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Southend University Hospital Requires improvement

We are carrying out checks at Southend University Hospital using our new way of inspecting services. We will publish a report when our check is complete.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 2 August 2016

We undertook this inspection 12-14 January and returned unannounced 24 January 2016. The main part of the inspection was a comprehensive announced inspection. We inspected Southend Hospital and the outpatient’s service for children and young people at the Lighthouse Child Development Unit.

This service was not triggering as high risk from national data sets or as an outlier.

Southend University Hospital NHS FT is part of the Success Regime. This includes Southend, Basildon and Mid Essex trusts working together to influence system change across the health economy. This process is key to improved care in the NHS.

During the first day of the inspection the junior doctor’s strike was in progress. The trust was offered the option to cancel the inspection but declined. We noted that the trust had a clear plan for patient care during this period of industrial action.

During our inspection the trust was on a high state of escalation due to the increased number of patients coming in to the hospital. This had existed for some time before our inspection.

We rated the services offered by Southend University Hospital NHS Foundation Trust as ‘requires improvement’.

Our key findings were as follows:

  • The increase in the number of beds at the trust had put additional strain on the services, but in particular a strain on the staff.

  • Staff nurse to patient ratios were too high particularly in medicine and musculoskeletal surgery.

  • High numbers of elective surgery cancellations were seen in addition to clinic cancellations all relating to the alert status, capacity and congestion within the hospital.

  • Good patient outcomes were evidenced in particular the stroke service.

  • Staff went the extra mile for patients and demonstrated caring and compassionate attitudes.

  • The trust scored above the England average for Patient-led assessments of the Care Environment (PLACE) consistently for all categories assessed. (2013-2015)

  • Cleaning undertaken by nurses and technicians for November and December 2015 of high risk equipment was 95% and 97% compliance rates. There were no MRSA cases reported and lower than the England average rates of C.Diff.

  • Mortality and morbidity meetings took place but they did not follow a consistent format, and actions to support learning lacked timescales.

We saw several areas of outstanding practice including:

  • We rated well led for the emergency department as outstanding.The local leadership and team worked well to deliver the service.There governance practices ensured risks were identified and managed. They engaged staff to ensure they remained motivated.

  • Stroke service patient outcomes receiving the highest rating by Sentinel Stroke National Audit Programme.CT head scanning were delivering a 20 minute door to treatment time which was a significant achievement.

  • The trust had implemented an Early Rehabilitation and Nursing team (ERAN). The ERAN Team supported the early discharge of primary hip surgery and knee surgery patients.

  • The ‘Calls for Concern’ service, allowing patients and relatives direct access to the CCORT (critical care outreach team) following discharge home.

  • The learning tool in place within Radiology allowing learning from discrepancy in a no blame environment.

  • The Mystery Shopper scheme that actively encouraged people to regularly give their feedback on clinical care and services.

  • Safe at Southend was a new initiative to allow staff to share day to day clinical and operational issues with executive Directors for rapid action.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • Ensure staffing ratios comply with NICE guidelines, to ensure both patients and staff are not at increased risk.

  • Ensure duty of candour regulations are fully implemented, the trust was not able to demonstrate that they had met all parts of the requirements.

  • Ensure that clinical review is part of the process for cancelling elective surgical patients.

To see the full list of actions the trust must and should take please see the areas for improvement section toward the end of this report.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 2 August 2016

Effective

Good

Updated 2 August 2016

Caring

Good

Updated 2 August 2016

Responsive

Requires improvement

Updated 2 August 2016

Well-led

Requires improvement

Updated 2 August 2016

Checks on specific services

Maternity and gynaecology

Good

Updated 2 August 2016

Overall we rated the service as good but safety required improvement.

There were established local and divisional risk and governance arrangements. Staff felt the service had a profile on the trust board agenda. There were processes in place to share lessons learnt from incidents and investigations.

The trust promoted breastfeeding and women were supported in their chosen method of feeding. Women were positive about the care they had received. We observed staff interacting with women and their partners in a respectful compassionate way.

Women and their partners felt involved with their care and were happy with explanations given to them. Partners had the choice to stay to support women throughout the night.

There was an effective multidisciplinary approach to care and treatment, which involved a range of staff in order to enable services to respond to the needs of women. All staff told us that that working relationships between the professional groups was excellent.

Staff wanted to continue to develop the service and demonstrated this through implementing new ideas. For example the development of a range of specialist clinics to meet women’s needs.

Women using the maternity service received evidenced based care on the maternity service’s guidelines and national guidance.

