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Colchester General Hospital Requires improvement

Reports


Inspection carried out on 25 -27 July 2017 and an unannounced on 2 August 2017

During a routine inspection

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 carried out on 15th-18th September, 3rd and 8th October 2015

During a routine inspection

The Care Quality Commission (CQC) carried out a comprehensive inspection between the 15th and 18th September 2015. We carried out this comprehensive inspection as part of our regular inspection programme to follow up on previous inspections of trusts in special measures where further improvements were required. Colchester Hospital University NHS Foundation Trust was placed into special measures in November 2013 and was fully inspected in May 2014 where it was provided with an overall rating at the trust wide leadership level of inadequate. Further inspections of the trust’s primary location Colchester General Hospital were undertaken in response to concerns in November, December 2014, and July 2015 where urgent enforcement action was taken to protect patients from the risk of harm. Following the November and December inspection the rating for the location Colchester General Hospital was changed from requires improvement to inadequate.

Prior to this inspection the trust was identified as having seven elevated risks and twelve risks on the Care Quality Commission’s (CQC) Intelligent Monitoring system in May 2015. The overall percentage score of risk, which is how these reports and organisational risk is calculated, increased from 4.8% in March 2014 to 11.5% in May 2015.

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 2016 and the only services currently provided on site are outpatient services and ophthalmic eye surgery under local anaesthesia. Colchester General hospital has 560 beds and provides district general hospital care to 370,000 people in North Essex. For this inspection we inspected both sites but have reported on both in the one main location report.

During this inspection we found that the trust had capacity issues and were having to reassess bed capacity at least three times a day. We found that staff shortages meant that there was a high use of agency staff which did impact on the quality of care provided to patients. We found that required improvements, identified at previous inspections since May 2014, had not been undertaken, this included the service, maintenance and repair of equipment which was found to be poorly undertaken throughout the trust. Outpatient service provision had deteriorated and the trust had lost grip on the number of patients who required treatment through outpatients. End of life care provision had also deteriorated since it was last inspected in May 2014 with patients not receiving safe or effective care at the end of their life.

We have rated Colchester Hospital University NHS foundation Trust as inadequate overall, the location Colchester General Hospital as inadequate although we found that the trust employed staff were highly motivated and were working through many issues to drive improvements locally, they were however impacted by the high use of agency, some of whom were poor in quality of care, which caused them real frustration. We have rated the overall trust as inadequate as there was a lack of management oversight and robust governance systems in place to highlight the concerns we found during this inspection.

Our key findings were:

  • There was a significant and substantial shortfalls in registered nursing staff in a number of areas. Overall the trust had a shortfall of 244 (20%) registered nurse vacancies from Band 5 to Band 7 in May 2015.

  • There were wards throughout the trust which had very high agency usage noted with staffing on five wards ranging between 80-100% agency use at weekends and at night time. A further 6 wards had agency use above 30% continuously.

  • There were significant medical staffing vacancies with a shortfall of 81 WTE (15.8%), which meant that there was a high use of locum medical staff. The shortages of junior, trainee and middle grades was especially notable across medical and surgical specialties during the inspection.

  • We found the executive leaders in the trust were not always aware of the risks or significant issues within the trust and required inspections to identify these for them. Where risks were identified they had they either did not consider them to be significant or follow them through to completion.

  • The trust was reactive to risk when it was identified, such as taking action to improve services that were previously inspected however the high level of focus on one area was not always proportionate and worked to the detriment of other areas in the trust with risk.

  • Concerns with the equipment not being electrical safety tested, serviced, maintained or calibrated was identified during previous inspections in May, November, December 2014. During this inspection we identified that the equipment within critical ward and departments such as A&E, critical care, theatres and maternity was out of date. The trust was aware of this issue but failed to take appropriate action in a timely way. We raised this with the trust during the inspection and they provided us with a plan to ensure the equipment concerns were resolved by 31 March 2016.

  • Pressure on surgical services meant routine operations were frequently cancelled and patients were waiting longer than the 18-week referral to treatment target for operations. The reasons provided for cancellations were linked to bed availability and administration reasons but in many cases patients were not being rebooked quickly.

