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

At this assessment we rated this key question as inadequate. The service was in breach of legal regulations in relation to assessing, monitor and mitigate the risk to health, safety and welfare of service users. Therefore, we were not assured that that the service leadership, management and governance assured high-quality, person-centred care.

The service had a disjointed leadership team which led to multiple layers of leadership not feeling supported by their managers. Staff felt senior leaders were not visible or supportive creating a culture of distrust and low morale amongst staff. However, staff did feel supported by matrons.

The service did not work effectively with system partners to ensure patient safety and improve the quality of services. The disconnected leadership within the service led to poor communication internally and this was reflected in external meetings. Although meetings took place with partners, these were not effective at highlighting serious overcrowding issues and identifying solutions to improve safety and quality for patients.

Systems to monitor the risk and quality of service delivered were not effective at managing the risk or driving improvements. Risks which had been identified, such as infection control and overcrowding had not been managed to ensure the safety of patients. Audits were not always completed and when they were, results did not always lead to action to improve the safety and quality of the service.

The service did not have a proactive learning culture. We found the service had not implemented improvements from previous CQC assessments or patient feedback despite raising safety concerns. Communication channels to relay information to staff were not always effective and not all staff felt they were involved in decisions to improve the service. We found, staff did not receive feedback on some of our assessment findings and therefore were not able to effectively implement improvements on patient safety concerns.

The service did not always provide an inclusive environment for staff. Staff survey results showed staff in the service had experienced more discrimination than staff in other areas of the trust. There was a significantly lower number of staff with reasonable adjustments in the service compared to the organisational average.

This service scored 36 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. Staff did not understand the challenges and the needs of people and their communities.

Care group 1 which included all the services at Basildon hospital had a strategy document which outlined plans in the next 5 years to deliver high quality local services, equitable access and opportunities for staff. This identified some key areas requiring improvement for the emergency department such as the ambulance offload area and overcrowding but it did not identify or plan to address some of the key safety issues we found, and staff had raised. There was no evidence staff had contributed to the strategy and the plan did not outline how it would engage with system partners.

The organisations values of “excellent”, “compassionate” and “respectful” were posted around the hospital and in the department. Most staff could tell us what these were but told us they couldn’t always deliver the values due to the overcrowding and increasing pressure on them and the service.
We observed a culture in the department of low staff morale and distrust between leaders and staff. Staff described the culture as mixed and one that focussed on ambulance handover which had a detrimental effect on the quality of care. We heard examples of senior leaders placing pressure on junior staff to take more patients into the ambulance handover bay than was deemed safe. Staff told us about an incident where a junior nurse had missed a patient deteriorating in an ambulance because they were so concerned with offloading ambulances because of pressure from senior leaders. However, we did observe matrons trying to support staff to manage this balance.

The NHS staff survey for care group 1 showed, 71% of questions scored at least 3 points below the organisational average, while only 4% scored at least 3 points above the average. Staff feeling valued by the team, being kind to one another, showing appreciation and treating each other with respect all scored at least 3 points below the organisation average. Survey results also showed that only 40% of staff responded positively to the question “I am not planning on leaving this organisation”.

Leaders did not always share essential information and updates with staff. This caused issues because teams were not able to work together to improve patient safety. Following our 18-19 December 2025 visit, the service told us that urgent improvements would be implemented immediately. On 8 January 2025, we spoke to staff at all grades, including senior staff. They were not aware changes had been made, reported they had not received communications and were not aware of updates. This meant changes had not been implemented in practice and patients were still at risk.

Additionally, leaders told us they would carry out a mini audit of 10 sequential 1- hour ambulance offload delays, review the risk of avoidable harm to patients and undertake rapid harm reviews for patients who experienced delays to help determine potential learning and follow up the patient pathways. Leaders advised these audits had been completed. However, staff we spoke with were not aware of the audits or any findings.

In addition, when information was shared with staff, they were not always aware of it. We saw that a safety alert for an update to the current ambulance handover policy was shared, however, staff we spoke to were not aware of the change to the policy and had not seen the safety alert.

