Mid Cheshire Hospitals trust has made little progress in tackling recognised 'problem areas' and needs stronger leadership, the Commission for Health Improvement has found.
Its clinical governance review said the trust needs new anaesthetic equipment - a problem highlighted in a 1998 report from the Royal College of Anaesthetists.
CHI found most of the anaesthetic equipment was at least 10 years old.
Reviewers also urged the trust to tackle a range of issues highlighted by the Health and Safety Executive in 1999.
'Many issues, like clinical governance and risk management, have been devolved to the various heads of department. The trust lacks a layer of middle management and department heads often have to manage added responsibilities, with little guidance from senior management, ' the report found.
However, reviewers said staff were 'caring and responsive' to patients' needs, and praised the trust's work on education and training. In its action plan, the trust promised to strengthen its clinical governance strategy, develop training plans to reflect the clinical governance agenda, and undertake a comprehensive review of clinical risk mechanisms.