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Colchester General Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 2 November 2017

The Care Quality Commission (CQC) carried out an announced comprehensive inspection of Colchester General Hospital on the 25 to 27 July 2017. This was to review care provided at the trust since the new senior management team had come into post in May 2016.

The inspection team also undertook a further announced inspection on 2 August 2017 at the outpatients department at Essex County Hospital. At the time of inspection Essex County Hospital was in the process of deregistering.

Colchester Hospital University NHS Foundation Trust is comprised of two main hospital sites which are Colchester General hospital and Essex County Hospital. The Essex County Hospital is scheduled to close during 2018 and the only services currently provided on site are outpatient services and ophthalmic eye surgery under local anaesthesia. Colchester General hospital has 763 beds, spread across various core services, and provides district general hospital care to 370,000 in Colchester and the surrounding area of North East Essex and South Suffolk.

Colchester Hospital University NHS Foundation Trust was placed into special measures in November 2013 following an inspection into cancer waiting times. At the May 2014 inspection the trust well led aspect was rated as inadequate. The trust as a whole was rated inadequate following a comprehensive inspection in September 2015. The CQC undertook a further focussed unannounced inspection of Colchester General Hospital on 4 and 5 April 2016 looking specifically at the safety and caring elements of surgery, medicine and end of life care. The trust was not rated following this inspection. Overall findings were that significant improvements had not been made.

The CQC undertook regulatory action and imposed conditions under section 31 (1) (2) (a) of the Health and Social Care Act 2008 in December 2014, in respect of the emergency department, emergency assessment unit (EAU) and the operating theatres and the following regulated activities:

• Surgical Procedures

• Diagnostic and Screening

• Treatment of disease, disorder or injury

The trust reported regularly to the CQC to provide information and assurance that these conditions were adhered to, including exception reporting and risk assessments should the conditions be breached. We reviewed all aspects of the conditions during the inspection in July 2017 and the trust was compliant with imposed requirements following our previous inspection. The trust applied to have these conditions removed following this inspection.

A long-term partnership between Colchester General Hospital and Ipswich Hospital NHS Trust was recommended jointly by the CQC Chief Inspector of Hospitals, Professor Sir Mike Richards, and the Chief Executive of NHS Improvement as the only way of securing services for patients long into the future. Mr Nick Hulme was appointed as Chief Executive and Mr David White as Chair of the trust board on 17th May 2016. A managing Director was put in place to manage the trust on a day to day basis in June 2017. The respective boards are considering a Partnership between the two trusts The recommendation from the outline business case, 17 August 2017, was to form a single combined organisation with fully integrated clinical services.

We have been advised that subject to the boards approving the case, the Trusts will go on to develop detailed plans for the combined organisation. A final decision to form a single organisation will then be taken by both Trust boards around June 2018. This decision will also require approval from regulators NHS Improvement and the Competition and Markets Authority (CMA).

During this inspection we found that significant improvement had been made across all services at the Trust. The chief executive and managing director had created stability in the senior executive team that had not been previously in place. The executive team understood the challenges to good quality care and the wider challenges faced by the NHS, and could see the importance of exploring solutions such as the long-term partnership with Ipswich Hospital.

The team in place now worked together with more structured disciplines being embedded around executive and performance behaviours and responsibilities. Within the every patient, every day programme (EPED), the responsibility, accountability and ownership of service improvement had been given back to the local leaders. We saw many examples of local leaders and senior staff being highly motivated, engaged in seeking solutions to drive improvements locally.

We have rated Colchester Hospital University NHS Foundation Trust as requires improvement overall despite significant improvement being seen at the trust. The trust recognises that it is on a journey to Good and senior and local leaders are aware of where actions are still required to improve services.

Our key findings were as follows:

We saw several areas of outstanding practice including:

