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Southend University Hospital Requires improvement

Reports


Inspection carried out on 9 and 10 February 2017

During an inspection to make sure that the improvements required had been made

Southend University Hospital NHS FT is part of the Essex 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.

We undertook a short announced focused inspection at Southend Hospital on 9 and 10 February 2017 in response to concerns raised to CQC. We found that the trust is under significant capacity pressures and all the risks we saw were known to the senior management team. Actions were in place to deal with most of these issues. We have not rated this inspection in line with our current guidance. However, we will return to Southend Hospital to review actions taken in line with the current improvement plan and the issues raised within the report.

We found:

  • There were shortages of medical and nursing staff but that the trust was managing the risks associated with these shortages. However, continued focus needs to be kept on ensuring that the service has sufficient staff to ensure patient safety.
  • Mandatory and safeguarding training was not always undertaken in line with the trusts target.
  • Staff had a good understanding of incident reporting procedures and received feedback on incidents reported.
  • 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.
  • Leaders were visible and approachable. There were opportunities for leaders to engage with staff at ward level and listen to their concerns.
  • Some wards reported issues with outliers being seen by the correct team. I am aware that there is a buddying system being discussed and this will assist this issue.
  • There were no named pharmacists for surgery. Reconciliation of medicines was not done in a timely manner. An example was found that in February only 10% of admissions had had their medication reconciled within 24 hours.
  • The stroke unit staff were unclear if they still operated as a HASU. They told inspectors that they did at times. Senior staff told us that there was no HASU.
  • At times in the stroke ward nurse to patient ratios was 13:1 and in Benfleet the ratio was 3 to 4: 25 patients.
  • There was conflicting information about the BAMS unit medical staffing. We were told by staff that they had put forward a plan for changes but that these had been dismissed. However the medical director appeared unaware of this plan during his interview.
  • There are challenges within the consultant body which impact upon the patient experience and capacity of the hospital. There was little evidence of a plan in place to address these. However impacts were seen through the lack of specialist nurse and capacity issues within outpatients.
  • There were concerns around the extension to SAU which was behind doors so sight of these patients was limited. We also found that there were approximately 12 patients to one toilet in this area.
  • There was a disconnect between the senior management team and the workforce and a lack of appetite to change. Staff felt that they were not always supported to change and that change took a long time.
  • There were several established systems to ensure good clinical governance and monitor performance, clinical governance, mortality, and morbidity and infection control.
  • Patient record keeping was of a very good standard, allergies, national early warning scores (NEWS) and paediatric early warning scores (PEWS) were all clearly documented within the Emergency Department.

We saw several areas of outstanding practice including:

  • There was a stroke emergency phone, which provided direct contact between the emergency department and the stroke ward.
  • Surgeons are undertaking innovative surgery for stroke patients during which they remove the blood clot to ease pressure on the brain. This reduces the symptoms that stoke patients’ experience.
  • Ambulatory wound unit on Balmoral ward taking referrals from community, podiatry, GP’s as well as wound care for discharged patients. Focused on early intervention and admission avoidance.
  • The musculoskeletal team had created a Trauma Assessment Centre (TAC) within the ED as an extension of the fracture clinic, where patients were streamed directly to be seen for treatment.

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

Importantly, the trust should:

  • The hospital should ensure there are sufficient numbers of suitably qualified, competent, skilled and experienced consultant medical staff to meet the needs of patients in the medical service.

  • The hospital should ensure there are sufficient numbers of suitably qualified, competent, skilled and experienced junior medical staff available on BAMS to meet the needs of patients.

  • The hospital should ensure there are sufficient numbers of suitably qualified competent, skilled and experienced nursing staff available in the medical and surgical services to meet the needs of patients.

  • The hospital should ensure that there are processes in place to make sure that medical outliers are reviewed by their speciality team in a timely way.

  • The hospital should ensure that staff complete mandatory and safeguarding adults and children training in line with trust targets.