  • Pressure on the cancer services meant that there were many reported incidents of patients who had gone more than 100 days without treatment for their cancers. Cancer performance on the RTT was also poor and showed a downward trend noted between July 2014 and May 2015, though some improvement was noted between May and September 2015.

  • The disjointed approach to the management and booking of outpatients placed pressure on the service with some bookings going through the division and some going through the central booking team. The trust executive team were not clear on what their risks within outpatients were without the numbers for each service. There was also a real lack of understanding at the trust board level of what was required for the monitoring and management of admitted and non admitted referral to treatment times.

  • The trust was not aware of the current patient backlogs and active patient waiting lists in outpatient services. Following the inspection we were informed about the issues with validating outpatient data and the backlog of pathways. It was subsequently found that there were in the region of 370,791 open referrals that required review of which around 149,000 were high risk. This backlog and pressure meant that there were long and in some cases severe delays for some specialties and not all patients being followed up appropriately.

  • The longest wait noted on the 18 week pathway was in the region of 116 weeks.

  • As of January 2016 the trust confirmed that they had commenced the validation of the open referrals on their system to assess if there had been any adverse impact of this issue on patients, and ensure patients receive appropriate treatment.

  • We observed several examples of patients who should have been receiving dedicated end of life care who were not because staff had not identified that they were at the end of their life.Due to the lack of identification of patients at the end of their life the standard procedures for end of life care plans were not given priority or utilised when needed.

  • Operational management of the beds, capacity, and flow was not organised well by the leaders of the services and did not provide effective outcomes which delivered support to services in need to capacity including the emergency department and intensive care.

  • The approach from the trust the monitoring of mortality including the undertaking of mortality and morbidity meetings to review trends and improve patient care was inconsistent. There were areas where these meetings and reviews were not taking place.

  • The trust has seen a steady increase in mortality over the last six months. At the time of the inspection the last Hospital Standardised Mortality Ratio (HSMR) for the trust was 103 and their Summary Hospital-level Mortality Indicator (SHMI) was 106.7 however their weekend mortality ratio was 113.6.

  • The way in which responses to complaints and concerns were handled by the trust was not consistent, with some poorly investigated and non-supportive responses being issued, which resulted in further complaints being raised about the complaints process. This was evident with the trust being highlighted as one of the top reported trusts in England where complaints management and responses are referred to the Parliamentary Health Service Ombudsman.

  • The four hour standard was only being achieved for around 80% of patients, with significant numbers of patients waiting more than 4-12 hours for admission.

  • Overall there had been some improvement in the care delivered on the medical wards.However, Safety was rated as inadequate.

  • Care on some medical and surgical wards as well as the postnatal ward was poor with patients not being treated with sufficient dignity and respect and call bells not always being answered promptly.

  • There was improvement in the culture of being open in some areas of the hospital, however staff in many areas still felt unable to speak up about concerns they had regarding services and care.

However, we also found examples of innovation and good practice including:

  • There was notable desire from the staff to make the changes needed to improve their departments and services to ultimately provide good care to patients. The enthusiasm of staff to deliver this was positive.

  • The core permanent employed trust staff working on the frontline were, in the majority, dedicated professionals who wanted to provide the best care possible to their patients and were caring, however they felt let down because the agency staff employed did not all show the same commitment to values of good care.

  • There were areas were good and innovative practice was taking place particularly in maternity with hypnobirthing and in critical care with staff being involved in research, which has led to national and international publication of their research.

  • The mortuary team worked exceptionally well to provide a service when capacity for patients was limited and were innovative and resourceful to cope with demand.

There were areas of poor practice where the trust needs to make improvements.

Importantly, the trust must ensure that:

  • Ensure that there is a suitable training provision in place to support staff to recognise and identify patients at the end of their life so that appropriate treatment can be provided.

  • Ensure that staff receive training to use the dedicated end of life pathway so that patients can receive appropriate care at the end of their life care and treatment.

  • Ensure that do not attempt cardiopulmonary resuscitation (DNACPR) decisions are undertaken in accordance with national guidance and best practice.