The service did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

We found fractured leadership throughout the service. We observed and staff told us that there was a disconnect between the senior nursing leadership, the hospital leadership and the trust executive team.

Services within the trust were divided into care groups. Care group 1 consisted of all the services within Basildon Hospital and services below this were divided into divisions. Division 1 incorporated the emergency department and acute medicine services. There was a senior leadership team which consisted of a Deputy Director of Nursing, Deputy Director of Operations and Clinical Director, supported by a deputy senior management team and then nursing matrons.

Generally, frontline nursing staff spoke highly of the support they received from the nurse in charge of the unit and the matrons. However, staff consistently told us the hospital leadership team were not supportive and did not understand the challenges of the department. Further, we heard from both junior and senior staff that the executive team were not visible or supportive in the department. Staff told us this made the significant challenges and pressures facing the department more difficult to address. We observed this in practice, during our assessment on 17 December 2024, over 200 people attended the department, which was unprecedented and resulted in significant pressure on the department. However, we spoke to staff the next day who told us that no senior leaders or members of the executive team had visited the department to support decision making and moral.

There were 3 matrons who all had key areas of responsibility. We found they were visible during the day and staff knew they could either book an appointment or go to the office to speak to one of the matrons. However, the matrons shift finished at 6pm which meant often when pressure was building in the department, the matrons were not there to provide support and leadership to staff.

There was also a disconnect between what senior leaders thought was happening and what was happening in the department. On Tuesday 17 December, we were told by senior leaders that hot food would be given to patients in the department due to significant waiting times. We found that this was not the case and there was no mechanism for hot food to be delivered. Staff at all levels below hospital management level told us they had raised this several times and it was reflected in the provider’s October and December 2024 patient survey results.

The leadership team was not supporting the department and staff when the number of patients reached a level where people were at risk of not receiving appropriate treatment. No staff could recall seeing senior leaders in the department, including when it was extremely busy. The lack of senior leaders’ presence meant they did not have meaningful understanding of challenges in the department. This also limited the ability for leaders to fully understand staff concerns and act accordingly. The lack of effective oversight put patients at risk and failed to identify risk to patients and staff.

Leaders explained the services were in the middle of a leadership restructure. Some recruitment had been completed and some was in process. The previous postholders remained in place and they were using the previous structure to ensure there were no gaps until the restructure was completed. They planned to have a clinical director in post in January 2025.

People did not always feel they could speak up and that their voice would be heard.

The Freedom to Speak Up Guardian’s (FTSUG) main aims are to protect patient safety and quality of care, improve experiences in the workplace and promote learning and improvement. Staff could use other channels, such as reporting through their line manager, if their concerns fell outside any of these categories.

Whilst staff were not always knowledgeable about who the FTSUG was, they were aware of how to obtain the contact details and how they could be supported. We asked two members of staff if they knew who the FTSUG was and both said they didn’t know, but they knew where to find this information out.

Following our first site visit on 17 and 18 December 2024, the FTSUG had visited the department and had further visits planned. They were now engaging directly with the staff team, to discuss concerns and possible solutions. This meant staff were better listened to and there was a process to escalate concerns, anonymously if needed.

The staff survey showed 61% of staff in the service would feel secure raising concerns about unsafe clinical practice, this was below the organisation average of 65%. However, 52% of staff felt confident the organisation would address concerns about unsafe clinical practice.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The service did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The service had a governance system including current and future performance and risk management. However, these were not always focused on tackling operational challenges in ways that complemented how effective actions could affect the overall success of the service provision.

The emergency department senior clinical leadership team met weekly to review patient safety and performance. This was presented to the hospital senior leadership team and Integrated Care Board leads each week. There was also an executive touch point on Monday mornings to address any issues over the weekend. However, these did not always lead to significant risks in patient safety and quality of care being addressed. Divisional leaders for the emergency department and acute medicine (Division 1A) met monthly to review the performance and risks within the service. However, while some of these risks were identified, the actions implemented did not always keep patients and staff safe. We found despite this governance framework leaders did not often have a realistic and current view of key issues in the emergency department.

