Colchester General Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. We also checked people’s liberty was protected where this was in their best interests and in line with legislation.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant people were not always safe and protected from avoidable harm. The service was in breach of legal regulation in relation to the safe care and treatment.

This service scored 31 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not always have a proactive and positive culture of safety based on openness and honesty. Staff reported incidents in line with policy, however, they did not always receive feedback or timely updates relating to raised concerns. Lessons were not always learnt to continually identify and embed good practice.

We were not assured that there were effective systems in place to share information about incidents with staff in a timely manner. Staff stated that there were delays in receiving feedback after incidents had been reported. Staff were not always aware of incidents that had recently occurred, which were relevant to their area of work. Staff were not always able to give examples of recent incidents that had been discussed at daily huddles, team meetings and via email.

There was a delay in reviewing reported incidents. There were 40 incidents overdue for review at the time of our assessment. This meant that there could be a delay in identifying learning and implementing changes in practice.

Staff did not always feel confident to deal with a complaint raised directly to them, in order to resolve these locally in line with trust policy. However, staff told us that they would escalate any complaints to the senior nurse in charge. We observed staff responding appropriately to a patient’s complaint during our assessment. The complaint responses that we reviewed during our assessment offered apologies and explanations with evidence of a thorough review in line with policy.

People and staff were encouraged and supported to raise concerns about risks to safety. Most staff knew what incidents to report using the trust’s electronic incident management system. Staff gave us examples of incidents they had reported, however there was a delay in receiving feedback or they could not see any action being taken.

Incident reviews showed evidence of learning actions, such as staff reminders to complete risk assessments where there was a failure to follow trust policy.

Senior leaders had oversight of themes from incidents and complaints. These were discussed at governance meetings with learning actions to address these issues.

‘Every bay, every day’ had been newly implemented to ensure senior nursing staff spoke with every service user to address any concerns, complaints or queries on a daily basis. Matrons reported a reduction in complaints since its introduction but were yet to audit this to demonstrate its effectiveness fully.

A new quarterly Reflective Learning Forum had been established in July 2024 to promote reflection and learning within the trust. The forum encouraged input from front-line clinicians with a view to improving patient safety and quality of services, and all colleagues were welcome to attend the forum.

The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. Staff did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

The management of risks to people across their care journey was not always effective. Although patient risk assessments were fully completed on admission, there were delays in the review of these assessments in 3 out of 7 care records reviewed during our assessment. This meant that risk management would be ineffective and could lead to errors, near misses, and accidents, ultimately impacting the quality of care and potentially causing harm to patients.

The service did not always perform well in audits focused on the management of risks to people. Pressure ulcer risk assessment audits completed in the 3 months prior to our assessment found an average rolling compliance score of 88.6%, against trust standard of 95%. Compliance in the completion of falls and bed rails assessments found an average rolling compliance of 72.7% and 84.6%, against trust standard of 95%.

We reviewed the 3 most recent safeguarding referrals made and found there was a lack of sharing on information on discharge to ensure safe care to support people moving into the community.

We were not assured that staff were recognising and escalating deteriorating patients consistently in line with trust policy to keep people safe. The trust used an electronic patient observation recording system, which enabled clinical staff to record and calculate a patients National Early Warning Score (NEWS2). The service provided us with audit data for the escalation of patients who triggered with a NEWS >5 or 3 in 1 parameter, which showed variable performance. Audits were not always consistently carried out in all areas due to low staffing and complex admissions. However, staff were able to communicate the process for escalation of a deteriorating patient and we saw evidence of this within medical records.

During the previous inspection in November 2022 we found that staff did not always complete risk assessments for Venous Thromboembolism (VTE) for all patients. We reviewed VTE compliance audit data for the 3 months following assessment and found compliance remained below trust target. The trust informed us this poor compliance was in part due to the way that cases were documented. However, the trust’s review found that the treatment had been delivered. The care records we reviewed demonstrated that VTE risk assessments had been completed. Senior leaders told us nursing staff were reminding medical teams at board rounds to complete the assessments and older people’s wards were having advanced clinical practitioners leading on audits to improve the worse performing wards as well as discussions at governance meetings.