  • The service’s dedicated childrens transition team was the only one in the region and other trusts sought advice from them. The transition team worked with other teams to meet the more complex individual needs of patients at the age of transitioning to other services. For example, they ran a joint clinic with the epilepsy specialist nurse three to four times a year.
  • The neonatal unit (NNU) was piloting a ‘discharge passport’ to empower parent involvement in ensuring a timely discharge for babies.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • The trust must ensure that nursing and medical staff complete all safeguarding and mandatory training including basic life support.
  • The trust must ensure that all equipment is maintained and fit for purpose.
  • The trust must ensure that initial assessments within the emergency department are undertaken and documented to maintain an accurate clinical record based on clinical judgement, and that initial assessments in the emergency department are documented.
  • The trust must ensure access to a designated mental health assessment room.
  • The trust must take action to ensure that patients are clinically risk assessed as safe to wait for out patient appointments.
  • The trust must ensure that medical records contain completed risk assessments relevant to patient care.
  • Ensure that patient’s records are appropriately stored in accordance with legislation at all times
  • The trust must ensure that staff administering contrast for diagnostic imaging investigations use a patient group direction or have it prescribed.
  • Ensure that do not attempt cardiopulmonary resuscitation (DNACPR) decisions are undertaken in accordance with national guidance and best practice.
  • The trust must ensure that the design and layout of the paediatric emergency department enables effective oversight of paediatric waiting areas to ensure patient safety.
  • The trust must ensure that there is an effective governance and risk management framework in place to identify and assess all risks relevant to the emergency department.
  • The trust must ensure that patient’s dignity is protected in changing cubicles in In Beta X-ray.
  • The Trust must ensure that the doors for Beta X-ray are fully fitted and a risk assessment is in place to ensure patients are not a risk of unnecessary exposure of ionising radiation.
  • The trust must ensure there is an effective process in place for timely review of policies and procedures and that these comply with national guidance and best practice.

Action the hospital SHOULD take to improve

  • The trust should improve its overall performance in the management of referral to treatment times.
  • The trust should ensure that clinics are not cancelled without exploring every option in order to contribute to reduced waiting times.
  • The trust should ensure the clinics start on time.
  • The trust should ensure that all staff are aware of translation services for non-English speakers.
  • The trust should ensure that clinical audit is undertaken and where data is not submitted, that it is followed up.
  • The trust should ensure that all staff have received an appraisal and frequent supervision.
  • The trust should review admission times and fasting periods for patients awaiting surgery to meet the nutritional and hydration needs of the patient.
  • The trust should ensure managers and senior staff have the relevant level of skill and experience to perform their roles.
  • The trust should ensure that staffing levels reflect the needs of patients at all times.
  • The trust should ensure that it reviews its existing staff practice in relation to MCA and DoLS specifically in relation to the cohorting of patients in supervised bays.
  • The trust should ensure that domestic staff follow infection control procedures, wear correct uniform, identification and personal protective equipment at all times.
  • The trust should improve its overall performance in the management of patient falls.
  • Continue to work to improve delayed discharges and discharges that occur between the hours of 10pm and 7am.
  • Continue to work to improve attendance and documentation of meeting minutes at mortality and morbidity meetings.
  • To ensure that patients diaries are being completed in line with guidance, and that these diaries are used throughout the patient journey.
  • To improve the recording of actions following governance meetings and ensure that these are followed up and that evidence of learning or changes in practice are recorded.
  • Ensure there are appropriate formal systems to share actions and learning from incidents consistently among all staff in the service.
  • Update the policy for safeguarding children in line with best practice and national guidance, for example to ensure all child protection cases are overseen by a paediatrician.

On the basis of this inspection, I have recommended that the trust be removed from the special measures process.

Professor Edward Baker

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 2 November 2017

Effective

Good

Updated 2 November 2017

Caring

Good

Updated 2 November 2017

Responsive

Requires improvement

Updated 2 November 2017

Well-led

Requires improvement

Updated 2 November 2017

Checks on specific services

Maternity and gynaecology

Good

Updated 2 November 2017

We rated maternity and gynaecology services as good because:

  • Equipment that was in use throughout the department was serviced and calibrated.
  • The midwife-to-birth ratio was in line with or better than the recommended England average.
  • The number of consultant hours provided to the service was in line with guidance from the Royal College of Obstetricians: Safer Childbirth; Minimum Standards for Organisation and Delivery of Care in Labour, 2007.
  • Outcomes for women who used services were in line with or better than expected when compared with other similar sized services.
  • An external organisation provided the termination of pregnancy service unless there was a confirmed fetal abnormality. The trust would perform the termination under these circumstances. We were assured that in doing so that the trust followed all elements of national guidelines and legislation.
  • The service took part in national and local audits as well as reviewing their service in line with nationally published recommendations.
  • Feedback from people who use the service, those who are close to them and stakeholders was positive about the way staff treated women. Most women were positive about the care provided.
  • The service had responded to the changing demand of its service users.
  • Access to the service was through a simple route, which enabled the medical team to see women soon after arrival.
  • Bed occupancy rates for the service were generally lower than the England average of 58% with 55% occupancy for 2016.
  • Staff spoke positively about the clinical leads for the service with their involvement and approachability.
  • Governance and risk management systems within maternity and gynaecology were well established.
  • The service engaged well with the women who lived within the catchment area by linking up with the local mother and baby groups to seek feedback on services provided by the hospital.
  • The Rosemary suite for mothers who had miscarried or delivered a stillbirth had undergone a refurbishment since our last inspection and provided a family room in addition to the delivery room and separate bedroom.