However, medical staffing and the numbers of supervisors of midwives were not in line with national guidance.

There were no displays of information for people using the services about how to make a complaint if they were dissatisfied. The majority of women and their families we spoke with did not know how to make a complaint.

Medical care (including older people’s care)

Requires improvement

Updated 18 May 2017

We found:

  • There were shortages in permanent consultant staffing, particularly on Bedwell Acute Medical Service (BAMS) and in the department of medicine for the elderly (DME). Data provided by the trust showed the actual number of consultants in these specialities was consistently below the planned number from December 2016 to February 2017. The trust provided information showing that vacant posts were covered by agency doctors, however medical staff told us that agency cover was not consistently available and we saw gaps in the BAMS consultant staffing rota.
  • Thirteen out of the 28 staff we spoke to expressed concerns about timely consultant review and discharge of patients due to staffing shortages.
  • There was a shortage of junior doctor staffing on BAMS. At the time of our inspection the planned number of junior doctors for BAMS was four and the actual number of junior doctors was two.
  • Five out of nine medical staff we spoke to expressed concerns around the organisation and management of the junior doctor rota. They described it as ‘poorly organised’ and ‘too complex’. Staff told us there could be gaps in daytime medical staffing due to the organisation of on-call duties for medical staff.
  • There were shortages in nursing staffing across the medicine service due to unfilled vacancies. The whole time equivalent (WTE) establishment for registered nursing staff in the medical service in January 2017 was 374.5 and the number of nursing staff in post was 298.9. There were 75.6 WTE vacancies.
  • We saw that the ratio of nurses to patients on Paglesham ward was 1:13. This was not in line with the Royal College of Nursing recommendations of one nurse providing care for no more than eight patients.
  • Staff compliance with mandatory training was variable. On BAMS, staff compliance with mandatory training was 68%, which was lower than the trust target of 85%.
  • Staff compliance with safeguarding training was variable. Compliance with adult safeguarding training level one and two was below the trust target on BAMS. Compliance with child safeguarding training level one and two was below the trust target in three clinical areas we visited.
  • Staff compliance with sepsis training was highly variable. Training records dated 2 November 2016 showed compliance with sepsis training ranged from 26% on BAMS to 92% on the respiratory unit.
  • The process for in-reach to BAMS from speciality medical teams was inconsistent. Two members of staff on BAMS told us that some medical speciality teams found in-reach difficult due to staffing and workload.
  • There was a high number of medical outliers. From November 2016 to January 2017, the number of outliers on medical wards ranged from 117 to 203 per month. The number of medical outliers on surgical wards ranged from 171 to 429 per month in this period. There was concern about the medical review of medical patients on other non-medical wards. Records showed that not all received a daily medical review. Staff also expressed concerns about this and stated that they felt that there was a shortage of medical consultants.
  • There was a high number of bed moves after 10pm for patients in the medical service. From August 2016 to January 2017, data showed that there was an average of 352 bed moves after 10pm, per month.
  • Two senior staff on Benfleet ward told us that one bay on the ward was used as a hyper acute stroke unit (HASU) and that this bay would often have male and female patients accommodated together. However, this bay was not categorised as a HASU by the trust and should not have accommodated male and female patients in the same bay. On the days of our inspection, this bay was not used as a mixed sex bay.
  • Staff identified difficulties in communication between different speciality teams. One junior doctor told us about difficulties in communication between medical teams in the emergency department and BAMS. Two consultants told us there could be “friction” between different specialities and spoke of a “silo culture” which could cause difficulties when agreeing where junior doctors spent their time.

However:

  • All staff had a good understanding of incident reporting procedures and received feedback on incidents reported.
  • Senior managers completed detailed investigations into serious incidents and shared this learning with staff throughout the medical service.
  • Clinical areas were visibly clean. Staff were compliant with bare below the elbows practices and we saw staff completing hand hygiene appropriately. Results of a trust audit of personal protective equipment dated January 2017, showed positive results.
  • Staff stored medicines securely and completed twice daily checks of controlled drugs (CDs) to ensure that all stock was monitored and accounted for.
  • Patient records were stored securely in lockable trolleys in staff areas.