During the previous inspection in November 2022, we found staff did not always communicate discharge information well for patients leaving the wards to return to the community. During our assessment in April 2025, we found that these concerns had not yet been addressed. Healthwatch told us that the feedback they received often related to older people and their families not understanding discharge plans and a lack of communication We received information from care homes indicating that discharge planning for residents returning from hospital was ineffective, with concerns raised about insufficient information sharing and a lack of appropriate referrals to support their ongoing care needs. Medical discharge summaries audit data showed compliance ranging from 75-94%. However, leaders acknowledged a need to standardise the quality of information due to the complaints received. A doctor told us that the lack of electronic notes was impacting on their ability to complete these as they were required to read through an admission history to complete a comprehensive summary.

Care and support was not always planned and organised to ensure continuity and safety with other key partners.

Where people were moving between departments, we saw evidence of written handover and observed verbal handover between wards.

A boarding patient is one who has been admitted into a ward and is temporarily placed in a non-dedicated bed space, often a hallway or waiting area, due to bed capacity issues. Staff told us they completed additional risk assessments for boarding patients on transfer to ensure they were safe to be cared for in the non-designated ward area.

The service did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. Staff did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They did not always share concerns quickly and appropriately.

Staff did not have a strong understanding of safeguarding and how to take appropriate action. For example, 7 out of 8 staff spoken with during our assessment were unable to demonstrate knowledge about different types of safeguarding and their individual responsibilities to prevent, identify and report abuse in line with trust policy. In addition, 6 out of 9 staff we spoke with did not know what trust processes to follow in the event of disclosure of safeguarding concerns.

Staff compliance with safeguarding training did not always meet the trust target. Data reviewed following the assessment demonstrated a compliance for doctors of 77.6% against a trust target of 90%. However, nursing staff were 97.4% compliant.

We were not assured that information regarding safeguarding concerns was effectively shared with staff. We were told safeguarding concerns were discussed during huddles to inform staff of referrals made. However, staff were unable to inform us of any recent safeguarding incidents or concerns relating to sexual safety and any learning from recent safeguarding concerns. This meant that staff had no situational awareness when implementing new safeguarding measures on the wards.

We reviewed the 3 most recent safeguarding referrals made and found a lack of referral for ongoing pressure ulcer management, lack of equipment provision and lack of discharge letter to support people moving into the community.

Leaders told us that information regarding basic safety measures and how to raise concerns was given to every service user admitted to wards. However, service users we spoke with during our assessment were unable to confirm that they had received this information. We spoke to 9 staff and only 4 staff could confirm that this was carried out.

The service did not have effective processes to implement the Mental Capacity Act (MCA) or Deprivation of Liberty Safeguards (DoLS) in care records when caring for those who may lack capacity to consent to make their own decisions, or who are subject to restrictions on their liberty. We reviewed 9 medical records for evidence of best interest decision making where staff were acting under the Mental Capacity Act. We found that in 4 records there was no evidence of capacity assessment or best interest decision making processes, in accordance with the Mental Capacity Act (MCA 2005). This meant that staff could not demonstrate they were legally compliant within the realms of the act.

We spoke with 8 staff (registered nurses and healthcare assistants) and asked them to explain their understanding of MCA and DoLS. 5 staff members were unable to explain their understanding. We were therefore not assured that staff would act in accordance with the Mental Capacity Act 2005 (MCA 2005) when providing care and treatment.

During the assessment we reviewed 11 records where staff informed us there was a mental capacity assessment and/or DoLS application in place. We found 6 records failed to evidence documentation of an MCA and/or DoLS. Monthly audits completed by the safeguarding team showed a poor average compliance of MCA and DoLS within care records. This meant, actions of staff were not delivered within a legal framework where restraint and restrictions were imposed.

The service did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We were not assured that a robust system was in place to ensure that therapists were receiving timely referrals to prevent deconditioning and optimise function ready for discharge. Nursing staff were responsible for referring patients for mobility assessments following admission. The process had been recently implemented. Staff told us there were occasions where people had been nursed in bed, resulting in a decline in their function, resulting in a failed discharge and readmission. This was further supported by the complaints and serious incidents we reviewed following the on-site assessment.