However:

  • Whilst most staff attended mandatory training there was a low rate of training compliance for Immediate Life support for Adults at 25%.

  • The staffing vacancy rate at Clacton was 16.32 whole time equivalent (WTE) below the actual required staffing levels of 20.9 WTE for Clacton. Increased bank staff and rotation of staff mitigated this when there was increased activity in an area.

  • Medical staff training in safeguarding looked after children had a compliance rate at 53%.
  • Several midwives expressed their concerns about feeling intimidated. They confirmed that the head of midwifery had completed a recent staff and student midwife survey, which had highlighted their concerns. This issue was being addressed by the management team at the time of our inspection.
  • We received several comments through our comment cards about poor attitude of staff providing care to mothers on the postnatal ward. The waiting times for elective gynaecology have moved from a backlog of 91 in January 2016 to 148 in June 2017.
  • The midwifery co-ordinator for the delivery suite was supervisory but not supernumerary on the staffing roster. This meant that when they cared for pregnant women there was the potential for them to be unavailable to support colleagues as and when required.

Medical care (including older people’s care)

Good

Updated 2 November 2017

We rated this service as good because:

  • Staff knew how to report incidents and deal with complaints.
  • There were clear procedures for managing and referring safeguarding concerns in relation to children and adults who may be at risk of abuse. Staff we spoke with knew how to make a referral and who to refer their concerns to within the trust.
  • We reviewed 36 patient records and found all risk assessments were completed, national early warning scores (NEWS) and risk assessments clearly documented.
  • Staff adhered to the trust hand hygiene and ‘bare below the elbow’ policy, and wore personal protective equipment such as gloves and aprons during care.
  • Staff used national early warning scores (NEWS) on the medical wards to monitor and identify any deteriorating patients. All records we reviewed showed that staff routinely completed NEWS and alerted senior staff to any patient that may be deteriorating.
  • The trust had dedicated care pathways for both dementia and Parkinson’s disease.
  • The trust takes part in the quarterly Sentinel Stroke National Audit programme (SSNA). On a scale of A-E, where A is best, the trust achieved grade A in the latest audit, December 2016 to March 2017.
  • The trust results in the 2015 Heart Failure Audit were better than the England and Wales average for all four of the standards relating to in-hospital care.
  • The proportion of non-ST- elevation infarction (nSTEMI) patients referred for, or that had, angiography at the trust was 95.3%, which was better than the England average of 79%.
  • Ward teams had access to a range of allied health professionals and team members described good collaborative working practices between the teams. There was a joined-up and thorough approach to assessing the range of patients’ needs and a consistent approach to ensuring assessments were regularly reviewed and up to date.
  • The Friends and Family Test (FFT) response rate for medicine at the trust was 49%, which was better than the England average of 25% between March 2016 and February 2017.
  • During our inspection we spoke with 12 patients and 14 relatives, all, with the exception of one family were consistently positive about their experience of care and support at the hospital.
  • Staff respected and recognised patients’ individual needs and choices at all times. Staff utilised care plans and person centred planning to respect patient decisions and promote choices in order to provide holistic care.
  • Patients on the stroke unit had access to psychological support, and could be sign posted to specialist counselling services where appropriate.
  • The trust had significantly invested in the recruitment of discharge co-coordinators who worked across the wards to promote the safe and timely discharge of patients.
  • Between February 2016 and January 2017, the average length of stay for medical elective patients at the trust was 3.6 days, which is lower than England average of 4.2 days.
  • The following specialties were better than the England average for admitted Referral to Treatment Times (RTT) (percentage within 18 weeks), geriatric medicine, neurology, and rheumatology.
  • Local leaders, for example ward sisters and matrons were highly respected by staff we spoke with and staff felt respected and engaged with the services.
  • The trust had action plans in place to address performance issues, for example in relation to the National Diabetes Inpatient Audit (NaDIA).
  • All nursing staff we spoke with knew what the localised risks were and the risks on the medicine risk register.
  • We found a strong culture of multidisciplinary staff working on the wards we visited
  • Staff said that the senior leadership team held open forums, and that often the Chief Executive Officer would go onto the ward areas, sometimes as early as 6am to see the patients and staff.

