedback was to a good standard. | 3.5, 3.6, 3.7 |
Recruitment It was reported that the trust is in the process of recruiting two additional medical staff to support with the post take shift and share the workload to make things easier. | 1.1 |
Teaching and training The trust has a highly engaged faculty with a positive attitude towards training and teaching. In the main, all resident doctors were able to attend teaching and are receiving monthly educational meetings with supervisors. | 1.1, 2.1, 4.6 |
Good practice
| Description | Reference number and/or domain(s) and standard(s) |
|---|---|
Acting up week The Internal Medicine Training Year 2 acting up week was a really good initiative. | 3.8 |
Areas for improvement
Immediate mandatory requirements
| Review findings | Required action | Reference number and/or domain(s) and standard(s) |
|---|---|---|
Patients seen in ED and referred to medicine are reviewed during the post-take round, with follow-up tasks often assigned to F1 doctors. Due to their limited experience, F1s may struggle with unfamiliar tasks, such as ensuring scans are accepted by Radiology. Additionally, with up to 25 patients in the clinical area, delays in completing follow-up tasks contribute to sub-optimal patient care. | Trust response to immediate mandatory requirement received. | IMR1 |
F1s advised they are often covering the inpatient medical wards out of hours on their own. While a medical registrar is listed on the rota, this role is not always covered, meaning F1 doctors feel isolated without immediate support. Given their level of experience and the volume of patients it is not appropriate for F1 doctors to be providing this level of ward cover when senior support is not immediately available. Furthermore, with the number of jobs that are required to be undertaken, this is leading to delayed care for patients. | Trust response to immediate mandatory requirement received. | IMR2 |
Mandatory requirements
| Review findings | Required action | Reference number and/or domain(s) and standard(s) |
|---|---|---|
Induction GP and IMT doctors reported feeling that the trust induction did not prepare them for working the on-call shift in the hospital, including overnight. The departmental inductions were generally well received but some F1 doctors felt they did not receive sufficient role specific guidance particularly, in terms of shadowing or knowing what to expect. Higher specialty doctors reported the induction process was seen as helpful but brief, with some feeling it could have included more detailed training. | Review the GP and IMT induction experience to improve preparedness for on-call work. Work in collaboration with departments and resident doctors to improve departmental inductions. Review the F1 shadowing experience. | MR1 |
Rota and workload Foundation doctors reported it is difficult to take a break while on-call due to service pressures. F1s are no longer permitted to be RMOs, but some shifts had not been updated to reflect the change. Resident doctors experienced a pressure to stay beyond shift hours to complete tasks, often resulting in feeling obligated to remain after their shift has ended. | Review current arrangements and monitor end times and break periods. All rotas should be updated and reflect that F1 resident doctors are no longer permitted to be RMO. Encourage completion of exception reports and ensure that reports are acted upon. | MR2 |
Exception reporting Some doctors reported being deterred from completing exception reports by their supervisors. In addition, the doctors said they struggled with understanding how to raise concerns regarding excessive work hours. | Review and explore concerns and ensure access to exception reporting tools. Senior staff should be reminded of the importance of exception reports and resident doctors should be encouraged to complete them without bias, discouragement or fear of reprisals. | MR3 |
Facilities Out of hours facilities require attention particularly in relation to the mess and access to food. A lack of adequate workspace was also reported, with insufficient computing and desk space. | Review and improve facilities with a focus on adequate workspaces and access to food out of hours. | MR4 |
Learning opportunities IMS1 doctors felt there was a lack of time allocated for clinic attendance and gaining procedural skills. Some doctors reported being discouraged from attending off ward clinics and procedural training, particularly in respiratory medicine. Some doctors reported attending clinics in their personal time. | IMS1 doctors should be encouraged to attend clinic sessions and support given to complete workplace-based assessments without conflicting clinical duties. | MR5 |
Supervision Several GP and IMT doctors mentioned a lack of clarity regarding educational and clinical supervision, with some waiting months to be assigned a supervisor. Some higher specialty resident doctors advised they did not receive clear information about their supervisor or who to contact before starting. | Review and clarify supervision arrangements and expectations in place for GP, IMT and higher specialty resident doctors. Review and improved educational meetings and corresponding documentation. | MR6 |
Recommendations
| Recommendation | Reference number and/or domain(s) and standard(s) |
|---|---|
Teaching and training A lack of departmental teaching in the Acute Frailty Unit (AFU) was reported and not all departments have teaching elements, and this should be improved to become more robust. | 3.7 |
Handover and post-take ward round The handover process is not being used effectively for teaching purposes, potentially missing opportunities for learning and development. The post-take ward round should be used more effectively as a training and teaching opportunity. | 3.7 |
Educational meetings Educational meetings can be improved, particularly in terms of documenting conversations that take place. Specifically, a need to include CiP and GIM discussions, which should be reflected in the induction documentation. Documentation should include a description of experience and evidence for each generic and clinical CiP. All IMS2 residents should have an induction document that clearly sets out their GIM experience and expectations for evidence to be gathered. | 4.3, 4.5 |
Report approval
Report completed by: Joycelyn Boyce, Deputy Quality Manager
Review lead: Prof. Phil Bright, Head of Postgraduate School of Medicine
Date approved by review lead: 23 January 2025
NHS England authorised signature: Prof Andy Whallett, West Midlands Postgraduate Dean
Date authorised: 11 March 2025
Final report submitted to organisation: 4 April 2025