Documentation of appropriate strategies to de-escalate were not seen in 2 care plan records where physical restraint had been used. For example, we did not see any de-escalation plans in place to support care for a service user who had challenging physical behaviour requiring 2 security staff. This meant that staff were not following least restrictive practice in line with trust policy and national guidance. Staff that were responsible for 1:1 observation had not reviewed the health passport to understand their needs, communication preferences, and any required adjustments. We saw care records for 2 people who had required chemical and physical restraint. Staff had completed incident reports to record the use of chemical restraint in line with policy.

During the assessment we observed people receiving 1:1 or 2:1 supervision by 3rd party security staff. We spoke with 4 security staff across 3 medical wards (Peldon, Layer Marney and Copford) who were unable to communicate their roles and responsibilities whilst providing 1:1/2:1 support. They were unable to demonstrate knowledge of the individual they were supporting, de-escalation methods they would use if required and specific training they had completed to fulfil their duties. Following our assessment we were provided with training records for all third party security staff which showed that they had completed Prevention Management of Violence and Aggression (PMVA) accredited by the Restraint Reduction Network.

We observed on 2 occasions that both security staff were distracted and not observing the service user whilst providing 2:1 supervision on Layer Marney ward. This meant the service user was not being closely observed and could have come to harm. This was supported by incident data from December 2024 to April 2025, which demonstrated a lack of skill, competence and knowledge of security staff used for 1:1/2:1 monitoring. There had been 5 reported incidents which related to falls resulting from a lack of close supervision and patients being left unattended.

There was a balanced and proportionate approach to risk that supported people and respected the choices they made about their discharge destination. Where appropriate, people were encouraged to take carefully managed risks to live fulfilling lives. We saw evidence of this with regards to discharge planning through observed conversations at board round and observing senior staff involving the person and their family regarding a complex discharge. Therapists told us they discussed risks of not accepting recommended equipment or advice to await restart in care and supported people to make informed decisions.

The service did not always detect and control potential risks in the care environment. Staff did not always make sure equipment, facilities and technology supported the delivery of safe care.

Wards entrances were not within line of sight for staff across medical wards and doors were left open during the day. This meant that confused patients were able to leave the ward more easily. One ward used screens to prevent people from absconding. Senior leaders told us that wards were locked down and secured from 8pm until 6am, however, we observed staff and estates management looking for a key to secure D’arcy ward the day of our onsite assessment. Staff told us that this had not been completed prior to our visit. This meant that service users were not protected from harm during the night when ward staffing was minimal.

We observed a lack of professional curiosity to challenge visitors on the ward during assessment on D’arcy ward. Staff also told us that visitors had accessed the ward after it had been locked down after 8pm. Staff did not challenge the presence out of hours.

We found a trolley with multiple COSHH substances left unattended on Peldon ward. Chlorine disinfectant tablets were not stored safely and correctly within the sluice room, which was not locked, on D’arcy and Peldon ward. This meant systems were not effective to protect vulnerable service users from accessing dangerous products. We escalated these concerns and action was taken to ensure cupboards were locked.

The emergency assessment unit (EAU) had a high acuity area with 5 beds for close monitoring. The central monitor was poorly located at the nursing station and not in a central position. This meant that close monitoring was difficult during periods of high demand. We were informed this was on the risk register. The side room was not fit for purpose as it would not allow for easy access in the event of a deteriorating person requiring resuscitation. Staff told us that this room was only used for those that were not for resuscitation. However, there was no space for relatives to sit with their family member due to its size.

The hospital used a ‘boarding’ practice to maintain flow during periods of high demand within the emergency department. This meant that people were admitted to a ward where a bed was not immediately available. Staff told us that these beds would be placed in bays or non-designated areas such as corridors. We did not observe any boarding care during our on-site assessment. Staff had reported 19 incidents where boarding breached trust criteria in the 6 months prior to our assessment. This meant that service users were not always cared for in safe environments.

We requested to review the last 3 health and safety audits for medical wards. Leaders informed us audits were completed annually and supersede previous versions. We saw the current health and safety audits which were visual inspections identifying health and safety risks. Across the 4 older people’s wards, fire drills and ligature risk assessments were not always completed. Documentation did not evidence if this had been completed following identification during the previous audit. Therefore, we could not be assured that all risks were identified and actioned to ensure that they complied with current Health and Safety Regulations.