  • Staff understood their responsibilities regarding safeguarding adults and children. We asked six members of staff about safeguarding and all of them were able to tell us how they would report a safeguarding concern and what they would report.
  • There was a stroke emergency phone, which provided direct contact between the emergency department and the stroke ward. This meant that the stroke consultant could be immediately alerted to any patient presenting with signs of a stroke in the emergency department. The ward manager on Benfleet ward told us the early review and transfer of patients admitted with signs of stroke worked well.
  • The average referral to treatment time for admitted patients in the medical service from January 2016 to January 2017 was 98%.
  • Staff worked together to meet patients’ individual needs. Staff gave us examples of coordinating care to meet the needs of patients with learning disabilities and told us about actions they took to improve the experience of patients living with dementia.
  • There were clear processes for sharing information with staff in the medical service. Senior staff shared information with staff through team meetings, information noticeboards and through the trust ‘weekly roundup’ newsletter.
  • There was a positive culture within speciality teams on medical wards. Nursing staff described positive working relations with medical staff in their speciality. Junior doctors described consultants as supportive and approachable.

Urgent and emergency services (A&E)

Good

Updated 18 May 2017

We found:

  • The emergency department (ED) staff raised concerns about the ability to lock down the major trauma and resus areas efficiently in an emergency. The security of the department was on the ED risk register.
  • There was no controlled access on any of the adult ED areas. This meant the department was not safe from a security or major incident perspective, as anyone could enter the department at any time. We noted on several occasions patients and visitors entering the department who were lost or looking for other departments.
  • At the time of our inspection, data supplied by the trust showed staff achieved 80% compliance with safeguarding adults’ level one training and 73% with level two. Staff achieved 92% compliance with child safeguarding level one, 88% compliance with level two, and 75% compliance with level three.
  • At the time of our inspection, data supplied by the trust showed overall staff compliance with mandatory training was 77% and 84% with local induction.
  • Blunt abdominal trauma (BAT) is a common reason for patients attending ED. Focused assessment with sonography for trauma (FAST), is a valuable diagnostic that can often facilitate a timely diagnosis for patients with BAT. FAST was not always available in the ED. This issue was on the ED risk register due to concerns regarding the ability to diagnose life-threatening conditions quickly.
  • Between February 2016 and January 2017, the trust declared 2,418 black breaches. These were most prevalent between September 2016 and December 2016, ranging between 248 and 349 per month respectively. Black breaches are occasions where handovers from ambulance arrival to offloading the patient to the ED took longer than 60 minutes.
  • The Department of Health’s standard for emergency departments is that 95% of patients should be admitted, transferred, or discharged within four hours of arrival in the ED. Data supplied by the trust showed that in November 2016, the trust achieved 77%. The trust achieved 73.1% in December 2016, and 81.4% in January 2017, all below the 95% target. However, during our inspection we observed the trust achieving 100% on the 10 February 2017, 98.4% on the 9 February 2017, and a reported 93.1% on 8 February 2017.
  • Data supplied by the trust showed the percentage of patients waiting between four, and 12 hours from the decision to admit, until being admitted was 1.7% in November 2016, 1.5% in December 2016, and 0.8% in January 2017. This was lower than the England average, which ranged between 12% and 9% for the same period and showed an improvement in performance by the trust over the three-month period.
  • Staff raised concerns regarding access to mental health services for children entering the department. Staff gave examples of children waiting for extended periods for assessment and support, often overnight, due to the restricted access to specialist mental health support.
  • Staff we spoke with said that the senior management team lacked visibility in the department, even during exceptionally busy periods or significant times of need.
  • Since our last inspection, issues remained regarding collaboration with other specialities within the hospital.

However:

  • Staff knew how to report incidents and deal with complaints and there was a learning culture within the ED.
  • Since our last inspection, the trust had installed a controlled access system in the paediatrics area to restrict any unauthorised access to clinical areas.
  • We found that overall medicines were stored securely. Controlled Drugs were stored following safe and good guidance procedures.
  • There were clear procedures for managing and referring safeguarding concerns in relation to children and adults who may be at risk of abuse. Staff we spoke with knew how to make a referral and who to refer their concerns to within the trust.
  • We reviewed 18 patient records and found all risk assessments were completed, allergies, national early warning scores (NEWS) and paediatric early warning scores (PEWS) were all clearly documented.
  • At the time of our inspection, we found no significant concerns regarding staffing the ED, the trust took appropriate action to cover any shortfalls and recruitment was proactive and ongoing to fill any unfilled posts.
  • There were several established systems to ensure good clinical governance and monitor performance, clinical governance, mortality, and morbidity and infection control.
  • The ED had a specific risk register for its service. Senior staff monitor the risks identified, and take appropriate action to mitigate any impact on patients and staff.
  • The ED had a clear management structure and there was good leadership.
  • Staff spoke very highly of the leadership and management provided by the clinical lead, associate director, and matrons and said they were approachable, and listened to their concerns.