  • Ensure that mental capacity assessment are undertaken in the patients best interest, prior to agreeing medical decisions regarding care or treatment.

  • Ensure that staff are trained and assessed as competent to use equipment which is required for the provision of patient care.

  • Ensure that there a policy, procedure and strategy for end of life care is developed.

  • Ensure there is a robust incident and accident reporting system, including reporting of lessons learnt to all groups of staff.

  • Take action to ensure patients receive appropriate and timely clinical review and that the system for escalation of a patients deteriorating condition is robust.

  • Ensure that there are sufficient numbers of qualified, skilled and experienced nursing staff in all patient areas at all times.

  • Complete a review of senior medical staffing and consultant support, especially within Orthopaedics, to ensure that there are sufficient numbers of qualified, skilled and experienced medical staff at all times, across all specialities.

  • Ensure that there are sufficient numbers of suitably qualified medical staff, below consultant grade, on duty at all times.

  • Ensure that medicines are stored in accordance with manufacturers and legislative guidance and that staff take appropriate actions when temperatures breaches occur.

  • Ensure that patient’s records are appropriately stored in accordance with legislation at all times.

  • Ensure that policies and procedures are formalised and in place and that all staff have awareness and can access trust policies and procedures.

  • Ensure that temporary and locum medical staff have access to the appropriate hospital systems to ensure continuity of patient care.

  • Review admission times and fasting periods for patients awaiting surgery to ensure the nutritional and hydration needs of the patient are met.

  • Ensure local audit and review of patient outcomes is consistent across all areas.

  • Ensure that all staff have receive an appraisal and frequent supervision.

  • Review handover arrangements and ward rounds to ensure that they are effective and include the multidisciplinary team to ensure holistic review of a patients care and treatment.

  • Review the process for obtaining patient consent to surgery to ensure that patients have adequate time to consider informed consent.

  • Review staff communication with patients and relatives to ensure that patients are treated with dignity and respect, to include maintenance of patient privacy during nursing handover.

  • Review the arrangements for internal transfers of patient, including moves at night, to ensure this is kept to a minimum.

  • Ensure a robust system for risk assessment is in place and that the governance structure introduced is consistent across all areas to ensure safe care and treatment.

  • Improve patient care to those on cancer pathways by reducing waiting times for treatment.

  • Improve mandatory and statutory training rates.

  • Ensure that patients are risk assessed and prioritised in outpatient pathways.

  • Ensure that duty of candour is undertaken in all outpatient cases where significant delays have been identified and the patient was placed at risk of harm.

  • Ensure that there is a robust safety oversight of dermatology service provision.

  • Ensure that staff are enabled to freely speak up about concerns and provide feedback about services and care without fear of reprisal.

  • Review the processes formotality and morbidity within the divisions to ensure that risks, trends and lessons are learned from patient deaths.

The trust should also:

  • Provide support to medical staff throughout the trust on breaking bad news to patients and their families.

  • Review the handover procedures on wards so that patient privacy is respected.

  • Review the fridge capacity within the mortuary and develop a future plan for the sustainability of service provision.

  • Review working relationships and arrangements in place to support rapid and fast track discharges for patients at the end of their life.

  • Undertake audits and monitor activity on preferred place of death to meet patients preferences.

  • Reviewing the nursing, and medical and leadership establishments within end of life care.

  • Improve governance arrangements by improving learning and the identification of trends from complaints and incidents.

  • Review the arrangements and focus on end of life care to ensure that its given sufficient priority on the directorate, board and patient council agenda.

  • Review the complaints process to ensure that lessons to be learnt are communicated to staff.

  • Ensure there are sufficient therapy staff out of hours and at weekends to provide services and minimise delays to patient discharge.

  • Review staff communication and engagement within the therapy services and theatre.

  • Review the length of time patients are on trolleys within the emergency department, EAU, SAU and on Copford ward and ensure risks of harm to patients is minimised.

  • Improve staff understanding to raise concerns and report incidents and near misses.

  • Ensure the care and treatment of those patients identified as having a long term conditions reflects current evidence-based guidance, standards and best practice.