However:

  • Data supplied by the trust from April 2017 showed the majority of wards within the medicine division were below the trusts identified staffing requirements. This issue was on the trusts corporate risk register and potentially impacting on patient care, for example the number of patient falls, and medication omissions.
  • Data supplied by the trust showed a high level of patient falls on medicine wards between January 2017 and June 2017. Although staff had begun to cohort patients, the impact of this practice was still under review and patient falls were still occurring in some areas of the service in July 2017.
  • Between January and June 2017, there had been 84 occasions where staff omitted patient medication on Peldon ward, this improved following a change of ward management and focused improvement plan.
  • There were low rates of training compliance for medical and dental staff in respect of mandatory safeguarding courses with Safeguarding looked after children compliance the lowest at 48%.
  • We found instances where staff did not follow the trust policy on Mental Capacity Act (MCA) or Deprivation of Liberty Safeguard (DoLS). We highlighted this to the staff and action was taken immediately.
  • The trust participated in the 2016 Lung Cancer Audit and the proportion of patients seen by a Cancer Nurse Specialist was 65.7%, which did not meet the audit minimum standard of 90%.
  • The trust was not JAG (Joint Advisory Group on Gastrointestinal Endoscopy) accredited at the time of our inspection.
  • Trust figures provided prior to inspection showed an increase from the previous year in the number of patients having two or more ward moves, particularly in patients with two moves, which increased from 14% to 20%.
  • We reviewed clinical governance meeting notes from 2 March 2017 and noted the previous meeting was in November 2016, some three months previous. We noted that governance was key issue on the corporate risk register.
  • The following specialties were above the England average for admitted RTT (percentage within 18 weeks), geriatric medicine, neurology, and rheumatology. Some staff we spoke with felt there was unnecessary pressure placed on them to take and discharge patients from the wards and that at times this was uncomfortable for them to manage.
  • The majority of staff we spoke with on the wards were unaware of any local vision or strategy held by the trust in relation to the medical division. However, all staff said that they aimed to put the patients first.

Urgent and emergency services (A&E)

Requires improvement

Updated 2 November 2017

  

We rated this service as requires improvement overall because:

  • We found out of date equipment and medicines in clinical areas, leading to concerns that the checking processes in place were not robust.
  • The department lacked a dedicated mental health assessment room and medical records lacked a formal mental health risk assessment.
  • There was no named safeguarding lead for the department and staff had not reached the Trust’s safeguarding training target for safeguarding children and adults.
  • Medical and nursing staffing levels were below establishment figures.
  • Paediatric medical records did not always contain a documented pain score.

  • The emergency department was not meeting the standard for the national four hour target, which states 95% of patients should be treated, discharged or admitted within four hours of arrival.
  • The time patients spent in the emergency department was consistently higher that the England average from March 2016 to February 2017.

  • Senior staff felt unsupported; there was a lack of support for senior emergency departmental staff from the executive team.
  • Not all risks were identified on the emergency department’s risk register.
  • Divisional governance meetings and senior staff meetings appeared to lack a standard agenda.

However:

  • Staff knew what constituted an incident and how to report and escalate incidents using the electronic system in place.
  • Controlled drugs were stored securely and had been regularly checked.
  • Regular clinical assessment took place for patients waiting on ambulance trolleys to ensure that clinical deterioration was identified in a timely manner.

  • The median time from arrival in the department to initial assessment was better than the England average for 11 months from March 2016 and February 2017.
  • NHS Friends and family test results for people recommending the emergency department were better than England average.
  • We observed staff caring for patients in a kind and compassionate manner.
  • Staff took steps to ensure that the dignity and privacy of patients was respected.
  • Staff had access to a range of specialist nurses and teams to tailor care to a patients specific needs.
  • Medical records contained ‘alerts’ to indicate if a patient had additional needs meaning staff could address individual needs.
  • Processes were in place to assess the demand on the department, with clear escalation processes to maintain patient flow.
  • We saw that complaint information was shared with staff to enable learning from complaints.
  • Local management in the emergency department were supportive and encouraging with staff.
  • The emergency department used quality scorecards to monitor performance.
  • There was a clear vision in place which staff were aware of.
  • Staff reported a good culture within the department; in particular, they told us that senior nurses within the department were always approachable and supportive.

