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Inspection Summary


Overall summary & rating

Good

Updated 24 May 2016

Basildon and Thurrock University Hospitals NHS Foundation Trust serves a population of around 415,000 in south west Essex covering Basildon and Thurrock, together with parts of Brentwood and Castle Point. The trust also provides services across south Essex. The trust provides an extensive range of acute medical services at Basildon University Hospital, which includes The Essex Cardiothoracic Centre and Orsett Hospital as well as x-ray and blood testing facilities at the St Andrew's Centre in Billericay. The trust employs more than 4,000 staff and has more than 10,000 public members. The trust became one of the first 10 NHS foundation trusts in April 2004.

The trust was placed into special measures following reviews by Sir Bruce Keogh June 2013 following concerns around quality of care and high mortality. The Care Quality Commission undertook a comprehensive inspection of the trust in March 2014 and rated the trust as Good. Following this inspection the Commission recommended to Monitor that the trust could come out of special measures.

We undertook a responsive inspection to the critical care unit in March 2015 in response to concerns relating to safety with staffing shortages within the critical care outreach team, areas for improvement within the effectiveness of the service, responsiveness on patient pathways and the pace at which change had been implemented. Subsequently the rating for this service overall changed from ‘Good’ to ‘Requires Improvement’.

We returned to inspect on 16th February 2016 and inspected all the key questions in the critical care service with a view to providing a new rating. We did not undertake a full comprehensive inspection of the trust, this inspection focused solely on the general critical care unit. We found that the service had made significant improvement in the delivery of the service which we have detailed through this report, and we have changed the rating of the service to ‘Good’.

The change to the ratings of the critical care service has also changed the overall trust rating for the key question of ‘is the service safe?’ to Good overall.

Our key findings were as follows:

  • There were significant improvements made to how safe, effective, responsive and well led the service was since our last inspection in March 2015.

  • Staffing levels for nursing, medical and therapies staff had improved and were at a safe level.

  • The mortality ratio for the unit has reduced significantly since our last inspection where it was 1.8 and is now 1.0 on the ICNARC SMR and 0.83 on the APACHE model.

  • The critical care unit acquired infection in the blood rates per 100 admissions was consistently in line with or better than the England average of four.

  • The critical care unit does not currently meet the core standard of 50% of registered nurses having a recognised critical care course with 27% of nursing staff who had completed their certificate in critical care, however a number of staff were currently on the course and the rates by the end of the year were expected to reach over 50%.

  • We observed good use of mental capacity assessments and deprivation of liberty safeguards during the inspection.

  • The completion of DNACPR forms has significantly improved since the previous inspection with a greater awareness of what is required of the medical staff with regards to DNACPR.

  • There had been notable improvements in the leadership of the critical care and outreach service.

  • Morale and culture within the critical care and outreach service had improved significantly since our previous inspection.

Following our inspection the trust should:

  • Improve the mandatory training rates for the critical care outreach team.

  • Ensure all staff receive updated equipment competency training.

  • Reduce the delayed discharges over four hours from the critical care unit to the main wards.

  • Reduce the number of transfers out of hours between 10pm and 7am.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Good

Updated 24 May 2016

Effective

Good

Updated 24 May 2016

Caring

Good

Updated 24 May 2016

Responsive

Good

Updated 24 May 2016

Well-led

Good

Updated 24 May 2016

Checks on specific services

Maternity and gynaecology

Outstanding

Updated 3 August 2015

We did not inspect Maternity and family planning during our inspection in March 2015.

In 2014 we found maternity services provided to women and babies were outstanding. There were arrangements in place to implement good practice, learning from any untoward incidents and an open culture to encourage a strong focus on patient safety and risk management practices.

The trust had provided safe staffing levels and skill mix and had encouraged proactive teamwork to support a safe environment. We noted that with increasing numbers of births, the trust should consider national guidance which recommends additional consultant hours and the employment of consultant midwives to maintain safe practice in the future. Patients told us they felt safe in the hands of the staff and staff said they felt supported by the trust in managing risk and keeping their patients safe.

There was strong evidence of research and an embedded ethos of shared learning. National guidance was being implemented and monitoring systems to measure performance were in place. We found a consistent track record of high quality, safe care which delivers good outcomes. Care was consistently delivered in line with evidence-based, best practice guidance and the highest professional standards. There was good collaborative working with partners and other agencies and maternity specific training courses across all groups of staff to support effective care was of a high standard.

