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Colchester General Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 8 January 2020

Our rating of services. We rated them as requires improvement because:

A summary of this hospital appears in the overall summary above.

Inspection areas

Safe

Requires improvement

Updated 8 January 2020

Effective

Good

Updated 8 January 2020

Caring

Good

Updated 8 January 2020

Responsive

Good

Updated 8 January 2020

Well-led

Requires improvement

Updated 8 January 2020

Checks on specific services

Medical care (including older people’s care)

Good

Updated 8 January 2020

Our rating of this service stayed the same. We rated it as good because:

  • We rated safe, effective, caring, responsive and well-led as good.
  • Staff understood how to protect patients from abuse. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff provided good care and treatment and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.

However:

  • During our inspection, we found a number of patient safety concerns mainly related to one ward only. This included not having enough nursing staff with the right qualifications and skill mix to keep patients safe, medicines were not prescribed and administered correctly and risk assessments were not consistently completed and updated. The concerns were mainly isolated to one ward. The trust responded immediately to ensure that patients were safe and we continue to monitor progress to their action plan through regular engagement.
  • Leaders did not run all services well and support staff to develop their skills. Most staff felt respected, supported and valued; however, some staff felt that their concerns were not acted upon.
  • Not all governance and management functions performed together effectively. Control measures to mitigate identified risks were not always robustly monitored.

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.

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.

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.

Surgery

Good

Updated 8 January 2020

  • The service had enough staff to care for patients and keep them safe. Staff understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. Medicines were safely prescribed and administered. Staff recognised and reported incidents and near misses. Staff collected safety information and used it to improve the service.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients. Staff advised patients how to lead healthier lives and supported them to make decisions about their care and treatment. Key services were available seven days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However:

  • Although the service provided mandatory training in key skills, not everyone completed it.
  • Resuscitation equipment was not always checked in line with professional guidance.
  • The service did not effectively audit compliance with the World Health Organisation’s Five Steps to Safer Surgery checklist.
  • Medicines were not always recorded and stored in line with trust policy.
  • Changes made from never events were not yet fully embedded in clinical practice.
  • Referral to treatment times were below the England average.
  • The access and flow in recovery needed improving. Patients could not always be discharged from recovery to the ward as ward capacity was full.
  • Although there were clear processes for managing risks, issues and performance, we were not assured that service risks were always effectively identified.

Urgent and emergency services

Requires improvement

Updated 8 January 2020

Our rating of this service stayed the same. We rated it as requires improvement because:

We rated safe, responsive and well-led as requires improvement. We rated effective and caring as good.

  • The service did not have enough staff to care for patients and keep them safe. Not all staff had completed the required mandatory training. Staff did not consistently assess risks to patients presenting with acute mental health illness and act on them, particularly in relation to environmental risks. Safe processes were not always followed to ensure medicines were always stored and recorded correctly.
  • The service did not have enough medical and nursing staff with the right qualifications, skills and training to keep people safe from avoidable harm.
  • People could not always access the service when they needed it and sometimes had to wait for treatment.
  • The service did not operate effective governance and risk management systems. Not all risks the service faced had been effectively identified, monitored or mitigated (where possible) by leaders within the service.

However,

  • The service controlled infection risk well. Staff understood how to protect patients from abuse. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff provided evidence-based care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers made sure staff were competent. Staff worked well together for the benefit of patients, and supported them to make decisions about their care. Key services were available seven days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • Leaders used reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care.

Maternity

Good

Updated 8 January 2020

We rated it as good because:

  • We rated safe, caring, effective, responsive and well-led as good.
  • Midwifery and medical staff had training in key skills. The service controlled infection risk well. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service. The design, maintenance and use of facilities, premises and equipment kept women safe. Staff were trained to use the equipment. Staff managed clinical waste well. When providing care in the women’s home staff took precautions and actions to protect themselves and others.
  • Staff provided evidence based care and treatment, gave women enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of women, advised them on how to lead healthier lives, supported them to make decisions about their care. Key services were available seven days a week.
  • Staff treated women with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to women, families and carers.
  • The service planned care to meet the needs of local people, took account of women’s individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. They were focused on the needs of women receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However:

  • The service did not have enough midwifery staff with the right qualifications, skills, training and experience to keep women safe from avoidable harm. The service continued to include supervisory staff in clinical duties due to staff shortages, which meant that they were unavailable to support junior staff.
  • Whilst most staff felt respected, supported and valued, some staff felt that appropriate actions were not always taken to address behaviour that did not meet the trust’s values.

Outpatients

Good

Updated 8 January 2020

This is the first time we have inspected this service separately from diagnostic imaging, so we cannot compare previous ratings. We rated it as good because:

  • The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed patient safety well. The service controlled infection risk well. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service. However, some documents within the patient records were not always secure.
  • Staff provided evidence based care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care. Key services were available seven days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually. However, the trust strategy and vison was under development and the service did not have its own vision and values.