Systems to monitor the risk and quality of service delivered were not effective at managing the risk or driving improvements. The risk register for the service dated 20 January 2025 highlighted the top risks in the department were patients presenting with mental illness and emergency department overcrowding. However, not all the actions to reduce the risks had been identified or implemented. For example, during our assessment we highlighted significant concerns over how patients entered the department and the oversight of the waiting room. Staff and patients had raised these concerns, but action had not been taken prior to our assessment. The actions outlined on the risk register mainly focused on updating policies rather than taking action to understand the risk and implement solutions.

Leaders did not take swift action to respond to risk. After a cluster of incidents in November 2023, it was identified that there was a need for improved communication and processes between the emergency department and intensive care unit. A working group was started in early 2024 but was then suspended. At the time of our assessment on Monday 10 March only 1 meeting had been held. We heard the meeting had identified the need to have an up-to-date standard operating procedure which improved the recognition management and escalation of deteriorating patient and improve outcomes, particularly when patient were being managed in resus and majors. We requested meeting minutes, terms of reference and an action log for this meeting but the trust did not provide them.

Information and data were not always available to support decision making and the oversight of performance. Whilst the service had policies and procedures and staff knew how to find these, we found they were not being followed due to the demand on the service and staff. The service did have an audit schedule; however, these were not always carried out due to staffing pressures and action was not always effective at improving safety. For example, the service submitted an audit which showed the compliance with clinical observations being taken on time was between consistently below target (63%-71%) between January and December 2024. However, this had been on the risk register since 2021, with several actions being implemented but no significant improvement. We also found audits of infection control, the environment and equipment did not lead to improvement. This lack of oversight put people and staff at risk and created a risk that resources would not be used as effectively as they could have been, or where patients could otherwise be signposted to.

Data used to monitor the department’s performance was not always accurate. Patients could wait in the department for 1-2 hours before being booked in at reception, but this time was not recorded. This meant that the data on patients’ time of arrival to the department was not accurate and was not reflected in several metrics used to assess the performance of the department. This risk had not been captured despite staff and patient feedback and no action had been taken to address this risk.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

Leaders communicated with system partners, but this was not always effective to identify and implement solutions, particularly in times of extreme pressure. We found the disconnect between leadership levels within the trust impacted the quality of the information shared with external partners.

Each afternoon when there were pressures on capacity, the trust met with system partners such as the Integrated Care Board (ICB), mental health and ambulance service to provide an update on site pressures. We observed one of these meetings on Tuesday 17 December and found there was not effective working to address the significant pressures in the emergency department. Trust staff on the call told us there was no help available from the system. However, senior leaders from the hospital did not highlight the significant demand and pressure or challenge system partners to provide more support despite the department seeing unprecedented numbers of patients. However, we were told that a further meeting would take place later that day with the on-call executive from the trust and the wider system.

Leaders also told us there were significant challenges from the number of mental health patients accessing the emergency department. Whilst they worked closely with the local mental health trust, who had services on the same site, both providers were under pressure and staff told us they did not always work well together. Leaders described occasions where the mental health urgent treatment centre had closed without informing the trust.

The provider had a mechanism for sharing learning with system partners. One example of this was the external alert process where the service could ask system partners to review incidents that relate to their organisation for which the service had detected a potential incident or opportunity for learning. While this process allowed organisations to provide feedback following the external alerts being received or these events may follow their designated investigation processes, any outcome was not shared with the service.

Leaders described trying to work with GP alliance partners but resources across the system were an issue. This impacted particularly in one region, where low GP numbers meant the emergency department became the first path patients would take. We observed several patients in the waiting room who had attended the department with a letter from their GP and thought this was a referral.

The provider was working with other providers and the NHS to resolve support for any patient with mental health support needs. There were policies and procedures that were followed for working with others including, physiotherapy, designated frailty teams, occupational therapy, reablement and social care teams.

Leaders also told us there were significant challenges from the number of mental health patients accessing the emergency department. They worked closely with the local mental health trust, who had services on the same site, but they were also challenged. Following a serious incident with a mental health patient the provider had completed work on ligature assessments across the trust and were exploring recruiting their own registered mental health nurse bank to provide additional support to staff and mental health patients.