The maternity services continuously reviewed and acted on information about the quality of care that it received from patients, their relatives and those close to them and the public. They were able to demonstrate the difference this has made to how care was delivered.

Risks at team and directorate level with regard to the delivery of high quality care were identified, analysed and mitigated systematically before they become issues which impact on the quality of care. The leadership model in maternity services encouraged cooperative, appreciative, supportive relationships among staff and teams and compassion towards patients.

Medical care (including older people’s care)

Good

Updated 3 August 2015

The service was issued a compliance action around the management of medicines following the inspection in March 2014. When we returned in March 2015 we found that the safety of medicines management had improved but further improvements were needed. We found that the number of patients experiencing delayed discharges because of medicines delays had reduced. The recording of administration of patient’s medicines needed to be improved on Osler, along with storage on Osler ward.

Patients care was effective because staff used evidenced based guidance and research to support their practice. We found that teams of staff worked well together and this made patients care less disjointed.

We found that patients were cared for with compassion. We saw improvements had been made with record keeping to make sure patients care needs were accurately recorded. Innovative practice was being used in order to reduce the amount of falls and injury patients experienced. Pressure ulcer prevention was proactively managed by staff on wards. Infection control and prevention was effectively managed on all the wards we visited. Data reviewed also told us that the trust was performing the same as others in England.

We noted continual improvements in falls management, accurate record keeping practices and venous thromboembolism assessments in March 2015. Staff awareness was good in safety management and ongoing monitoring was being actioned to safeguard patients.

All acute medical patients were seen within 12 hours by a consultant seven days a week. Medical staff told us that led to clear management plans being in place. Consultants told us that their on call commitments were manageable and systems in place worked well.

The service was well led because; staff were involved and understood their role within the hospital in terms of being part of the continuous improvement.

Urgent and emergency services (A&E)

Good

Updated 3 August 2015

In 2014 the department did not have enough consultants to provide care ‘on site’ all of the time, but there was a system of on call duty that did provide staff with access to a consultant at any time on the day. The hospital had an active recruitment programme in place to improve this situation. The hospital needed to improve the observation of patients in the waiting area prior to entering the A&E department. In 2015 we found that service had improved the observation of patients in the waiting room and the trust had taken action to ensure that there was adequate medical cover provided to the A&E department. The service was continuing their work on recruitment and safe staffing levels in the department. We noted that work was on going to improve the development and training of staff internally with progression routes to consultant level which was positive.”

Patients were treated with compassion and respect throughout their stay in the accident and emergency. Staff made sure patients were involved in discussions about their care and understood what was happening to them.

The services in A&E were responsive. In 2014 the department had improved the patient flow through the system because of the greater numbers of patients attending. As a result patients were seen and treated in a timely way upon their arrival in the department.

In 2014 it was evident that the culture of the department had changed in the past 12 months. We found complaints were investigated in line with the trust policy and senior staff made sure that all staff learnt lessons from this process in order to improve patient experience.

There had previously been concerns about the effectiveness of the leadership within the department that affected its performance. In 2015 we found there was good clinical leadership and that staff continued to work well as a team and were motivated and positive about working for the trust and in A&E. Staff were well supported by clinical leads and senior management.

We however identified new concerns regarding the Clinical Decision Unit (CDU). We found that there was not enough registered nurses to provide safe care and that the CDU admission protocol was not followed as the trust was on black alert.

Surgery

Good

Updated 3 August 2015

In 2014 we identified that improvements were needed in the way the trust managed the use of the day surgery unit at night. We found bed capacity was pressured and patients who could not be accommodated on a general surgical ward were being placed in the day surgery unit overnight. When we returned to inspect the day surgery unit in March 2015 we found the day surgery unit was not used as an escalation ward to accommodate hospital beds.

In 2014 improvements were needed to make sure the administration of controlled drugs was accurately recorded in some of the surgical areas. In March 2015 we checked controlled drug records and procedures and found all records to be correct using safe procedures and practices.

Patients care was effective because staff were using evidence based guidance and research.

In 2014 people were well cared for but some people were not included in conversations about their care during ward rounds and information above people’s bed did not promote their dignity. We saw patient’s privacy and dignity was respected in all areas during our inspection in March 2015.  Individual patients were included within ward rounds and the planning of their care.

Information that should help staff understand what they are doing well and where they need to improve was not available on all the surgical wards we visited. In 2014, staff on some of these wards did not understand what they could be doing better in terms of falls and pressure ulcer prevention. In March 2015 we visited two surgical and two trauma and orthopaedic wards during our inspection and within the ward entrances, we saw performance notice boards with up to date information informing both staff and patient’s what care was being delivered well and what areas could do better.