  • The hospital should ensure staff are trained in the recognition and management of sepsis to the appropriate level in line with trust targets.

  • The hospital should ensure all fridge temperatures for the storage of medication are recorded and acted upon in line with trust guidance.

  • The hospital should ensure that male and female patients are not accommodated in the same bay on the stroke unit.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on Announced 12-14 January 2016, unannounced 24 January 2016

During a routine inspection

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 carried out on 7 August 2014

During an inspection to make sure that the improvements required had been made

Southend University Hospital is an established 700 bed general hospital and provides a range of services to a local population of some 338,800 in and around Southend and nearby towns. The trust provides a range of acute services including acute medical and surgical specialties, general medicine, general surgery, orthopaedics, ear, nose and throat, ophthalmology, cancer treatments, renal dialysis, obstetrics and gynaecology and children's services. Southend University Hospital is the South Essex surgical centre for uro-oncology and gynae-oncology surgery. The trust achieved Foundation Trust status in 2006.

We inspected this hospital on 7 August 2014 in response to concerns of stakeholders and information of concern received into the CQC. Southend University Hospital NHS Foundation Trust was found to be in significant breach of its terms of Monitor authorisation since 2011-2012 due to their failure to demonstrate that there were appropriate arrangements in place to provide effective leadership and governance. There were also concerns around the trust’s failure to meet cancer and C. Difficile targets.

This was a responsive review undertaken by six inspectors from CQC and two specialist advisors in A&E and governance practices. Only the services within the A&E department and the governance structures at Southend Hospital location were inspected. We have identified that the service was not compliant with some regulations following this inspection. We have not rated the service as this was a focused inspection however a further comprehensive inspection will be undertaken in the future to determine ratings of all services within the trust.

Prior to the CQC on-site inspection, the CQC considered a range of quality indicators captured through our intelligent monitoring processes. In addition, we sought the views of a range of partners and stakeholders.

The inspection team make an evidenced judgment on five domains to ascertain if services are:

  • Safe
  • Effective
  • Caring
  • Responsive
  • Well-led.

Whilst we noted some good practice there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • Improve its cleaning schedule within the A&E department.
  • Improve the security and storage of medicines within the A&E department.
  • Increase the number of permanent trained nurses, paediatric nurses and consultants within the A&E department.

In addition the trust should:

  • Take prompt action to ensure that the children’s A&E department is in line with national guidance.
  • Review working with the psychiatric liaison services to improve the care provided to patients within the department.
  • Ensure that there are robust systems in place for checking stock to ensure it is in date and safe to use within the A&E department.
  • Review the management and directorate structure which supports A&E to improve clinical excellence.
  • Improve on the overall achievement rate of doctors attending mandatory training.
  • Ensure that all doctors within the A&E department have received children’s safeguarding level 3 training.
  • Review the process for equipment reported as faulty within the service, ensuring it is repaired or replaced in a timely manner.

  • During this inspection we found that the essential standards of quality and safety were not being met in some areas. As a result of our findings we have issued the trust with compliance actions. We have asked the provider to send CQC a report that says what action they are going to take to meet these essential standards.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 16, 17 October 2013

During an inspection to make sure that the improvements required had been made

We carried out this visit to check on improvements made to the service following concerns identified when we last visited the service in May 2013. Overall we found that the required improvements had been achieved in the areas where we visited.

We found that improvements had been made to the arrangements for ensuring that people were treated with respect and involved in making decisions about their treatment. People we spoke with told us that they were treated well, and that they received the care and treatments that they expected. People said that staff treated them with respect, involved them in making decisions about their care and treatment and they received information and explanations in a way that they could understand.

We found improvements in how risks to the health and safety of people were managed. Appropriate safety checks, assessments and observations were carried out and recorded. These practices and procedures were regularly monitored to ensure that the improvements made were sustained.

Staff we spoke with reported that there had been improvements and that they had support from senior colleagues and opportunities for learning and development. Staffing levels and skill mix were regularly monitored and there was an on-going recruitment plan to address staff shortages.

