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Provider: Basildon and Thurrock University Hospitals NHS Foundation Trust Good

Inspection Summary


Overall summary & rating

Good

Updated 15 July 2016

Basildon and Thurrock University Hospitals NHS Foundation Trust serves a population of around 405,000 in south west Essex covering Basildon and Thurrock, together with parts of Brentwood and Castle Point. The trust also provides services across south Essex. The trust provides an extensive range of acute medical services at Basildon University Hospital, which includes The Essex Cardiothoracic Centre and Orsett Hospital as well as x-ray and blood testing facilities at the St Andrew's Centre in Billericay. The trust employs more than 4,000 staff and has more than 10,000 public members. The trust became one of the first 10 NHS foundation trusts in April 2004.

The trust was placed into special measures following reviews by Sir Bruce Keogh June 2013 following concerns around quality of care and high mortality. The Care Quality Commission undertook a comprehensive inspection of the trust in March 2014 and rated the trust as Good. Following this inspection the Commission recommended to Monitor that the trust could come out of special measures.

We returned to inspect on 17th and 18th March 2015 and inspected those key questions where the service had been rated as requiring improvement which are reported in a separate report. We did not undertake a full comprehensive inspection. We undertook an inspection of the critical care service during this inspection due to concerns received about the leadership and responsiveness of the service.

In 2014 we inspected Basildon University Hospital and found significant improvements to the care delivered to the population. We found very good care in most of the services we inspected. We saw some very good examples of care and treatment in maternity and children’s services. When we returned in 2015, we saw that significant changes had been implemented across the medical care and surgery services and several areas of improvements, particularly on the management of medicines; overall we rated these services as good. We inspected critical care services and found this service has concerns relating safety with staffing shortages in the outreach team, responsiveness on patient pathways and leadership. The rating for this service overall has changed from ‘Good’ to ‘Requires Improvement’.

Ratings in A&E, Medicine and Surgery improved from requires improvement to good and the overall rating for Basildon University Hospital remains as Good. In 2014 we were not rating the effectiveness of urgent and emergency services. In 2015 we have now rated this as Good. Whilst the critical care service was rated requires improvement in terms of safety, effectiveness, leadership and responsiveness the aggregated rating for the hospital remains as good.

We undertook a responsive inspection to the critical care unit in March 2015 in response to concerns relating to safety with staffing shortages within the critical care outreach team, areas for improvement within the effectiveness of the service, responsiveness on patient pathways and the pace at which change had been implemented. Subsequently the rating for this service overall changed from ‘Good’ to ‘Requires Improvement’.

We returned to inspect on 16th February 2016 and inspected all the key questions in the critical care service with a view to providing a new rating. We did not undertake a full comprehensive inspection of the trust, this inspection focused solely on the general critical care unit. We found that the service had made significant improvement in the delivery of the service which we have detailed through this report, and we have changed the rating of the service to ‘Good’.

Our key findings from 2015 were as follows:

  • Within the A&E service improvements were noted in the waiting area with patients being routinely observed and monitored for signs of changing or deteriorating conditions. However we identified that the protocol for patients to be admitted to the CDU was not being adhered to at the time of the inspection as the trust was on black alert and nurse staffing levels were not appropriate.
  • The streaming process within A&E was now embedded and working effectively as a pathway for patients through the department.
  • Medicines management in all areas inspected had improved significantly and was safer for patients, though improvements in the recording of medicines administration was still required on Osler Ward.
  • We noted significant improvements in the care provided to patients in surgery. Patients’ privacy and dignity was respected and patients spoken to all felt well cared for.
  • The critical care outreach team had been depleted through maternity leave and resignation and the trust had commissioned a review prior to our inspection.
  • There were also significant delays on occasions in discharging patients from critical care unit which impacted on the responsiveness of the service.
  • The pace of change within the critical care, although improving, required further work to ensure that patients receive a timely service.
  • Patient outcomes as recorded by the Intensive Care National Audit and Research Centre were poor in four out of the seven areas reviewed.

Our key findings from Critical Care in 2016 were as follows:

  • There were significant improvements made to how safe, effective, responsive and well led the service was since our last inspection in March 2015.

  • Staffing levels for nursing, medical and therapies staff had improved and were at a safe level.

  • The mortality ratio for the unit has reduced significantly since our last inspection where it was 1.8 and is now 1.0 on the ICNARC SMR and 0.83 on the APACHE model.

