Basildon University Hospital

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of people who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities. This is the first assessment for this service. This assessment did not cover all parts of our Assessment Framework; therefore, we did not rate the service, and we have only given scores for those areas which we have assessed. We will carry out future assessments to cover other parts of the Framework and will update our website with our findings. We found that the service did not always have effective governance arrangements in place. Staff did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. The service was in breach of legal regulations in relation to governance.

We have not awarded this service a score for Well-led.

Find out about when we will not publish a key question score and what we look at when we assess Well-led.

We did not look at Shared direction and culture during this assessment. There is no previous rating for the Well-led key question so we cannot yet publish a score for this area.

We did not look at Capable, compassionate and inclusive leaders during this assessment. There is no previous rating for the Well-led key question so we cannot yet publish a score for this area.

We did not look at Freedom to speak up during this assessment. There is no previous rating for the Well-led key question so we cannot yet publish a score for this area.

We did not look at Workforce equality, diversity and inclusion during this assessment. There is no previous rating for the Well-led key question so we cannot yet publish a score for this area.

The service did not always have effective governance arrangements in place. Staff did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The service did not always have effective systems to manage current and future performance and risks to the quality of the service. The service used a nationally recognised capacity and risk tool, but staff told us capacity escalations at times of high demand were not always acted on effectively by leaders. A review of capacity trackers during our assessment demonstrated that capacity escalations at times of high demand were not always acted on effectively by leaders. leaders acknowledged there had been an increase in demand on the service, which had impacted on safe staffing levels. Leaders reviewed and adjusted staffing levels daily but recognised this was not a long-term solution. Leaders had drawn up a workforce plan, but the trust’s financial position meant there had been a freeze on recruitment.

The service did not always have clear and effective governance arrangements. It was not always clear what action was being taken in response to areas of concern identified during meetings. The completion of actions that had been identified as part of divisional triumvirate meetings was not monitored. There was no evidence of staff meetings for the PED. Information was communicated through other forums such as emails and huddles. However, meetings would have provided an opportunity for staff to discuss and raise any concerns.

The service did not have a systematic programme of clinical and internal audit. We were not provided with evidence of any care records audits or audits of the track and trigger system completed in the PED. There was limited evidence of audits which monitored compliance with national guidance and which monitored patient outcomes. Audits were not always being completed at the frequency set out in the provider policy. It was not always clear what actions had been taken in response to areas of concern identified during the completion of audits.

The service did not always ensure that information was collected, analysed and managed appropriately. A significant amount of information requested as part of our assessment was not provided or available.

We did not look at Partnerships and communities during this assessment. There is no previous rating for the Well-led key question so we cannot yet publish a score for this area.

We did not look at Learning, improvement and innovation during this assessment. There is no previous rating for the Well-led key question so we cannot yet publish a score for this area.