Broomfield Hospital

On this page

• 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.

This service scored 4 (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 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. For example, 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 on a daily basis and local leaders regularly worked clinically. Leaders recognised that this was not a long-term solution. Leaders had drawn up a workforce plan for nursing staff but the trust’s financial position meant that there had been a freeze on recruitment.

Some staff felt changes were being made to service provision without adequate consultation with staff. They felt this lack of collaborative working had further impacted on the poor culture within paediatrics.

The service did not always have clear and effective governance arrangements. We were not assured that all relevant topics were covered during divisional triumvirate meetings. For example, there was no evidence that performance data, audit outcomes, risks, incidents and patient feedback were reviewed and discussed during the meetings. We were not provided with evidence of any other governance meetings or any team meetings for staff in the PED.

The service did not have a systematic programme of clinical and internal audit. 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.

The service did not always have robust arrangements to 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.