England's smallest acute trust, Isle of Wight Healthcare, has been accused of lacking effective leadership and having significant problems with the organisation of care in a report by the Commission for Health Improvement.

During its visit in the summer, CHI found 'patients being cared for in inappropriate settings' by staff without 'the support or training needed to give the best care', and a high number of cancelled operations - it was one of three trusts deemed as needing special help in this area. At any one time around 30 patients were in wards which were not suited to the care they needed, with patients of individual clinicians being looked after across a large number of wards.

Although there was a perception that the trust had too few beds, CHI concluded that organisation of care is so poor that this 'needs to be addressed before proper judgements can be made as to whether more beds are needed'.

Bed and financial pressures and poor waiting-list management were compounded by recruitment problems among senior clinicians.

Yet CHI found committed staff who felt valued and who were able to provide a good level of care.

The CHI report said it was to the 'great credit' of staff that they also coped with the disruption of a major programme of building works and that most patients were 'complimentary of the care and attention they received'.

But it criticised the lack of ownership of problems and 'poor working relationships that exist within and between some clinical teams and between departments' , with evidence of internal conflict and senior staff below board level resistant to change.

With the chief executive not routinely involved in clinical governance activities and an 'overstretched' medical director, 'CHI found little evidence of a willingness or ability to 'grasp the nettle' and deal with some of the most difficult remaining cultural changes needed to improve services and the patient experience.'

The trust is continuing to wrestle with the problem of providing services for a small population, and a recent review has concluded that it cannot support a full range of clinical services and should be developing close clinical links with mainland services.

Nevertheless, reviewers commended the trust's ability to offer a broad range of services and praised its clinical risk management and complaints-handling systems, with a hotline for reporting risks and incidents which are reviewed weekly. The trust was also congratulated for bringing together the attitudes and cultures of the two trusts from which it merged.

An action planning day last Friday following the publication of the CHI report brought together 70 staff and patient representatives, including 16 consultants, in what chief executive Graham Elderfield described as a very positive event.

'Consultants were feeding back from the working group and significant improvements in clinical leadership were emerging'. He said the report was being viewed as 'a very good lever for change'.