  • The emergency department had implemented a public volunteer programme to provide support to patients and relatives within the department.

Surgery

Good

Updated 2 November 2017

We rated surgical services as good overall because:

  • We reviewed 31 patient records and found all risk assessments were completed, national early warning scores (NEWS) and risk assessments clearly documented.
  • Staff adhered to the trust hand hygiene and ‘bare below the elbow’ policy, and wore personal protective equipment such as gloves and aprons during care.
  • We found a strong culture of multidisciplinary staff working on the wards we visited.
  • Between January 2016 and December 2016, patients at the trust had a lower than expected risk of readmission for elective admissions.
  • During our inspection, we spoke with 22 patients and three relatives. Feedback was consistently positive about their experience of care and support at the hospital.
  • Between March 2016 and February 2017, the Friends and Family Test (FFT) response rate for surgery at the trust was 40%, which was better than the England average of 29% during the same period.
  • There were two dementia care nurse specialists (DCNS) within the trust. The DCNS are notified of every patient over 75 admitted as an emergency via the dementia assessment tool (DAT). All suitable patients are assessed as per FAIR (Find, Assess and Investigate, Refer) utilising the DAT tool for dementia and delirium.
  • There was evidence of learning from complaints across the service.
  • Between February 2016 and January 2017 the average length of stay for surgical patients, both elective and non-elective admissions, was lower (better) than the England average.
  • Staff were aware of the new vision for the trust of, "Delivering great healthcare to every patient, every day". This was evident through the renaming of medical outliers to guests and the increased accountability for these patients.
  • There was a clear governance structure in place for the service.
  • There was an open culture of sharing and learning around complaints and incidents.
  • Staff felt supported and valued by their colleagues.

However:

  • Medical staff compliance with mandatory training was variable. Patient manual handling was the lowest performing subject area at 59%, with only 58 of 99 required staff members attending the training.
  • Nursing staff compliance with safeguarding children update Level 3 was 58%
  • Data supplied by the trust from April 2017 showed the majority of wards within the surgical division were below the required establishment figures. This issue was on the divisional risk register.
  • The trust’s referral to treatment time (RTT) data, between April 2016 and March 2017, for admitted pathways for surgical services had been consistently worse than the England average, and had remained relatively stable at around 60% over the 12 month period.
  • Cancelled operations, not treated within 28 days, was higher than the England average at 12 %.
  • Theatre utilisation had not shown any significant improvement in the 12 month period between April 2016 and April 2017, with the percentage of used sessions, late starts, early finishes and cancellations remaining relatively static and all below trust target. This issue was on the divisional risk register.
  • Only 76% of surgery staff had received an appraisal in the year April 2016 to April 2017.
  • The average theatre utilisation rate at Colchester General Hospital in April 2017 was 78%. This issue was on the divisional risk register.
  • Staff at a local level were uncertain as to the surgical strategy.
  • Staff felt morale was improving, but nursing staff felt that the number of vacancies and subsequent pressure was still affecting staff morale.

Intensive/critical care

Good

Updated 2 November 2017

We rated this service as Good because:

  • There was a good culture of incident reporting and learning from incidents. Duty of candour was understood and discharged appropriately by staff, and we observed this directly during our inspection.

  • There had been a significant improvement in the servicing and cleanliness of equipment since the last inspection. We found all equipment to be visibly clean and in date with electrical safety checking.
  • Infection prevention and control practices were good as were compliance rates for internal audits.
  • The critical care outreach team, provided outreach services into wards, proactively identifying patients who would benefit from closer monitoring, as well as monitoring patients discharged from the unit back into the wards.
  • Nursing and medical staffing levels were in line with national guidance recommendations.
  • Treatment and care was provided in line with best practice and recognised national guidelines.
  • There were numerous examples of good team work across medical, nursing and allied health professionals. Staff worked collaboratively to provide the highest possible care for patients.
  • Feedback from patients and relatives during our inspection was overall very positive.
  • The unit was very responsive to complaints and we saw evidence of where learning from complaints had occurred, as well as bespoke reflective learning and development for individual staff.
  • There was a positive culture within the unit, and staff praised the leadership team for being supportive and approachable.