Staff completed safety checks of specialist and emergency equipment, and we saw adult resuscitation equipment was checked daily. Staff were able to explain how they would order specialist equipment such as pressure relieving cushions and mattresses. There was a process in place to report faulty equipment.

Staff disposed of clinical waste safely. Sharps bins were labelled correctly and not over-filled. Staff separated clinical waste and used the correct bins.

We observed that call bells were accessible to patients if they needed support. However, people told us that often there was a delay in staff responding to call bells due to poor staffing levels.
Equipment, including special or adaptive equipment was available and used to deliver care and treatment that was suitable for the intended purpose.

The service did not always have enough staff to keep people safe from avoidable harm and or to provide right care and treatment. At the November 2022 inspection we identified a breach of regulation relating to staffing, and we issued a requirement notice. During the assessment carried out on 9 and 10 April 2025 we identified the same issues.

Nursing staffing numbers were lower than planned in all areas. The trust used an electronic system to monitor staffing twice daily to support the staffing Matron to make decisions regarding safe staffing across the division and organisation. When staffing was escalated, managers told us they moved staff to where they were most needed using staff within their own division. However, the trust reported 8 incidents in the 3 months prior to our assessment in relation to staffing shortages not meeting acuity of patients. A review of Learn from patient safety events (LFPSE) data from December 2024 to April 2025 showed 2 incidents of falls related to lack of staffing on wards. Leaders attributed poor compliance with pressure ulcer risk assessment and management to staffing challenges. A review of staffing dashboard showed staffing was below planned for medical wards for February 2025. We were not assured there were effective resources and correct skill mix to reduce adverse outcomes.
Staff told us low staffing was a regular occurrence and was having a direct impact on morale and they could not always meet the demands placed on them in a timely manner. For example, one patient reported they would wait for days for a shave and a relative reported their loved one was not supported at mealtimes due to staffing shortages.

Staffing data from December 2024 and January 2025 showed fill rates during the day of less than 80% for unqualified staff and less than 85% for qualified staff. Staff told us that low staffing impacted on their stress levels. A nurse stated “we are moved from ward to ward. I don’t feel it is safe and I can not give a good quality of care for patients. I do not Datix staff shortages anymore as it is an ongoing issue”. Another staff member we spoke with told us it was the 3rd time he had been moved during his shift.

Although agency staff were booked to fill gaps in rosters, they often cancelled shifts at the last minute. We saw volunteers on wards to support patients during their admission.

Staff completed mandatory training such as dementia awareness, moving and handling and resuscitation to deliver safe and effective care. Mandatory training compliance was 83% for doctors, which was below the trust target compliance rate of 90%. However, compliance was 95% for nursing staff. Staff we spoke with reported having an induction and specialist training to enable them carry out their role.

Nursing sickness and turnover rates were lower than the target of 7%, whereas medical staff rates were higher than the target of 8%. Where able, managers used bank staff to cover gaps in roster for registered nurses rather than agency staff. This meant risk was reduced as staff were familiar with working on the ward. Data provided should a nursing vacancy rate of 13% and 23% for medical staff for medical care wards.

During our previous inspection in November 2022, staff did not always have constructive appraisal of their work to support development. During this assessment, the hospital appraisal compliance remained low at 83.3%, which was below the target of 90%. Ward managers were aware of staff members requiring an annual appraisal and dates had been set for them.

A review of therapy services for inpatient medical care wards showed vacancies in occupational therapy and dietitians. Occupational therapy and physiotherapy provision was reduced on EAU; data showed that 35% of patients were not being seen when required. Staff told us that they would escalate patients requiring review on wards but often staff could not be moved to areas of demand until the afternoon. Staff reported reduced morale due to a cut on all bank and overtime. Leaders informed us this was due to a reduction in external funding that had previously provided additional capacity at weekends. Matron performance reports from January to March 2025 showed delays in diagnostics and therapies. We were told at times patients were frustrated and refused to stay in hospital as they were not receiving therapy over the weekend.