The trust had held risk summits with the Integrated Care Board and local mental health trust to try and identify improvements. The trust had commissioned a review of its support for people with mental health needs. This was currently at draft stage and the final version was due in January 2025.

As part of the provider’s winter planning and delivery, a ‘flow and discharge cell’ had been created in early November 2024 with representatives from system partners and community collaborative to support patient flow in transitioning discharges from acute sites into out of hospital community and mental health bed capacity. As a result of this the length of stay for patients awaiting reablement to return home had improved. A community collaborative is a partnership between primary care, community health services, community mental health services, social care and the community and voluntary sector. It aimed to provide better joined up health and care services in local neighbourhoods and aimed to make it easier for people to access the care they need, when and where they need it and by the right person. It will also enable people to stay well for longer and more independently, in their own homes.

The service did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

Leaders told us learning, improvement and innovation were a priority, however, we found missed opportunities to learn and improve services for patients, including serious safety and quality concerns.

Whilst there were processes about ensuring learning happened when things went wrong, we found either limited amount of learning or a lack of embedded procedures. For example, the practice education team had recently delivered hydration refresher training as hydration risk assessments were identified as needing improvement on audits. However, when we completed our assessment, this was still a key issue for patients. Therefore, we could not see that learning had been effective and this had not been recognised by leaders.

We also found the leadership team had not used learning from patient and staff feedback to improve services. The friends and family test survey, urgent and emergency care survey and the staff survey raised significant concerns in specific areas. However, we did not see any of these concerns had been addressed to have a positive impact on patient care, for example provision of food, cleanliness or queuing.

Leaders did not always encourage reflection and collective problem-solving. The staff survey results for division 1 (emergency department and acute medicine) showed the service scored 3 points lower for being able to make suggestions to improve the work of team or department (25.4% against an organisation average of 44.5%). The service also scored lower 3 points lower for deciding changes which affect my work and the ability to make improvements happen in my area. This meant staff felt leaders did not always consult them on changes or they could bring new ideas to help improve the service.

There was mixed feedback on staff learning and development. Staff told us they were not always supported to prioritise time for developing their skills and abilities and the funding for study leave had been reduced by 50%. The staff survey showed that 50% of staff felt there were opportunities to develop their career in the service, this was in line with the organisational average. However, the survey also showed the service was below the average for giving staff opportunities to develop knowledge and skills and supporting staff to reach their potential.

We observed some of the channels for sharing learning with staff were not effective. For instance, there was a weekly safety briefing read during handover to share important information with staff, but we observed staff talking and looking at their phones during the briefing and when we asked about the content of previous briefings, staff could not describe the information. We did not see evidence that leaders had reviewed or assessed these channels or sought more effective ways or sharing learning with staff.

Leaders did not address concerns raised at previous CQC assessments of the emergency department. CQC carried out an assessment of the children’s emergency department two weeks prior to our December 2024 assessment and raised concerns with infection control and the environment. These had not been rectified during our December visit. Similarly, when we visited the department in January and March 2025, we some of the significant concerns raised had not been addressed.

Leaders described the main challenge as the pathways through urgent and emergency care. They acknowledged the layout of the emergency department was not suitable for the volume of patients, especially leading to problems offloading from ambulances. They stated they had submitted bids to improve the area and had development plans for the arrival and waiting areas to improve oversight. However, we did not see a commitment using learning and innovation to address challenges to make the current department safe for patients.

The service took part in quality improvement initiatives. The purpose of quality improvement is to enhance patient care and outcomes by continuing refining processes and services. The service had recently completed successful initiatives to improve compliance with VTE prescribing on admission in the department to 100% and introduced a standard proforma to improve documentation on ascitic drains. The department had three more quality improvement initiatives that were in progress.

The provider also took part with national improvement programmes undertaken by the Royal College of Emergency Medicines (RCEM) including caring for older people in the ED. However, throughout our assessment, we observed older people, particularly those living with dementia did not receive a high standard of care.