  • Consider reviewing the policy for patient movement out of hours.

  • Ensure there is a timely review of the provision of services within the endoscopy unit.

  • Ensure the security of patient records to minimise the risk of access by an unauthorised person.

  • The trust should ensure there is a consistent approach to patient handover within the division to ensure patient’s privacy and dignity is maintained.

  • Review the process for the creation of temporary records in outpatients.

  • Review caring, culture and morale on the wards highlighted in the inspection report as requiring support to improve the attitude and care provided to patients.

  • Review the staff morale and concerns highlighted by staff in outpatient booking centre, therapies, endoscopy and radiology to find a resolution which improves services.

Following our inspection at Colchester Hospitals University NHS Foundation Trust a new chief executive was appointed and a new action plan drawn up against the feedback provided at the inspection. We note that since our inspection there has been some limited progress against our areas of concern. I am therefore recommending that the trust remain in special measures for a period of three months during which time they will submit a weekly dashboard of key improvement indicators to relevant stakeholders in order that we continue to monitor improvements. Based on the findings of this inspection I have recommended that further regulatory action be taken and required the trust to make significant improvements on the care and service they provide to patients.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 08 and 14 July 2015

During an inspection to make sure that the improvements required had been made

Colchester General Hospital is part of the Colchester University Hospital NHS Foundation Trust. The hospital is an acute hospital providing accident and emergency (A&E), medical care, surgery, critical care, maternity, children and young people’ services, end of life care and outpatient services, which are the eight core services always inspected by the Care Quality Commission (CQC) as part of its new approach to hospital inspection.

Colchester General hospital is a 560 bed district general hospital, in Colchester. The trust as a whole employs over 4,000 staff, the majority of whom are based at Colchester General. The hospital provided a range of elective and non-elective inpatient surgical and medical services as well as a 24-hour A&E, maternity and outpatient services.

We carried out this focused inspection on 8th July 2015 in response to information of concern around staffing, performance and care received by patients in the surgery and medical care inpatient wards. We returned to the hospital on 14th July 2015 to conduct an inspection at night after receipt of further concerns relating to staffing and care provided to patients at night time.

Our key findings were as follows:

  • Staffing levels on the wards were meeting the trust defined numbers required with support from agency staff due to the low numbers of permanent trust staff available. However the numbers of staff on duty to provide patient care on Birch and Brightlingsea and Mersea ward were not sufficient to meet the levels of patient dependency seen on the wards during our inspection.
  • Staffing levels were determined on numbers of nurses per patients. Acuity and dependency was not taken into account when routinely staffing the wards. Whilst these numbers were met with the support of agency and bank nurses these numbers did not always meet the needs of the patients on the ward.
  • There was an inconsistent approach to providing local induction to agency, temporary and redeployed staff. Competency and induction checklists for staff were not available on the wards for the shift leads to review to ensure that safe care was provided to patients and we found that staff had not been inducted or trained to safely work in the service.
  • The completion of records was poor on all wards, two medical wards were better than the others however records were incomplete and difficult to navigate.
  • IV Cannula Care monitoring and recording placed patients at risk of infection.
  • Incidents of poor hand hygiene were observed throughout the wards.
  • Consent for procedures did not always follow trust policy, particularly when a person lacked metal capacity to make a decision regarding treatment.
  • The use of Deprivation or Liberty Safeguards did not follow the national guidelines in two of the four cases we reviewed.
  • The completion of ‘Do Not Attempt Cardio Pulmonary Resuscitation’ (DNACPR) forms was not undertaken in line with best practice guidelines in eight of 11 cases reviewed.
  • Monitoring of deteriorating patient conditions using the national early warning scores (NEWS) was inconsistent throughout the wards.
  • Pressure ulcer care recording was limited, particularly on Birch and Brightlingsea wards. There was no grading or treatment plans, review dates, turn requirements or needs assessments. Turns that we saw recorded were tick box based and we were not assured that patients received turns to reduce the risk of pressure damage to their skin.
  • Oral Care on Aldham and Brightlingsea was poorly recorded and the observation through physical view was that patients’ oral hygiene was in poor condition on these wards.
  • On the Emergency Assessment Unit (EAU) the trust was complying with the conditions which were imposed on their registration in December 2014.
  • Staffing levels on the EAU had improved however this improvement was supported by the use of bank and agency staff.