However:

  • Whilst governance processes were in place, actions plans and some meeting minutes lacked detail. Governance recording processes and quality measures were yet to be embedded.
  • Whilst the service had worked to improve attendance at the mortality and morbidity meetings, these were often poorly attended, with sparse minutes and no clear actions or learning from deaths recorded.
  • Due to new staff taking over the nurse led follow up clinic, there had been a number of months in which data was not received in relation to numbers attended, patients referred to other services such as psychology, or feedback into the service from patients once they had been discharged.
  • Data from the East of England critical care network showed that between April 2016 to March 2017 there were 179 delayed discharges (those between four to 24 hours). Discharges more than 24 hours were 239 from the same period. However it was noted that the unit was working to improve this by early identification of patients that could be discharged, as well as completing a business case to potentially expand the unit providing a high dependency/level 1 facility that could be used for step down. There was no evidence that delayed discharges impacted upon timeliness of admission to the unit.

Services for children & young people

Good

Updated 2 November 2017

We rated this service as good because:

  • Nursing and medical staffing levels and skill mix were generally appropriate to meet patient needs.
  • There was a comprehensive local audit schedule to monitor performance, and participation in national audit, with actions for improvement following audits.
  • Policies and procedures were up-to-date, and based on national guidance and best practice.
  • Staff were well supported to develop their skills and competencies. For example, the transition nurse lead was on a degree pathway to complete an adolescent health course.
  • Multidisciplinary team (MDT) working was strong both internally and externally. MDT meetings involved all relevant staff and everyone had an opportunity to contribute.
  • All observations of staff interaction with patients showed compassionate care and staff tailored their communication to suit the needs of each child.
  • Parents and families were actively involved in the care of their child and staff took time to ensure they understood information given to them.
  • There was a dedicated community nursing team working in schools and the wider local area to meet the needs of the local population.

  • Discharge planning was integral to patient care plans throughout the patient’s stay in hospital. The NNU had implemented a ‘discharge passport’ aimed at involving parents more centrally in discharge planning. There was a focus on nurse-led discharges in straightforward cases, meaning nursing staff did not have to wait for a doctor to approve the discharge.
  • There was a team of specialist nurses to provide support for patients with diabetes, epilepsy and asthma, gastroenterology, urology and oncology.
  • There was a dedicated transition team for adolescents approaching their transfer to adult services. They worked with other teams to meet the more complex individual needs of patients at the age of transitioning to other services. For example, they ran a joint clinic with the epilepsy specialist nurse three to four times a year. There was a gradual, long-term approach to transition starting around the age of 14, which included a ‘transition passport’ system, where staff from both paediatric and adult services documented changes and progress.
  • Complaints were discussed as part of the patient safety group which took place weekly as part of the medical handover.

  • There was a comprehensive strategic vision for the service for the next three years.
  • The risk register was closely monitored and up-to-date, and matched the areas of risk we saw on inspection. Risks were reviewed at a weekly risk management meeting by the service leads. This fed into the monthly ‘two at the top’ risks, which were circulated among staff and escalated up to the trust clinical governance team.
  • The clinical and nursing leads showed strong leadership and oversight of the service. Staff said they were well-supported by the leads.
  • There was a positive, supportive culture in the service.
  • The service had initiatives to engage the local population and service users; for example, there was a support group called ‘Little Miracles’ for mothers who had previously had their children treated in the neonatal unit.

However:

  • We were not assured that staff were consistently reporting all incidents through the electronic incident reporting system, or that formal systems to ensure actions from incidents were not shared consistently among all staff.
  • There had been an increase in medicines incidents between March and May 2017. This was due to inconsistent checking of drug charts by theatre staff when children were taken for surgery, and different types of documentation used by the paediatric and theatre teams. However, the service had recently introduced red stickers in the patient notes as an action to address this.
  • The 13 sets of patient records we reviewed were variable in their content and completion. For example, one set of notes did not include the time of review or why the patient was reviewed, and a discharge summary did not indicate whether there were any medications allergies.
  • The policy for safeguarding children was not in line with best practice; for example, it did not set out who was responsible for completing body maps, and it was not trust policy or procedure to have all child protection cases overseen by a paediatrician.
  • Children undergoing surgery had to be transported through the adult recovery area to reach the children’s recovery area.
  • There was no flagging system within records to highlight clearly patients with learning disabilities.

End of life care

Good

Updated 2 November 2017

End of life care at Colchester General Hospital was rated good overall.

