Broomfield Hospital

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. This was the first assessment for this service. This key question has been rated Inadequate.

The service had a poor learning culture and staff did not always raise concerns in fear of reprisals. Nursing managers investigated incidents but were not always given support to implement training for staff. Children and young people were not always 6 and kept safe. Staff understood risk but were not always supported to manage it. The facilities and environment did not always meet children and young people’s needs. There were not always enough staff with the right skills, qualifications and experience to manage the demand on the service. Nursing managers aimed for staff to receive training and regular appraisals to maintain high-quality care, however this was often not accommodated due to demand on the service. The service did not always ensure that medicines and treatments were safe and met people’s needs, capacities, and preferences by enabling them to be involved in planning, including when changes happen.

Following our assessment the concerns raised demonstrate a breach of Regulation 12 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and Regulation 17 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This service scored 34 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We scored the service as 1. The evidence showed significant shortfalls. The service did not have a proactive and positive culture of safety based on openness and honesty. Leaders did not always listen to staff and lessons were not always learnt to continually identify and embed good practice.

Young people and their families using the service told us they were able to raise concerns about their care but were not always signposted to give feedback and make suggestions on improvements following incidents.

During this assessment staff told us learning and education sessions would often be postponed and there would be minimal staff attendance to live skills and drills simulation training due to high demand on the service. Staff told us learning was not prioritised, and leaders would be more reactive than proactive following an incident. Staff also told us there was an embedded “blame culture” around learning from incidents and were concerned they would be treated negatively and were worried about their job security if they were involved in an incident.

The service had systems in place to log incident management however there were delays in reporting processes. Evidence reviewed showed leaders did not always actively listen to concerns of staff and identified lessons learned were not always actioned promptly to embed good practice. For example, there had been delays approving action plans after incident investigations, meaning months may have passed before meaningful changes and staff learning was implemented. We also requested evidence of morbidity and mortality review meetings, this was not provided, therefore we were not assured the appropriate actions were being taken following safety incidents.

We scored the service as 1. The evidence showed significant shortfalls. The service did not always work with people and health system partners to establish and maintain safe systems of care. They did not always monitor children and young people’s safety. There was limited oversight of continuity of care, including when people moved between different services.

Young people and their families using the service told us care pathways between departments were not always timely and they could experience long waiting times. They were not always told what was going to happen and why. Some parents whose children were awaiting surgery told us they had familiarised their child with the ward they thought they were being admitted to but were moved onto another ward at the last minute which caused distress and confusion.

The service had guidance and procedures in place for transition of care between paediatric departments. However, staff told us safe care pathways and systems were impacted by the lack of capacity, high acuity and demand on the service. Staff raised concerns over the high numbers of children they discharged to return for treatment (ambulate) and told us this was not always safe. There was no cap on how many children that could be ambulated which put additional pressure on an already very busy unit. Staff told us there was minimal clinical oversight of these children, and processes were not always safe, putting children and young people at risk. For example, over the last 12 months 479 children and young people were readmitted to hospital within 30 days of discharge. There was no evidence to demonstrate if current care pathways were effective and safe and if outcomes and interventions were consistent for all children and young people.

Staff stated they had escalated care pathway safety concerns to senior leadership teams, who acknowledged demand is high but had taken limited visible action to address the risk and impact on staff and people receiving care. Evidence showed there were multiple reviews from patient safety incidents relating to ongoing concerns over the safety of children and young people receiving care at the hospital.

However, neonatal teams told us they worked effectively with maternity leads and pathways into the neonatal unit and transitional care were well managed. Admission and assessment of newborn babies was coordinated by maternity leads at the hospital, with standalone triage and admission and discharge processes.

Healthcare partners told us there were clear pathways for referrals into their external services and staff had guidance and processes to follow. Partners received and shared feedback on care pathways from young people and their families but were unsure how this was used to improve care within the hospital. Community mental health partners met with leaders daily to discuss care plans and said this was beneficial and assisted continuity with care outcomes. Healthwatch Essex had received concerns from children and their families around unclear pathways for ADHD and autism care. Concerns had been raised over unclear communication particularly if care involved multiple departments.

The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. Leaders did not always manage or monitor children and young people’s safety to ensure there was continuity of care, including when they moved between different services. There was a lack of long-term oversight of effective pathways to improve care experiences.