We identified the following areas of poor practice where the trust needs to make improvements.

Importantly, the trust must ensure:

  • That the staffing numbers on inpatient wards take into account the acuity and dependency needs of patients.
  • That the agency staff, bank staff and trust staff who work on a ward for their first shift receive a local induction to the ward.
  • That the medicines policy in place is adhered to in that only staff who have completed competency training on IV medicines are able to administer IV medicines and the responsibility for the keys remains with the nurse in charge.
  • That the door to the roof terrace on Birch ward is secure at all times.
  • That improvements are made with regard to the awareness and understanding of mental capacity and deprivation of liberty safeguards.
  • That patients are informed of decisions not to resuscitate where appropriate to do so and where this is not possible that the Mental Capacity Act 2005 has been adhered to.
  • That staff adhere to its policies including resuscitation, consent and moving and handling.

In addition the trust should ensure:

  • That the resuscitation trolleys are checked in accordance with the trust policy.
  • That it improves the culture of openness throughout the trust so that the staff can speak without fear of consequences for doing so.
  • That observations of patients at risk of deteriorating are undertaken in a more timely way.
  • That agency and bank staff on wards are appropriately observed and provided with support during their shifts.
  • That prescribed medicines are administered in a timely way.
  • That a review of the culture around care on Brightlingsea ward is undertaken.
  • Review the lighting on Birch ward to ensure that that patients’ are able to rest at night time.
  • Ensure lessons from incidents are learnt and shared amongst all staff.

The trust is already in special measures we have informed Monitor of these breaches, who will make sure they are appropriately addressed and that progress is monitored through the special measures action plan.

The Care Quality Commission has taken further enforcement action against this trust as a result of the findings from this inspection. This enforcement action, to place conditions on the trust’s registration to ensure that patients are protected from the risk of harm, was required because we were not assured that patients would be safe unless we took this action.

A comprehensive inspection will be undertaken in September 2015 to determine if improvements have been made.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 12, 27 November and 23 December

During an inspection to make sure that the improvements required had been made

Colchester General Hospital is part of the Colchester University Hospital NHS Foundation Trust. The hospital is an acute hospital providing accident and emergency (A&E), medical care, surgery, critical care, maternity, children and young people’ services, end of life care and outpatient services, which are the eight core services always inspected by the Care Quality Commission (CQC) as part of its new approach to hospital inspection.

Colchester General hospital is a 608 bed district general hospital, in Colchester. The trust as a whole employs over 4,000 staff, the majority of whom are based at Colchester General. The hospital provided a range of elective and non-elective inpatient surgical and medical services as well as a 24-hour A&E, maternity and outpatient services.

We carried out this responsive inspection to respond to information of concern around performance and care received by patients in the accident and emergency department and the emergency assessment unit.

The inspection team consisted of six experienced CQC inspectors including one paramedic and four nurses, one inspection manager and the Head of Hospital Inspection for the area. The inspection took place on 12 November and we returned to follow up a whistleblowing concern on 27 November 2014. Both of these visits were unannounced.

Our key findings were as follows:

  • Staff were exceptionally busy during our inspection and therefore did not always come across as caring to patients or treat patients with dignity and respect.  
  • We observed that the dignity of the deceased or dying was not always respected.
  • Patients largely spoke positively about the care that they received although at some times communication needed to be improved.
  • The emergency department was not always clean and staff in the emergency department and EAU did not adopt good hand hygiene techniques or hand washing practices.
  • We observed that people’s care was not always provided in their best interests in accordance with the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards.
  • The risk of patient deterioration was not acted upon in a timely way because the early warning indicators of deterioration were not always acknowledged.
  • The EAU did not operate their GP triage area because the 17 spaces had been converted into inpatient beds taking the unit to 62 beds in total.
  • Staffing levels on EAU were not sufficient and had not been assessed based on patient acuity in line with NICE guidelines. The patients on the ward during our inspection required a higher level of care.
  • Staffing levels in the emergency department were managed fluidly enough which left high risk areas such as resus short of staff on occasions.
  • The surges in activity meant that people had long waits to access services.
  • Patients were being stepped down from the emergency department resuscitation area into EAU without any clinical procedures in place to support patient care needs.
  • Care in the emergency department did not always adhere to NICE guidelines, particularly around head injuries.
  • Improvements were required in terms of the reporting and learning from incidents.
  • Governance structures at a departmental level were not robust and were in significant need of improvement.
  • Staff morale was very low across both areas and staff stress levels were high.