  • The critical care unit acquired infection in the blood rates per 100 admissions was consistently in line with or better than the England average of four.

  • The critical care unit does not currently meet the core standard of 50% of registered nurses having a recognised critical care course with 27% of nursing staff who had completed their certificate in critical care, however a number of staff were currently on the course and the rates by the end of the year were expected to reach over 50%.

  • We observed good use of mental capacity assessments and deprivation of liberty safeguards during the inspection.

  • The completion of DNACPR forms has significantly improved since the previous inspection with a greater awareness of what is required of the medical staff with regards to DNACPR.

  • There had been notable improvements in the leadership of the critical care and outreach service.

  • Morale and culture within the critical care and outreach service had improved significantly since our previous inspection.

We identified the following areas of outstanding practice:

  • We found the innovation around development of medical staff in the A&E service with career progression to consultant level to be a very innovative response to a national shortage of emergency department medical staff.
  • The preparedness of staff for major or emergency incidents in the medical care areas was outstanding. Staff were very aware of their responsibilities and were engaged with the trust’s processes.

We identified the following areas of poor practice in 2015 where the trust needs to make improvements:

The trust should:

  • Improve the management of medicines across the medical care directorate. There is a particular need to improve the recording of medicines administration and storage and prescription of oxygen.
  • Improve the governance from the top at executive level to the local wards and departments and ensure that risk assessments and service plans are available to staff providing direct patient care in escalation areas.
  • Continue to work and improve on the skill mix and staffing levels throughout the hospital particularly in the critical care service.
  • Review staffing and management structures for the critical care outreach service to ensure that an appropriate number of outreach staff are on duty for each shift.

Following our 2016 inspection we found that the trust should:

  • Improve the mandatory training rates for the critical care outreach team.

  • Ensure all staff receive updated equipment competency training.

  • Reduce the delayed discharges over four hours from the critical care unit to the main wards.

  • Reduce the number of transfers out of hours between 10pm and 7am.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Good

Updated 15 July 2016

In 2016 we found that critical care services were safe because there was a positive incident reporting and learning culture within the critical care unit. Staffing levels for nursing, medical and therapies staff had improved and were at a safe level. The change to the rating for critical care has provided the trust with an overall rating of 'Good' for safety.

In 2015 we found that the A&E service had made improvements in how it streamed patients in the A&E department and also improved on how it ensured that patients in the waiting room were clinically monitored and safely cared for. However we identified new concerns regarding the Clinical Decision Unit (CDU). We found that there were not enough registered nurses to provide safe care in the CDU. The CDU admission protocol was not followed as the trust were on black alert .

Staffing levels across the medical care and surgery services were safe with the trust continually focusing on recruitment and safe staffing numbers. This is an area where improvements have been sustained since our last inspection. However we found that there were concerns regarding recruitment and retention of staff on the critical care service and work was needed in this area. The critical care outreach team was particularly low on capacity however the trust were undertaking a review to ensure that all patients requiring this support received it in a timely manner.

At the last inspection the trust was issued a compliance action around the management of medicines, particularly in medical care. In 2015 we reviewed the management of medicines across medical care, surgery services and A&E services and found that significant improvements had been made though some improvements in the recording of medicines administration was still required.

We reviewed the learning from serious incidents across the medical care and surgery service following a recent never event and found that there was clear learning amongst staff and teams in each area to learn from incidents that had occurred.

Effective

Good

Updated 15 July 2016

In 2016 critical care services were effective.  Treatment and care was delivered in accordance with best practice and recognised national guidelines (ICNARC) NICE and care bundles.

In 2015 we did not look at the effectiveness of services across the trust as data we held suggested that what we had found in 2014 was still in place. The exception to this was within the critical care unit where we found that the effectiveness of the service needed to be improved as appropriate care bundles were not always in place or utilised. Compliance with care bundles is monitored monthly however further compliance in respect of antimicrobial care bundle is required to improve the service received by patients. The number of staff having undertaken appropriate training in the critical care area was not in line with national guidance. However the trust had mitigated this to some degree by putting in place a competency framework for nursing staff. Assessment of pain scores was not recorded as part of the deteriorating patient assessment. We found that the communication between medical staff required improvement to ensure the best outcome for the patient. We found that DNACPR decisions were increasingly undertaken with patients or their nearest family although some further work was required to ensure that this was embedded and enacted for every patient.

The aggregation of the evidence within the trusts services demonstrates a high level of compliance with national guidance and outcomes for patients therefore we have rated this domain to good at a trust wide level.