The hospital began a quality improvement project called Bures Ward to provide support for Enhanced Therapeutic Observations and Care (ETOC) and support ward staff for set periods in undertaking therapeutic one to one enhanced observation across a variety of clinical settings. These nursing and health care assistant staff were employed by the trust to cover shortages across specific specialties including medical care. Staff were inducted and had a 2 week period of shadowing to become familiar with wards and ways of working. Leaders were hopeful that this would further support staffing shortages. However, this had only begun a month prior to our assessment.

The service did not always assess or manage the risk of infection. Staff did not always detect and control the risk of it spreading.

The service did not ensure the risk of detecting and controlling the spread of infections was managed in line with policy and national guidance. At the last inspection in November 2022, infection, prevention and control (IPC) was identified as a breach as staff did not always follow infection control principles when wearing personal protective equipment (PPE). The safe storage of Control of Substances Hazardous to Health (COSHH) was also identified as a breach as hazardous substances had not been locked away safely from reach. During the assessment carried out in April 2025, we found that these concerns had not yet been addressed.

Staff were provided with PPE, which met recommended national guidance and was appropriate for the care they were delivering and the level of infection risk. During this inspection we observed staff repeatedly not following national guidance in the wearing of PPE, and barrier nursing. IPC audit data demonstrated PPE compliance of 64% in January 2025.

On Birch ward, we were told bays A and B were closed due to Norovirus. However, the doors were left open. National guidance advises to keep doors to single-occupancy room(s) and bay(s) closed as part of outbreak control measures. This meant there was an increased risk of Norovirus to people through the air, especially in situations where vomit or other bodily fluids were aerosolised.

There were no IPC checklists to demonstrate daily cleaning of ward areas by the ward housekeeper. Therefore, we were not assured that daily IPC protocols are being adhered to.

We observed gaps in equipment cleaning logs on Birch, Tiptree, Peldon and D’arcy wards between January 2025 to March 2025. Staff reported that this often happened due to the location of the files and some staff were not aware of the cleaning log. Therefore, we are not assured that trust IPC protocols were adhered to.

On D’arcy ward, we observed 4 IV fluids disconnected and not capped off placing those patients at risk of infections. We escalated this to the nurse in charge of the ward immediately.

Leader and managers monitored IPC standards against current relevant national guidance and shared learning with staff via daily staffing huddles, email communication and team days. Audit results and meeting minutes reviewed showed that processes in place were not robust to address recurrent IPC issues such as equipment and PPE use, which were identified during our onsite assessment.

Staff we spoke to were able to explain the process for cleaning and isolating patients during infection outbreaks. The IPC team were visible when there was an outbreak and would complete audits around IPC principles in line with trust policy.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Staff could not always access medications in a timely manner to deliver treatments to meet people’s needs. For example, during assessment we saw delays in administration of antipsychotic medicine for 2 patients during their admission. One person was in mental health crisis and staff were not aware of when the medication would be available. Due to this the mental health team were unable to assess the effectiveness of their treatment plan.

Therapists reported that, due to nursing staff shortages, analgesia was not always administered at regular intervals, impacting on rehabilitation.

A nutritional supplement was prescribed for a patient due to identified weight loss. It was not available for 8 days and staff were unsure of the process for ordering. This meant the person was not being effectively managed due to the delay in obtaining the prescribed supplement. We reviewed the trust policy for ordering prescribed nutritional supplements and the ordering form. Staff were not aware of the Nutrition Policy and Procedure v1.0 to reduce the risk of malnutrition in hospital.

Wards had pharmacy cover Monday to Friday to support safe and effective medicines management. Every ward had a pharmacy technician allocated who was responsible for checking and ordering stock once a week and order discharge medication in advance. However, staff told us the support did not meet the demand on the wards. Staff said “at times some drugs are not available” “there not enough stock of regular medications and we escalate”. When medication was ordered it would not arrive on the ward to support timely discharge. At times, staff said that they had discharged patients home, who had to return to collect medications the next day.

Controlled drugs were stored, recorded, administered, and disposed of safely. We saw that incidents were completed for the administration of controlled drugs in line with the medicines policy.
People receiving their medicines covertly were safely supported in line with the Mental Capacity Act 2005. We observed this during our assessment where staff discussed this at morning handover and a MCA and DoLS was in place to support this practice.