Intensive/critical care

Good

Updated 24 May 2016

We have rated the critical care service as good overall and noted that there has been a significant improvement to the service since our last inspection. Safety of critical care service was rated as good because there was a positive incident reporting and learning culture within the critical care unit. Staffing levels for nursing, medical and therapies staff had improved and were at a safe level. Mandatory training levels were in line with trust expectations for the critical care unit, except for the critical care outreach team where improvements in training rates were required. Critical care services were effective. Treatment and care was delivered in accordance with best practice and recognised national guidelines (ICNARC) NICE and care bundles. There was a multidisciplinary approach to assessing and planning care and treatment for patients. Critical care services were caring. Feedback from people using the service including patients and their families was very positive. Patients and their relatives were kept informed of their care and there was very clearly documented notes regarding the weekly meetings and communication that had taken place with them. Critical care services were responsive to patient’s needs. Whilst the number of delayed discharges and out of hours transfers remained high there were improvements in these areas, however more work was required to improve this further. The critical care outreach team provided support to patients on the wards where higher dependency care was required, avoiding critical care admissions. The process for the investigation and learning from complaints had improved since our previous inspection.

Critical care services were rated as good for being well-led locally.  There was a clear vision and strategy for the service. There was good evidence of ward to board leadership, communication and governance regarding the service. There had been notable improvements in the leadership of the critical care and outreach service. Morale and culture within the critical care and outreach service had improved significantly since our previous inspection.

Services for children & young people

Good

Updated 3 August 2015

We did not inspect services for children and young people during our inspection in March 2015.

In 2014 we found that services for children and young people provided by the hospital were good. There were good staffing levels; a strong skill mix had encouraged proactive teamwork to support a safe environment. There were arrangements in place to implement good practice, learning from any untoward incidents and an open culture to encourage a strong focus on child safety and risk management practices. Families told us they felt safe in the hands of the staff and staff said they felt supported by the trust in managing risk and keeping their patients safe.

Evidence based practice was being implemented and monitoring systems to measure performance were in place.

We saw good examples of care being provided with a compassionate and dignified approach. Children and young people were involved in planning their care and making decisions about the choices available in their care and treatment, including appropriate discharge planning.

The children and young people’s service understood the different needs of the communities it serves and acted on this to plan and design services. It was proactive in taking action to remove barriers that parents, children and young people face in accessing or using the service. There were good mechanisms for information sharing and willingness from staff for flexible working around responding to the needs of parent’s children and young people. The service had introduced several initiatives to encourage children, their relatives and those close to them to provide feedback about their care and were keen to learn from experience, concerns and complaints.

The service was well led, staff felt supported by senior management.

End of life care

Good

Updated 3 August 2015

We did not inspect end of life care services during our inspection in March 2015.

In 2014 we found end of life care was safe, effective and responsive of patient’s needs. Care was delivered in line with current best practice and we saw very good care for those patients who chose to end their lives at home. The rapid discharge pathway enabled patients to leave the hospital within four hours.

All of the patients we spoke with told us that care was good. They were treated with respect and dignity and felt involved in their care and treatment. The trust had developed its own end of life care pathway which had replaced the Liverpool Care Pathway. This had yet to be evaluated but staff told us it was effective and working well.

We found that the way in which the hospital managed medication could be improved to make sure it was in date and stored securely. Improvements were needed to make sure all patients’ records in relation to ‘do not attempt to resuscitate’ decisions were completed.

For the deceased we found they were cared for by a team of dedicated staff who maintained patient’s dignity after death. Bereavement staff supported families effectively.

Outpatients

Good

Updated 3 August 2015

We did not inspect outpatient services during our inspection in March 2015.

In 2014 the outpatient’s department was clean and safe for use. Equipment was well maintained but storage could have been more secure in order to prevent theft, damage or misuse occurring.

Patients were treated with compassion, dignity and respect. The outpatient survey in August 2013 showed that the majority of patients felt the care they received in the department was excellent, very good or good. We identified some good practice in the way the service responded to patient feedback and planned care to meet individual patient needs.

The outpatient service was responsive to the needs of the patients and was meeting the 95% target for referral time to treatment.

The outpatient service was well led because staff felt supported and received appropriate professional development. Meetings were held across the service to improve performance. There were innovative ways to gain patient feedback that were considered in planned service developments.