We scored the service as 1. The evidence showed significant shortfalls. The service did not work with staff and healthcare partners to provide good oversight of safeguarding processes and training.

Staff told us they received annual training for safeguarding and had clear guidance to follow. Staff we spoke to during assessment had good understanding of safeguarding. However, staff did not always receive safeguarding supervision or attend live skills and drills training in line with trust policy. Evidence reviewed showed the service had low compliance with supervision rates and an action plan had been implemented to increase compliance. Permanent and bank staff were not always compliant with safeguarding training. Despite inconsistencies around safeguarding processes and training we observed a child safeguarding incident with multi agency involvement. Staff where focused on the child’s needs and mitigated risks.

At the time of our assessment leaders told us there was a current vacancy for a band 6 registered safeguarding nurse which had impacted on effective oversight of their safeguarding processes. Staff told us there had been an increase in safeguarding referrals due to a surge of children and young people with mental health needs and that referral processes were often delayed whilst awaiting an available bed.

We requested safeguarding children meeting minutes for the last three months following the on-site assessment. They were unable to provide them, although stated quarterly system wide meetings did occur across the trust. They did not provide evidence when hospital leaders specifically met to discuss safeguarding cases, associated risks and learning. Internal recording systems did not ensure all relevant teams were made aware of safeguarding referrals and leaders did not always carry out monthly safeguarding audits.
Policies relating to safeguarding were not always tailored for children and young people and did not include when children and young people were being cared for in predominantly adult areas. We requested evidence of guidance or procedures for staff to follow when children and young people were admitted to adult wards; this was not provided. Therefore, we were not assured leaders had good oversight of any associated safeguarding risks.

We scored the service as 1. The evidence showed significant shortfalls. The service did not work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We received inconsistent feedback about involving people to manage risks. Young people and their families did not always feel involved in decision making about their care. A parent said they “...felt they were in limbo” with little information about treatment plans and diagnosis. However, young people and their families within the paediatric outpatient’s department told us staff were good at explaining processes and provided all the relevant information in a timely way.

Staff on wards and the paediatric assessment unit told us due to demand on the service they did not always get the time they needed to communicate with parents/carers and answer questions or involve them in managing risk. This impacted on the overall care experience for children and young people, for example a parent told us they had raised concerns about the care of her baby and needed reassurance from staff. However, staff were often busy, and the parent said that staff were not always responsive.

Other non-clinical staff told us they would often be the first point of contact for families and if a child looked unwell, they would escalate to clinical teams immediately. However, during busy times they would often have to escalate multiple times. They told us better clinical oversight of children and young people entering the departments were needed to improve early recognition and clinical management of an unwell child.

We requested evidence of how leaders managed and escalated low staffing numbers and managed service demand. Evidence was only partially submitted and did not show leaders had good processes in place to manage this risk. Leaders had told us they had set up a confidential social media chat group to escalate clinical risks to senior staff during times of high demand and low staffing levels. However, this communication channel lacked oversight and relied on senior staff being available to answer messages promptly and give advice. There was not always monitoring of this escalation method and was not linked to an agreed policy and procedure.

We scored the service as 2. The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care

Children, young people and their families did not always feel the environment on the in-patient wards, or the paediatric assessment unit (PAU) were safe and suitable to their needs. Some staff told us they had received complaints from parents due to lack of accessible bathroom facilities, which meant children with additional needs may have to go days without bathing.

Space in PAU waiting area was limited and would often be crowded with no seats available. The high dependency bay lacked external monitoring screens and was at the end of a long corridor. Parents were concerned if their child deteriorated staff may not be aware. However, families in the neonatal intensive care unit (NICU) told us facilities available were suitable and met their family’s needs.

Some staff told us they did not have enough space to safely monitor children receiving intravenous infusions. Staff also had concerns regarding the security of the unit. This was a particular concern at night when a ward clerk was not present. Security throughout paediatric departments had been logged on the services risk register, however there had been no reported incidents relating to security in the last 12 months.

