Broomfield 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 those leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities. This was the first assessment for this service. This key question has been rated Inadequate.

This meant there were widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care. Following our assessment concerns demonstrated a Regulation 17 breach of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. A Section 29A Warning Notice for Regulation 17 breaches was served to the Trust following our assessment.

Leaders and staff did not always have a shared vision and culture based on listening, learning and trust. Senior leaders were not always visible, knowledgeable and supportive, helping staff develop in their roles. Staff did not always feel supported to give feedback and were worried they would not be treated equally and be free from bullying or harassment. Young people and their families with protected characteristics did not always feel supported. Staff understood their roles and responsibilities but often felt understaffed and under pressure. Nursing managers did not always have the time to work with the local community groups. There was not always a culture of continuous improvement and staff were not always given time and develop and train.

This service scored 25 (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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of children, young people and their communities.

Staff at all levels were concerned senior leaders within the Trust did not fully understand the demand and pressure on staff and told us drastic change was needed. Staff said there was a blame culture when it came to incidents and safety. They told us leaders were quick to find someone to blame without looking at the bigger issues with staffing, capacity and leadership. Some staff said there was no psychological safety to voice concerns and would often leave shifts worried about children and young people’s outcomes.

Staff feedback did not reflect the vision, strategy and culture which the service promoted. Leaders did monitor the workforce but had limited resources to increase staff numbers and there were missed opportunities for leaders to engage staff to contribute to change and improvements to the service. One reason cited for this was lack of time outside of working directly with patients, for staff to attend meetings, read updates and use their experience to contribute to improving.

Senior trust leaders acknowledged the staff were under pressure and moral was low. They recognised the need for an uplift in nursing and medical staff, and they had continued to review the structures within paediatrics but had financial restraints on any proposed staffing increase.
Leaders also acknowledged there had been challenges with the culture within children and young people services across the trust. Action taken to address this involved commissioning independent reviews into root causes and identify recommendations. However, progress on implementation of improvement plans had been slow and staff were frustrated.

We requested current children and young people clinical and cooperate strategy. This was not provided. There was limited assurance the service had a clear shared vision, strategy and culture.

We scored the service as 1. The evidence showed significant shortfalls. 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 always have the skills, knowledge, experience and credibility to lead effectively.

Children and Young People services was part of the Women and Children division across the trust. Executive structures consisted of a Chief Executive Officer, Chief Medical Officer, Managing Director and Chief Nurse and Quality Officer. The service had a divisional Medical Director, Director of Operations, Deputy Director of Nursing for Paediatric and Neonate and a Director of Midwifery. Broomfield had an allocated Associated Director of Nursing

We requested evidence of how leaders engaged with staff and what opportunities staff were given to speak to divisional and executive leaders. Evidence provided showed local leaders carried out some virtual ward meetings, neonatal meetings being the best attended. However, records for the inpatient ward last 3 months meetings showed no staff attended. We did not see evidence how risks, patient safety and care quality concerns due to be discussed at these meetings was effectively communicated to staff.

There was a disconnect between leaders and staff and how they engaged. Despite monthly virtual meetings being available, staff told us there was limited opportunity to make suggestions to drive improvement. Information was often only shared on a “need to know” basis. Staff told us they worried their views and concerns were being mispresented at trust board level and there was a lack of transparency over risk. They told us board members may only have a limited view of the cultural issues within the paediatrics and in turn are not aware of long-standing issues.

There was minimal formal debriefs after incidents and consideration for staff wellbeing. Nursing managers did their best to complete appraisals and one to ones, but these would often be cancelled due to demand on the service. Information provided by the Trust did not show appraisal compliance rates and there were no identified actions to improve, review and explore different approaches.

Staff told us senior trust leaders were not visible and said they did not understand the day-to-day challenges staff faced. Not all leaders understood the context in which the service delivered care, treatment and support. Staff told us leaders did not always embody the culture and values of their workforce and organisation. They said leaders did not always have the skills, knowledge, experience and credibility to lead effectively, and they [staff] had lost confidence in senior leadership to make the changes necessary and described the service as “broken”.

We scored the service as 1. The evidence showed significant shortfalls. Staff did not feel they could speak up and that their voice would be heard.

Staff told us they were unsure of the freedom to speak up (FTSU) provision but had access to the Trust’s intranet for information. We requested information around the numbers of FTSU champions available within service. The trust had 37 trained champions with a further 3 awaiting course completion. There were no FTSU champions within children and young people services at Broomfield. Therefore, this staff group did not have representation at board level meetings to feedback.

There was lack of information to demonstrate that Trust leaders recognised the need for an embedded freedom to speak up provision within children and young people services and how it might help them support and improve staff wellbeing and services. The presence of ongoing cultural issues did not flag the need for a strong FTSU presence in children and young people services.

We scored the service as 1. The evidence showed significant shortfalls. The service did not value diversity in their workforce. They did not work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Medical staff felt very supportive of their nursing staff colleagues. They were concerned many senior experienced nurses were leaving and other less experienced nurses with potential reduced senior support. Staff did not feel they were not being treated equitability, and their knowledge and experience was not always valued.