  • There were systems and processes in place to report and investigate incidents involving palliative care patients and those at the end of life.
  • Staff were aware of their role and responsibilities in relation to safeguarding. The trust’s mandatory induction programme provided training from the palliative and end of life care team.
  • The trust had an end of life care facilitator, a palliative clinical skills nurse who worked across the trust to support ward based training and each ward had a palliative/end of life care champion.
  • Care and treatment followed national guidelines within individualised care plans for patients.
  • The trust monitored its own effectiveness with clinical audits and compared its performance with other trusts nationally.
  • The trust specialist palliative care team provided support Monday to Sunday between 9am and 5pm.
  • Staff were seen to provide kind and compassionate care across clinical areas. Patients’ dignity was maintained at the end of life. Patients and relatives felt well informed about the care being provided.
  • The specialist palliative care team and chaplaincy service provided emotional support to patients and relatives.
  • The specialist palliative care team (SPCT) and the ward staff were passionate about ensuring patients and people close to them received safe, effective and quality care.
  • The SPCT was led by a consultant in palliative medicine. The SPCT and the trust’s end of life care facilitator were focussed on raising staff awareness around end of life care (EOLC). The SPCT delivered education for medical, nursing and allied health care professionals at trust induction, preceptorship programme, study days, and also on the medical training programme.
  • The chaplaincy was able to contact religious leaders of other faiths and had over 40 chaplaincy volunteers on the list.
  • There was evidence of learning from complaints and concerns raised by patients and their relatives.
  • Staff across all areas of the hospital acknowledged the importance of end of life care. The executive team and senior nursing team were aware of the concerns with end of life care and were receptive to the need to improve the service for patients.
  • The trust had a clear strategy and vision in place for end of life care.
  • The trust was robustly monitoring the effectiveness and the responsiveness of the service to patients and their families. Minutes of meetings both operational and business meetings did demonstrate a review of key performance indicators.

However:

  • The Individual Care Record for The Last Days of Life (ICRLDL) recorded prescription, treatment and care plan. The ICRLDL had guidance on anticipatory prescribing but did not contain maximum doses or advise on the frequency of the administration of medication. This could potentially lead to inappropriate doses being administered. However we found no evidence that this had happened and there were systems in place so prescriptions were reviewed.

  • There was a lack of consistency in how patient’s mental capacity was assessed and not all decision-making was informed or in line with guidance and legislation when a do not attempt cardiopulmonary resuscitation order (DNACPR) was completed. In three cases we found that the patient was not made aware of the decision taken by medical staff not to resuscitate, despite the patient having capacity.
  • The trust had a process in place for fast track discharge, however it was acknowledged by the trust to not always be rapid or fast, with some cases taking up to 189 hours (7.8 days) in May and 119 hours (five days) in June to get a patient discharged. There were focused action plans in place to monitor and address this through a range of initiatives in the Every Patient Every Day programme.

Outpatients

Requires improvement

Updated 2 November 2017

We rated this service as requires improvement because:

  • Referral to treatment times (RTT) were worse than the England average in all but one measurement (urgent two week referrals where they were better) and below the operational standards.
  • There were 2,863 patients out of 12,194 patients who had waited 13 weeks and over for a first appointment. The number waiting had been below 1,500 for most of the year April 2017 – May 2017 but had increased in the month prior to our inspection.
  • There was still a significant backlog of patients shown as awaiting appointments although this had improved since the previous inspection, and review had shown that a large proportion of the backlog was likely due to appointments not being correctly reconciled on the system. There were processes in place to resolve this and every patient had been risk assessed whilst waiting in the backlog.
  • Medical staff compliance with mandatory training was variable, with adult basic life support being the lowest at 50%.
  • The trust overall cancellation rate was around 25% for the period April 2016 to March 2017. However patient cancellations were high at around 14%. The hospital cancelled around 8% of clinics at short notice (less than 6 weeks’ notice).

However:

  • There were no significant concerns identified within the diagnostic services we inspected, we found that there was learning from incidents and effective processes in place.
  • Leadership in the outpatients department was organised and effective and action plans had been implemented to address known concerns.
  • There was a positive culture and staff were proud of the care they gave despite numerous recent leadership changes.
  • Patients were treated with dignity and respect.
  • Staff in radiology were supported to develop, with radiographers learning reporting skills and a new radiographer consultant post in breast imaging.