Caring

Good

Updated 15 July 2016

In 2016 we found that critical care services were caring.  Feedback from people using the service including patients and their families was very positive. 

In 2014 we saw some examples of situations staff could have managed better. We saw patients were not spoken with during a ward round and we saw two patients were waiting for pain relief for over half an hour. These examples were in the minority and staff acted promptly when we highlighted the situation to them. Other patients were referred to as ‘feeders’  this did not promote their dignity. In 2015 we found that patients were cared for with dignity and respect. Patients were no longer referred to as ‘feeders’ and improvements towards treating patients as people had improved significantly in the surgery service.

People who spoke with us about their care all told us staff were caring and listened to them. We saw very good examples of caring and innovative practice that meant people were cared for. The team caring for maternity services had been commended on the compassionate care they provided. The children’s and young people’s team were recognised for supporting children to stay in touch with their families whilst they were in hospital.

We found that patients were treated with respect and dignity at the end of their lives and relatives were supported by the bereavement and mortuary staff.

Patients were offered ‘comfort rounds’ on all the wards we visited. This meant people were given drinks, food and snacks on a regular basis.

Responsive

Good

Updated 15 July 2016

In 2016 we found that critical care services were now responsive to patient’s needs.  Whilst the number of delayed discharges and out of hours transfers remained high there were improvements in these areas, however more work was required to improve this further.  The critical care outreach team provided support to patients on the wards where higher dependency care was required, avoiding critical care admissions. The process for the investigation and learning from complaints had improved since our previous inspection.

In 2015 we found that the trust had continued with its work to improve the service and increased working with local stakeholders and health and social care partners to improve care between the acute and community setting.

We reviewed the critical care service as part of this inspection following receipt of concerns related to the service responsiveness. The trust had the worst out of hours discharge of patients from the critical care unit. People frequently were not able to access services in a timely way for treatment. Patients were kept waiting on the ward above four hours for admission to the unit as there was limited capacity. Patient and relative feedback was generally positive however we heard from two complainants who felt that they were not taken seriously. The staff escalated these complaints and the trust senior team has offered to work with one of these complainants to improve services.

However the trust understood the needs of the local community it served and the impact upon the service they provided. They had worked with commissioners, GPs and other providers to ensure that pathways of care were in place to meet patients’ needs. This included a better streamlined system for A&E enabling patients to be seen quicker. The trust hospital supported vulnerable patients well to ensure care was delivered in their best interests. Staff had a good understanding of the Mental Capacity Act 2005 and knew how to support patients that could not make decisions because of a lack of capacity. The trust had worked collaboratively with the Royal College of Nursing to bring about improvements in the way it cares for people living with dementia.

Services were also in place to support people with a learning disability during their stay in the hospital. The trust had taken action to improve the way that complaints were handled. A complaints review panel identified and shared wider lessons from complaints. Changes had been made to processes and procedures following complaints and improvements in the timeliness of responses were seen.

Well-led

Good

Updated 15 July 2016

In 2016 critical care services were well-led locally.  There was a clear vision and strategy for the service. There was good evidence of ward to board leadership, communication and governance regarding the service. There had been notable improvements in the leadership of the critical care and outreach service. Morale and culture within the critical care and outreach service had improved significantly since our previous inspection.

In 2015 our overall judgment of the leadership teams remains unchanged. The trust was well-led by a strong, visible and respected leadership team. The leadership and management of the trust had a clear vision and a credible strategy to deliver high quality care to patients. The trust’s vision is to have ‘care and compassion at the heart of everything we do’. All of the staff we spoke with on the wards or in the focus groups understood this. Many of the staff told us about the executive team with enthusiasm and respect. Staff told us the executive were highly visible and they knew the staff on the wards.

Whilst the leadership of the critical care unit was judged to require improvement as there were a number of outstanding areas which the leadership team needed to address to improve the service. A management consultant had begun to work with the team to improve the leadership in this area.

Staff felt encouraged to speak up, raise concerns and be involved the trust they worked in. Communication from the Board to the ward had changed significantly, with staff feeling they could contact any member of the senior management team at any time.

Staff were supported by their peers and managers to deliver good care and to support one another. Staff said they felt proud to work at the trust, and were included and consulted about plans and strategies. The trust identified areas where improvements could be made, and organised work-groups and experienced staff to address them. Hence we rated this domain as good overall.