There were areas of poor practice found where the trust needs to make improvements.

Importantly, the hospital must:

  • Ensure that a patient’s mental capacity is assessed appropriately and that records are up dated and maintained in accordance with the Mental Capacity Act 2005.
  • Ensure that care provided in the best interest of the patient complies with the legal framework of the Mental Capacity Act Deprivation of Liberty Safeguards so that if a patient is restrained this is undertaken appropriately.
  • Ensure that treatment in the emergency department particularly around head injuries and chest pain, is provided in accordance with NICE guidelines.
  • Ensure that there is a standard operating procedure (SOP) in place for patients who are clinically assessed as safe to be ‘stepped down’ from the resuscitation department to the EAU.
  • Ensure that the early warning score system (NEWS) is used effectively to respond to the risks of patient deterioration in a timely way.
  • Ensure that there is a robust incident and accident reporting system in place to ensure that lessons learnt from investigations are shared with staff to improve patient safety and experience.
  • Ensure that staff complete their mandatory training and have access to necessary training, especially safeguarding vulnerable adults and children, mental capacity and resuscitation, and development to ensure they maintain the appropriate skills for their role.
  • Ensure that all patients’ records are kept up to date and appropriately maintained to ensure that patients receive appropriate and timely treatment.
  • Ensure that there are sufficient numbers of qualified, skilled and experienced staff at all times, particularly in the Emergency department and on the EAU.
  • Review the patient flow from the A&E department to ensure that patients are assessed to meet their needs and there are no unnecessary delays.
  • Review the complaints process to ensure that appropriate lessons can be learned and improvements made in service delivery.
  • Ensure all staff adhere to the infection prevention and control of infection policy and procedures, particularly with regard to hand washing, cleaning procedures and curtain changes in the Emergency department and on the EAU.
  • Ensure that do not attempt cardio-pulmonary resuscitation complies with best practice and national guidance, involves the patients or their representatives and that these discussions are recorded, those decisions are communicated with all staff to ensure that those decisions are respected.
  • Ensure that the plans for escalation of high patient activity in the emergency department are reviewed to ensure that the service responds to surges of activity in a timely way.

We would normally take enforcement action in these instances, however, as the trust is already in special measures we have informed Monitor of these breaches, who will make sure they are appropriately addressed and that progress is monitored through the special measures action plan.

In addition, the hospital should:

  • Review the involvement of staff within the emergency department and EAU to ensure that staff are fully aware and engaged with the trust vision, strategies and objectives and can contribute to the development of services.
  • Ensure that the bed base within the EAU is maintained at 45 inpatient beds and 17 GP triage beds where reasonably practicable.
  • Provide additional support to managers and staff within the emergency department and EAU at times of high service activity.
  • Review the information following clinical audits and ensure that any actions and learning are shared with staff.
  • Review the training available to staff on caring for people living with dementia or with a learning disability and provide training to ensure that staff have the appropriate skills for their role.
  • Review the procedures within the emergency department of transferring or transporting deceased patients during periods of high activity to ensure the dignity of the deceased is respected.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 6, 7, 8, 16 & 19 May 2014

During a routine inspection

Colchester General Hospital is part of the Colchester University Hospital NHS Foundation Trust. The hospital is an acute hospital providing accident and emergency (A&E), medical care, surgery, critical care, maternity, children and young people’ services, end of life care and outpatient services, which are the eight core services always inspected by the Care Quality Commission (CQC) as part of its new approach to hospital inspection.