During our assessment we observed the wards and paediatric departments were not always laid out to be suitable and safe for observing children and young people. The inpatient ward was a large ward split in the middle by two sets of unlocked doors. Not all fire exits had direct line of sight by staff, meaning there was a risk of people leaving the unit without staff seeing. This had not been highlighted as a risk. Although the door was alarmed and the service had a patient abscond policy, this policy was adult focused and offered little guidance to staff around children who may try and leave a ward or department.

As part of our assessment, we asked for evidence of current environmental risk assessments in all children and young people areas. This was provided but some risk assessment had taken place after our on-site visit. Furthermore, we requested a current legionella risk assessment the document submitted was out of review date. Therefore, we were not assured at time of our assessment that environmental risks were being identified and managed appropriately.

We scored the service as 1. The evidence showed significant shortfalls. The service did not always make sure there were enough qualified, skilled and experienced staff to meet demand. They did not always make sure staff received effective support, supervision and development. Leaders and staff did not work together well to provide safe care that met children and young people’s individual needs.

Parents and families told us staff were mostly polite and caring, as well as, supportive and knowledgeable when they asked questions. They told us at times clinical areas often appeared understaffed but said staff would do their best during busy times.

Staff told us there was a lack of staff at times of high acuity and demand. For example, the high dependency unit (HDU) was not always staffed by a HDU nurse during the evenings, and this was not in line with best practice and national guidelines. Some staff were unable to deliver the standard of care they wanted, and children and young people’s care could often be disjointed. Nursing leaders acknowledged teams were struggling and did not always have the right level of staff. Nurse’s managers would clinically help when busy, but this would impact on their ability to manage the services activity and risk.

Information provided showed there were no gaps with medical staffing, however nursing vacancy rates were 17.5% this was above the trusts 11.5% target. As part of our assessment, we requested a copy of the last formal review of staffing levels. This was not provided. Therefor we were not assured the service always made sure there were enough qualified, skilled and experienced staff. Leaders did not always make sure staff received support, training and development. Mandatory training targets for permanent, bank and agency staff did not meet compliance levels and there was no evidence of a training needs analysis being carried out.

We requested information around staffing rota’s showing staff planned and actual numbers on shifts. This was not provided. We also asked for evidence of escalation processes and action taken to mitigate staffing gaps. Evidence provided did not demonstrate clear management and oversight of staffing and skills gaps.

We scored the service as 2. The evidence showed some shortfalls. The service did not always assess or manage the risk of infection. They did not always risk assess and control the risk of it spreading or act on parents and families concerns.

Wards and department entrances all had signage for hand washing procedures and infection prevention control measures. Areas appeared clean and bright. Toilets were accessible and bins were emptied regularly. Staff washed their hands and used hand gel prior to care and treatment.

Families on High Dependency Unit (HDU) told us the space was too open and were concerned that non-immunised babies would be at risk of infection if others were infectious nearby. Staff also raised concerns about the crowded waiting area in the PAU as there was no isolation area for small babies and immunocompromised children. There was also no guidance for staff to follow when allocating bed spaces to minimise infection risk.

The service had allocated staff responsible for cleaning the departments and wards across paediatrics. Cleaning systems and processes were in place, which helped manage infection risks. However, infection prevention control (IPC) audit results showed gaps in reporting. Therefore, we were not assured there were effective monitoring and actions being taken in relation to IPC.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Staff told us the pharmacy team fully supported them. However, they told us that the main in- hours and out of hours pharmacy support varied. Staff told us that they had received medicines management training including patient group directions (PGDs) used in the paediatric department.

Staff told us that they were encouraged to report medication incidents and learning from incidents were shared widely.

Medicines were stored safely and securely in line with trust policies and procedures. Controlled Drugs (CDs) were stored in line with legislation and records of administration were mostly completed in line with guidance. Staff told us that unused CDs were disposed within the sharps bin that does have absorbable material which made it irretrievable.

The service had a process for obtaining relevant patient history for people presenting to paediatric departments and AE, however staff we spoke with did not have access to nationally held patient summary care records (SCR). Staff told us that there were sometimes delays in accessing relevant information as access was limited to senior members of staff. This meant benefits of reviewing SCR such as reducing the risk of prescribing errors and helping avoid delays to urgent care were missed. The service used paper prescriptions in the departments for patients.

The service had medicine management policies and guidance for staff to follow. Medicine management audits for inpatient areas showed good compliance.