Surgery

Good

Updated 18 May 2017

We found:

  • Nursing teams were regularly short staffed. Data provided by the hospital showed that planned versus actual staffing had dropped from 100% across the service in November 2016. We saw that in January 2017 Chalkwell surgical assessment unit (SAU) had 93.4% of their staff number of registered nurses at night and Shopland ward had 80.6% of registered nurses during the day shift. Shortfalls were covered by bank and agency staff where possible. Staff would also be allocated from other wards. Three senior nurses told us that this impacted the skill mix on the wards and that on occasion shifts would not be covered.

  • Three surgical wards we visited did not have a ward based pharmacist which meant that patient medicines were not reviewed by a qualified pharmacist. This meant that there was no oversite of medications management and could lead to medication errors.
  • There were a large number of medical outlier patients on surgical wards. In January 2017 there were 429 medical outliers across the surgical wards. Four nurses told us that patients were reviewed late in the day and a member of the surgical ward staff was not always present meaning that updates on the patient’s treatment were not communicated effectively.
  • During the period October to December 2016, 146 operations were cancelled of which 24 patients were not offered another appointment with 28 days.

However:

  • Staff had a good understanding of incident reporting procedures and received feedback on incidents reported.
  • Senior managers had completed detailed investigations into the recent never events and shared this learning with staff through team meetings, noticeboards and the ‘weekly roundup’ newsletter.
  • Theatre had established five extra Saturday all day theatre lists to help manage waiting lists. These lists were flexible and could be utilised by each speciality. The emergency service ambulatory care service had been established on Chalkwell ward to support the surgical assessment unit to help prevent unnecessary admissions.
  • Leaders were visible and approachable. There were opportunities for leaders to engage with staff at ward level and listen to their concerns.
  • Staff described positive working relations within their speciality teams and across the hospital as a whole.
  • Junior doctors were positive about the support they received from consultants.
  • Consultants we spoke with confirmed a positive culture of interdisciplinary working. There was regular internal multi- disciplinary team working with all teams supportive to provide the best outcome for their patients.

Intensive/critical care

Good

Updated 2 August 2016

Effective processes were in place to learn from incidents and staff used learning from incidents and complaints to improve their practice and deliver safer, more effective care. The environment was clean and staff followed infection control procedures. Medicines, including controlled drugs, were safely and securely stored.

Medical and nursing staffing numbers did not always follow guidelines laid down in the Core Standards for Intensive Care Units.

Patients received treatment and care according to national guidelines and best practice. We saw effective multi-disciplinary team working across the units, with good consultant input. Junior doctors were adequately supported to provide safe treatment and assessment. Physiotherapists, dieticians, microbiologists and pharmacists were highly spoken of by CCU staff and were available when needed.

Without exception, staff were complimentary about the leadership on the unit. Managers on CCU and ARCU demonstrated commitment to patient care, delivering a positive patient experience, developing and caring for their staff, robust governance and effective strategic planning.

Services for children & young people

Requires improvement

Updated 2 August 2016

Overall, we rated Children’s and Young People’s services at Southend require improvement.

We rated safe as requires improvement for a number of reasons including: poor documentation of patient notes, observation of poor hand sanitisation on entering and exiting the children’s ward, and poor hygiene maintenance in patient and parent’s bathrooms on the Neptune ward, robustness of incident reporting, the robustness of consent discussion and recording, and awareness of the Gillick competence as these were not audited on the ward. From our review of notes and information regarding gaining of consent there was no evidence that all staff were fully aware of the trust procedure. The children’s ward had no dedicated pharmacy cover including for controlled and cancer drugs. There were waiting lists for electroencephalogram (EEG) tests which record electrical activity produced by the brain and Autism Spectrum Disorder ASD appointments. There were concerns about adults staying on the children’s ward and the security risk this posed. Additionally, there were concerns about children receiving surgery on adults’ wards and whether staff competency levels on those wards were sufficient to deal with a paediatric medical emergency.

We rated effective as requires improvement because there was low compliance with the service own audit plan, which meant opportunities to improve were lost. We saw that the diabetic audit action plan had not been completed. Also, only 53% of children had received their antibiotics within the nationally prescribed one hour.

We rated caring as ‘good’ because the friends and family rating for December 2015 returned a positive response rate of 83% and positive parent and family feedback had been received for both paediatric outpatients and the Neptune children’s ward. There were good supportive systems in place for parents or carers dealing with the bereavement of a child, and volunteer members of staff organised provision of memory boxes in such instances which could contain objects to remind parents of positive experiences they had shared with their child.