Senior trust leaders acknowledged there were some cultural issues, and there were actions being taken. However, action plans did not incorporate workforce equality and did not utilise any staff networks input in the cultural transformation work needed in paediatrics. There was a lack of processes to ensure staff felt included in change management and could influence improvements. Decisions made were leadership led and did not always incorporate opinions of all staff groups.

National Health Service (NHS) survey results published March 2024, there was 190 staff from children and young people services that participated. When asked “Disability: organisation made reasonable adjustment to enable me to carry out” response 66.7%. This was below the trust s overall score of 70.2%. From all the questions within the NHS staff survey, children and young services, 67% of responses scored worst that the trust average.

Evidence reviewed in relation to trust Workforce Race and Equality Standard (WRES)reports and associated action plans, showed poor progress year on year. With objectives still outstanding from December 2023. This was similar in the trust Workforce Disability Equality Standard (WDES) action plans where deadlines had not been met and then just extended.

We scored the service as 1. The evidence showed significant shortfalls. 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.

Children and young people services had a governance structure that reported to the Deputy Director of Nursing Paediatrics and Neonates. Some staff told us they were unsure of senior leaderships structures and who held accountability for good governance. We requested evidence of the last 3 clinical governance meetings and associated action logs. This was not provided. We were not assured governance concerns and risks were be discussed and escalated appropriately.

We requested information on how they monitored all children and young people services polices, guidance and standing operating procedures. And how they were assured they were up to date, contain current national guidance or need review. The service provided a trust overview of policy compliance showing there was only 4 polices that were not compliant. However, on review of submitted data many polices relating to children and young people services were running on 12-month extension for compliance. Each policy extension had been risk assessed but we were not provided with this evidence.

Staff expressed concerns over the sustainability of the paediatric assessment unit and long-term staffing issues. They were continually losing staff and had many on long term sick leave. Current staff were exhausted, and morale was low. Staff told us leaders were not always proactive in addressing shortfalls in staff numbers and said the poor culture had discouraged staff taking up bank shifts. Leaders acknowledged the need to uplift the workforce to align with demand but told us the service would need substantial investment to achieve this. Some staff said changes were being made to service provision without adequate consultation with staff. They told us this lack of collaborative working had further impacted on the poor culture within paediatrics.

Data requested for service leavers showed 86 full time equivalent staff left children and young people services across the whole trust between December 2023 and October 2024. We also requested evidence of feedback collected from staff’s exit interview and how this shaped their long-term retention plan and workforce sustainability. This was not provided as the service did not collect this information.

A significant amount of information requested as part of our assessment was not provided or available. We therefore did not have assurance that the service collected, analysed and managed information appropriately. Evidence that was provided did not demonstrate a clear and accurate escalation of risk from ward to board. It was not clear how the board interrogated the information it was presented with to assure them of the accuracy or how they ensured staff and patient voices were heard.

We scored the service as 1. The evidence showed significant shortfalls. The service did not understand their duty to collaborate and work in partnership, so services work seamlessly for children and young people. They did not share information and learning with partners or collaborate for improvement.

Leaders told us they worked with community partners but could often be inconsistent due to funding and demographic restraints. However, the service did not have any parent or community forums to facilitate shared communication and engagement. This was a missed opportunity to share plans, challenges and seek further support, from the wider community to positively impact care delivery. Leaders confirmed there was a need for community engagement but said there were conflicting priorities across paediatric services, so it was still outstanding. The lack of engagement in this area showed work needed to align processes to meet changing populations needs.

We requested evidence how the service engaged and worked in partnership with local communities and external organisations. We were provided with posters advertising community events that had not been organised by the service. There was no evidence submitted to demonstrate the service proactively planned and participated in community and partnership projects. There had been missed opportunities to engage with external partners and community groups.

Community Healthwatch partners told us they would produce monthly reports but did not receive any assurance the information was being used effectively by the service or were fully shared/scrutinised by the Board. They said it would be beneficial to have a named contact from the service to enable prompt and effective communication and sharing of information. The service did not always understand their duty to collaborate and work in partnership, so services work seamlessly for children, young people and their families.

We scored the service as 1. The evidence showed significant shortfalls. 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.

We requested evidence of any quality improvement projects, participation in research projects and examples of any innovation. Information shared showed there had been 2 completed, 2 in progress with a further 4 quality improvement projects to been launched. However, it was unclear from the information provided what impact these projects had on quality across all services There was limited data to show what lessons had been learnt and what improvement measures had been put in place because of the project.

Staff told us there was limited opportunity to make suggestions and actively contribute to safe, effective practice and research. They felt disempowered to drive improvements and because of pressures on the service they had become disengaged. They would escalate concerns and suggestions to senior managers, but they said their hands were tied due to financial restraints and cultural issues within the service. Staff told us there were limited opportunities for career development. For example, funding for nursing apprenticeships had just been reduced. Some staff were actively seeking employment elsewhere due lack of improvements within the service and a feeling they were not being encouraged to develop their potential.

The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. Evidence reviewed showed there had been repeated themes from incidents and identified lessons to be learnt. The recommendations for improvement in care were not fully embedded. Culture issues around learning and improvement were having a direct impact on children and young people’s safety and putting them at risk.