The Royal Wolverhampton Hospitals Trust’s bid for foundation trust status has been deferred by Monitor after a recent Care Quality Commission inspection found essential standards were not being met, HSJ can reveal.

Monitor’s board met on Thursday to consider the trust’s application and decided not to authorise the trust, although the regulator declined to comment on the outcome of the meeting.

Royal Wolverhampton’s foundation trust bid was previously put on hold after a critical CQC report in July 2011 said its care “was not always safe”.

The CQC then carried out an unannounced inspection in July following a number of never events at the trust since May 2011.

Read the CQC report

This latest inspection found “inconsistent practices” across theatres. The report said these “increased the risk of harm to people during surgery because some important checks were either missed or not completed with the full involvement of all members of the theatre team”.

Inspectors highlighted examples where staff were talking and not “paying attention”. In other cases staff joined checks halfway through or left before they had been completed. In one case a surgeon continued operating on a patient during a safety check.

Inspectors added: “The trust did not always review the right things, at the right time, to manage the risk of poor surgical safety practice.”

They concluded the trust was not meeting two essential standards to ensure safe, appropriate care and that it had quality checking systems in place.

Cheryl Etches, director of nursing and midwifery, told HSJ the trust was “naturally disappointed” by Monitor’s decision and would take the “necessary action”. However, she said the trust was “absolutely confident” no patient had been put at risk as a result of the concerns identified by the CQC.

“We are on a journey that we haven’t arrived at yet,” she added.

“This is a cultural shift, whereas the teams were completing the checks informally for years we are now formalising it and saying the whole team has to be engaged. This is providing assurance for every patient.”

Trust managers were now regularly carrying out unannounced spot checks on surgical teams, she said.