Colchester General hospital was a 600-bed district general hospital, in Colchester. The trust as a whole employs over 4,000 staff, the majority of whom are based at Colchester General. The hospital provided a range of elective and non-elective inpatient surgical and medical services as well as a 24-hour A&E, maternity and outpatient services.

We carried out this comprehensive inspection as a follow-up to the inspection that was undertaken last year as part of the Keogh Mortality Review.

The inspection team included CQC inspectors and analysts, doctors, nurses, patients and public representatives, experts by experience and senior NHS managers. The inspection took place between 6 and 8 May 2014, with an unannounced visit on 16 and 19 May.

Overall, we rated this hospital as ‘requires improvement’. We rated it ‘good’ for providing caring care, but required improvement for safe, effective, responsive and well-led care.

We rated critical care and surgery services as ‘good’, but A&E, medicine, maternity services, children and young people’s services, end of life care and outpatient services all required improvement.  

Our key findings were as follows:

  • Staff were caring and compassionate and treated patients with dignity and respect.
  • Patients largely spoke positively about the care that they received although at some times communication needed to be improved.
  • The hospital was clean and staff were observed to wash their hands appropriately.
  • A review of nurse staffing levels had been undertaken and staffing levels had been increased. Safe staffing levels were being monitored and maintained but there was a heavy reliance on nurse bank and agency staff in some areas. Staff recruitment was continuing.
  • The hospital had worked hard to understand the causes for its high Summary Hospital Mortality Indicator (SHMI) but it was still statistically high.
  • Improvements were required in terms of the reporting and learning from incidents.
  • Governance structures at a departmental level needed to be more consistent.

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

Importantly, the hospital must:

  • Ensure that there is a robust incident and accident reporting system in place; including reporting staff shortages and that lessons learnt from investigations of reports are shared with staff to improve patient safety and experience.
  • Ensure that all equipment has safety and service checks in accordance with policy and manufacturer’s instructions and that the identified frequency is adhered to, including emergency equipment requiring daily checks, portable appliance testing and regular maintenance.
  • Ensure that all patients’ records are kept up to date and appropriately maintained to ensure that patients receive appropriate and timely treatment.
  • Review the process for referring safeguarding concerns to the local authority to ensure that these are undertaken appropriately for the safety and wellbeing of patients.
  • Ensure that there are sufficient numbers of qualified, skilled and experienced staff at all times, particularly in A&E, medical wards and children’s services including the high dependency unit.
  • Review handover arrangements to ensure that they are effective and the necessary information is passed to the next responsible staff team so that patients receive appropriate treatment in a timely manner.
  • Ensure that staff complete their mandatory training and have access to necessary training, especially safeguarding and resuscitation, and development to ensure they maintain the appropriate skills for their role.
  • Ensure that patients are assessed by appropriately trained and experienced staff within the A&E department.
  • Review the recording of necessary information such as arrival and discharge times in the A&E department to ensure that the information on performance is robust and correct.
  • Review the patient flow from the A&E department to ensure that patients are assessed to meet their needs and there are no unnecessary delays.
  • Review the complaints process to ensure that appropriate lessons can be learned and improvements made in service delivery.
  • Ensure all staff adhere to the infection prevention and control of infection policy and procedures, particularly with regard to hand washing and cleaning procedures on the maternity unit.
  • Ensure that all sterile fluids and medicines are stored in accordance with manufacturers and legislative guidance and that expiry dates are adhered to.
  • Review the arrangements for dealing with controlled drugs to ensure that they comply with national standards and legislation and that these are implemented and adhered to by staff.
  • Ensure that patients’ records are appropriately stored in accordance with legislation at all times.
  • Ensure that a patient’s mental capacity is assessed appropriately and that records are up dated and maintained in accordance with national guidance and recommendations.
  • Ensure that the assessment for a do not attempt cardio-pulmonary resuscitation complies with best practice and national guidance, involves the patients or their representatives and that these discussions are recorded, including when discussions have been deemed inappropriate.
  • Review the arrangements for internal transfer of patients in the night and ensure that this is kept to a minimum, particularly for frail and elderly patients.
  • Review the involvement of staff in trust-wide issues to ensure that staff are fully conversant with the trust vision, strategies and objectives and can contribute to the development of services.
  • Review the cancellation of outpatient appointments and take the necessary steps to ensure that issues identified are addressed and cancellations are kept to a minimum.
  • Review waiting times in outpatients’ clinics and take the necessary steps to ensure that issues identified are addressed.