Improvements were on-going to address the issues with premises and to ensure that the quality and safety of the service was monitored and improved.

Inspection carried out on 12, 13, 14, 15 May 2013

During a routine inspection

We carried out this inspection to assess how the hospital was delivering its services to patients to ensure their safety and promote their health and wellbeing.

People we spoke with gave us very mixed views about their experience of care at the hospital. Some people felt they were treated with kindness and told us that they were happy with the care and treatment they received. Others experienced less positive outcomes and told us that staff could be abrupt and uncaring and that they sometimes felt 'forgotten.'

We observed some staff caring and supporting people in a positive way. However, we also witnessed examples of poor engagement of staff and a lack of respect for promoting people's privacy and dignity.

The arrangements for staff training and support varied across the hospital. Some staff reported that they felt well supported and that they had opportunities for training and development. Others told us that they felt less supported and some told us that they felt bullied and harassed at work.

While there were systems in place for monitoring and improving people's safety and experience of care they received at the hospital, these were not always effective as not all staff were fully engaged in the hospital’s objectives and core values. Overall we found that a number of improvements were needed to ensure that effective systems were in place to provide safe, effective, caring and responsive services.

Inspection carried out on 19 October 2012

During a routine inspection

During our visit we spoke with patients in Accident and Emergency and outpatients departments, paediatric, medical and surgical wards and the maternity unit.

Patients told us that they were happy with how staff explained their care and treatment. They told us that everything was explained in a way which they could understand so that they could give their consent to the care and treatment they received.

People told us that they were very satisfied with the care and treatment they received at Southend University Hospital. One patient told us: ‘’Staff are so nice to me they have explained everything, they treat me with respect.”

Patients we spoke with told us that they were involved in planning their discharge from hospital. Patients said that they were given appropriate information and an estimated discharge date to assist them in making arrangements for leaving hospital. One patient and their relative who told us that staff had discussed discharge arrangements with them on the first day the patient was admitted into hospital. The patient required support in a care home. We were told that nursing staff and the hospital based social worker had dealt with this sensitively.

Inspection carried out on 20 March 2012

During a themed inspection looking at Termination of Pregnancy Services

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

Inspection carried out on 17 November 2011

During a routine inspection

Patients we spoke with confirmed they were happy with the care, support and treatment provided. Patients told us that since their admission to hospital they had been treated with respect and dignity and had no areas of concern. Comments included “I am very happy with the care”, “everything has been fine” and “staff have been very respectful”.

Patients who came in for planned routine treatment told us they had received written information regarding their stay in hospital and felt well informed. However those patients who had been admitted as an emergency were not aware of any written information being available, which included how to raise complaints or concerns about service provision.

Although patients were not always provided with information about the ward, they confirmed that staff were able to answer any questions they may have had. They told us that on their admission, the ward had been expecting them but they didn’t remember being given any information about the ward and the services available to them.

Patients told us that they were happy with the care and treatment they received during their stay in hospital. We were told ‘’The care is great’’ and ‘’Medical treatment and attention is superb.’’ Patients also confirmed that nursing and medical staff explained procedures and treatments and were available to answer any questions or queries they had.

One person said that they ‘’Could not fault the care and treatment or the dedication of most staff.’’

Inspection carried out on 12 July 2011

During an inspection in response to concerns

We spoke with patients in five of the six wards we visited and received positive and complimentary comments from everyone.

People described the standard of cleanliness as ‘quite reasonable’, ‘good’, ‘always very clean’, ‘the cleanest ward I’ve been on’ and ‘spotlessly clean’. They also told us that cleaning and bed changing was carried out everyday or ‘more if necessary’.

People consistently told us that nursing staff were very conscientious about washing their hands, using gel hand rub and putting on gloves and aprons before they provided any care.

Inspection carried out on 12 October 2010

During an inspection to make sure that the improvements required had been made

This section was not completed for this inspection. More information about what we found during the inspection is available in the report below.