We rated responsive as ‘good’ as the service had designed orientation sessions for children before attending hospitals for procedures to aid with alleviating any anxieties they may have had. Dermatology services had previously been provided off-site and had been relocated so children could be treated within a familiar environment. However, there was an issue with patient waiting lists where clinic appointment had been cancelled due to staff annual leave as this could in some cases add an additional six month wait for a follow up appointment for a child.

We rated well-led as requires improvement because local governance needed to be improved in relation to incident management. The leadership had failed to recognise the importance of this group of staff being part of any major incident response and as such ensure training was offered. There was an inconsistent approach to the cancellations of clinics, which increased the risk to those attending.

End of life care

Requires improvement

Updated 2 August 2016

We found the safety of end of life care service (EoLC) required improvement. The mortuary facilities were not secure and installations and equipment were worn out and unreliable. Not all wards looking after end of life patients were fully staffed and there were not enough EoLC consultants working for the trust. However, we also found incidents were reported and learned from, medicines were properly managed and hygiene practices were good.

The effectiveness of the EoLC service was good. Care and treatment followed national guidelines within individualised care plans for patients. This included pain relief and staff were competent. The trust monitored its own effectiveness with clinical audits and compared its performance with other trusts nationally. However, we also found the EoLC specialist service was not available seven days a week and Southend Hospital did not have seven day clinical nurse specialist cover. Specialist consultants were available only on call across the county ‘out of hours’.

We found EoLC services were caring. Relatives and friends of patients spoke very highly about staff at all levels in the service. Patient’s privacy and dignity was respected including after death. Staff gave relatives and friends of dying patients support and help. However, we also saw nurses and doctors were not good at finding out what patient’s spiritual needs were to prepare for dying.

We found responsiveness of EoLC services required improvement. The trust was not achieving preferred place of care for many end of life patients or able to discharge most of them within 24 hours when requested. The age and condition of the mortuary facilities had a knock on effect on the flow of the service and were often full to capacity. Some beds in the specialist wards were regularly used to care for patients not needing palliative or EoLC when the hospital was under pressure and this created risks. However, we also saw there was a specialist palliative care team available to help nurses and doctors and a weekly outpatient’s clinic. Most patients were contacted within 24 hours of being referred and there was a new bereavement suite in the hospital where relatives/friends could register a patient’s death.

Leadership of EoLC services required improvement. The short coming in the mortuary related to security, equipment replacement and lack of space which impacted on the service.  We also found the trust didn’t meet all the key signs of a good quality organisation in a national 2015 audit and not all risks and necessary improvements it identified itself were dealt with quickly enough.

Outpatients

Requires improvement

Updated 2 August 2016

We have rated this service as requires improvement for safe. This is because incident learning at directorate level was not well embedded; there were delays in patient follow up which had resulted in patient harm. The WHO check list was not embedded within diagnostic imaging and several pieces of diagnostic imagining equipment were listed as past their replacement dates. However we also saw that departments were clean, sufficient equipment was available to the staff and patient records were well maintained.

Effective was inspected but not rated; we found that multidisciplinary working was evident throughout the departments with excellent interaction from therapies staff. Staff training and re-validation were effective, as were supervision and appraisal systems. There was a good understanding of consent, Mental Capacity Act and Deprivation of Liberty Safeguards. Sonographers were becoming deskilled in anomaly scans which in turn were adversely affecting recruitment.

We have rated this service as good for caring. Feedback from patients and relatives was positive about the way staff treated people. Interactions between staff and patients were kind and friendly. Patients and their carers’ were involved and informed and complimentary about their experiences with staff at all levels, they felt staff took time to explain complex information in a way they could understand.

Responsive required improvement; there were significant access and flow issues in ophthalmology and respiratory services and there were no paediatric facilities within diagnostic imaging. However we also saw that the trust had good partnership working and excellent multidisciplinary team working. Learning from complaints was evident and the trust supported individuals with learning disabilities and dementia.

Well led required improvement; there were significant delays in follow up patient appointments in two specialities, these delays due to miss management had resulted in patient harm.  Joint meetings across all outpatients department and diagnostic imaging were not held therefore shared learning was lost.  Many items of diagnostic imaging equipment were significantly out of date; there was not a robust plan in place to address this. However we also saw that staff we spoke to were aware of the trusts vision statement and understood their role within the organisation.  There was good staff moral despite staff shortages in diagnostic imaging and staff felt valued and innovation was evident.