We would normally take enforcement action in these instances, however, as the trust is already in special measures we have informed Monitor of these breaches, who will make sure they are appropriately addressed and that progress is monitored through the special measures action plan.

In addition, the hospital should:

  • Review the blood testing processes in the A&E department to ensure that they are efficient and timely.
  • Review information given to patients on why they are waiting in the A&E department to allay anxieties.
  • Review the information following clinical audits and ensure that any actions and learning are shared with staff.
  • Review the training available to staff on caring for people living with dementia or with a learning disability and provide training to ensure that staff have the appropriate skills for their role.
  • Review staff communication and engagement to ensure that they are aware of the trust strategies and vision, including new initiatives such as the clinical care strategy for end of life care.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 27, 28 August and 3, 18, 19, 25 September 2013

During an inspection in response to concerns

We undertook a responsive inspection of Colchester Hospital University NHS Foundation Trust in August and September 2013 in response to information of concern received regarding cancer waiting times specifically in the specialities of urology (a surgical speciality, covering the diagnosis and treatment of disorders of the kidneys, ureters, bladder, prostate and male reproductive organs) and lower gastrointestinal. (Lower GI is a surgical service that covers diagnosis and treatment of disorders in the lower half of the gastrointestinal system, including colon and rectal diseases and disorders.)

The majority of people we spoke with told us that they were satisfied with the service they received. We visited the specialities of urology and lower GI outpatients and departments and spoke with 27 people receiving care and treatment. Six people described problems they had experienced in their treatment including delays in receiving care.

Inspection carried out on 8 January 2013

During a routine inspection

During this inspection we visited the maternity services, a surgical ward, a medical ward, the emergency assessment unit and reviewed the pharmacy services. We spoke to 33 people using the service and six relatives of people using the service.

In general people were very satisfied with the care and treatment they had received and in most cases were very complimentary about the attention and attitude of staff towards them.

On the Emergency Assessment Unit (EAU) we found areas of concern about staffing, care and how people's dignity was maintained that were not consistent with our findings in the other areas visited. We were told by the director of nursing and the chief executive that the days of our visit were the two busiest days for admissions in the last 12 months. We also found that there was ongoing investment in this area to ensure that people were cared for in a timely and appropriate way. These included increasing hours in the evenings and weekends that skilled staff were available.

We were unable to effectively audit and track some serious incidents concerning patient safety at the trust. This meant that the quality monitoring for the safety of people using the service was not reliable, so there were concerns about whether appropriate action, in relation to the incidents, had been taken by the trust.

During an inspection to make sure that the improvements required had been made

We did not speak to people about this outcome as we did not visit the hospital to carry out this review.

Inspection carried out on 20 March and 30 May 2012

During a themed inspection looking at Termination of Pregnancy Services

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

Inspection carried out on 23 November 2011

During a routine inspection

People with whom we spoke reported that they were listened to and respected by staff and most spoke highly about the information available. They felt that staff were well trained to provide care and treatment. They told us that they enjoyed the food offered by the service and that they were offered choice about what they ate. However, some people said they were not asked whether or not they wished to wash their hands before they ate. They said they were happy with the standard of cleanliness of the hospital.

Inspection carried out on 21 April 2011

During a themed inspection looking at Dignity and Nutrition

There were mixed experiences in respect of patients being asked how they wanted to be treated. Patients generally felt that care is given in a respectful way, but said they sometimes had to wait a long time when they called for assistance.

Patients felt they had not been given enough information about their care and treatment options and the risks and benefits of the treatment; or the facilities available to them. The majority of patients with whom we spoke had not been asked for any feedback on their care.

Patients were generally pleased with the choice and quality of meals available, including vegetarian options. Patients were generally comfortable in asking for food if they were still hungry and that food was available if they had to miss a meal.