Colchester General Hospital

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of people who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

At our last inspection, well-led was rated as requires improvement. At this assessment, the rating remained unchanged. This meant there were widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to the governance of the service.

This service scored 50 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Vision, values and strategy have been developed, through a structured planning process in collaboration with people who use the service, staff and external partners. This 3 year strategy commenced in 2025, aimed at improving patient outcomes and easing the system pressure at Colchester Hospital by bringing together community services and Medicine into a single division. Leaders understood the need for the aligned working with community partners to address flow and admission avoidance to meet the current bed deficit as well as having a strong focus on providing harm-free, high quality care. The divisional leaders were aware that the hospital was under extreme pressure, experiencing continued bed occupancy above the 92% threshold. This was deemed a significant challenge and consumed the attention and energy of leaders to the detriment of continuous improvement.

The results of 2024 NHS staff survey response rate for medicine at Colchester was 37.9% against the average Trust response of 48.7%. Results were above the average trust response on all domains excluding ‘we are safe and healthy’, ‘we work flexibly’ and ‘morale’. This was supported by staff we spoke to and data we reviewed. There was a clear plan to address these areas.

Staff told us they felt supported and valued by their matrons and they were visible and approachable. Matrons were on wards and addressed concerns raised such as staffing, however they were not always able to resolve challenges faced. Following an external review, ‘Be the change’ project had started in March 2025 to ensure the visibility of senior leaders to talk to teams and create a culture of a reset to improve the patients’ journey and emergency flow.

Actions implemented by leaders in response to incidents/complaints/safeguarding were not always effective.

There was an established leadership team comprised of a divisional director for medicine and emergency medicine, an associate director of operations and associate director of nursing, who made up the divisional triumvirate. They were supported by general and service managers for medicine and emergency medicine, senior matrons and deputy associate director of nursing, patient safety and experience coordinator and a governance manager.

Senior managers told us they visited clinical areas, supported on wards when required and met with matrons weekly. Matrons were ward based to increase visibility and met with their senior nurses to identify challenges and potential solutions. However, the 2024 NHS staff survey results for the division scored below the trust average for both burnout and morale. This meant that the actions taken by leaders were not effective to meet the needs of their staff.

Leaders of the service were able to describe the top 3 risks within the division. They told us that the new business plan would move towards a more preventative model to support care in the community and a single point of access. They acknowledged the stress that staff faced with boarding and moving staff to meet acuity and that this was further impacted on by staff sickness. They reported a need to ensure staff were not moved repeatedly during a shift and had spoken to matrons following our assessment to speak with staff prior to moving them.

People felt that they could speak up but they did not always feel that their voice would be heard. Staff escalated concerns regarding staffing levels and patients inappropriately cared for in corridors . However, despite reporting, these issues continued to occur and staff did not see any action taken to address the concerns raised. Staff, therefore did not feel confident that their concerns were always listened to.

The Freedom to Speak Up report for September 2024 to March 2025 showed a significant increase in staff raising concerns to the Freedom to Speak Up Guardian between January and February 2025. These concerns were raised by those who had tried to escalate their concerns through their own line management before or who had no confidence in raising them through their own line management. Themes included lack of recognition from leaders, overstretched workforce, and lack of support from line managers when on sick leave.

Staff feedback boards were not consistently updated with information about action taken by leaders in response to concerns and complaints raised. However, staff did report receiving emails and updates via the intranet.

Leaders actively promoted staff empowerment to drive improvement. They encouraged staff to raise concerns and promoted the value of doing so.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The service did not always have clear responsibilities, roles, systems of accountability or good governance. Staff did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Patient records were not stored securely on Birch, Tiptree, Peldon and D’arcy wards. We observe 2 computers left unattended with patient information on display. This meant that they were not protecting the privacy of patients.

The service had a clearly defined governance structure that supported the flow of information from frontline staff to senior managers and the trust board. Clinical Divisional Group level meeting fed into monthly Divisional Governance and Quality Board Meeting reported to weekly Medicine Divisional Management Meeting which ultimately had oversight from Executive Management Committee.
The meeting minutes that we reviewed showed that relevant topics were discussed, including audits, complaints, incidents and risks. However, divisional meetings were cancelled at times of operational pressure.

Meetings were not always effective in managing the risks identified. For example, all 3 divisional meeting minutes (from September 2024 onwards) reviewed highlighted a lack of compliance with Deprivation of Liberty Safeguards (DoLS). However, action plans were not effective in addressing this issue. During our onsite assessment, we found that staff did not always understand DoLS, when to implement it and what their personal roles and responsibilities were. The service did not always perform well in audits focused on the management of risks to people. Meeting minutes did not demonstrate senior leadership were aware of this and how they would address poor compliance at address underperformance against trust targets.

Staff meetings were also cancelled at times of operational pressure. This meant information was not always received or escalated to all staff in a timely manner from board to ward and vice versa. However, leaders told us that seniors met at lunch time, when work allowed, to take a few minutes to debrief each other. In addition, 1:1 sessions with ward sisters, discussed matters such as patient safety and audits.

The audit process of the service was not always robust enough to determine if the service was doing well and what improvements needed to be made. The October 2024 Divisional Governance and Quality Board meeting had identified that compliance with Venous Thromboembolism (VTE) risk assessments was 55%. However, a review undertaken by leaders demonstrated that compliance rates were being impacted by documentation issues, and the audit was not identifying when care had taken place. There was no action taken following this to modify audit processes; data reviewed following our on-site assessment still highlighted poor compliance (50-70%) against their audit tool. Therefore, the audit results were not reflective of safety and level of patient care against trust policy.

Various policies and procedures were in place to cope with unexpected events. Business continuity plans were in place for all areas of the division which detailed strategic arrangement and activities undertaken within the trust to support the emergency preparedness.

The service understood their duty to collaborate and work in partnership, so services worked seamlessly for people. However, staff did not always share information and learning with partners and collaborate for improvement.

The trust had a patient experience, carers and co-production strategy, which was aimed at working together with patients, their carers, staff, and external NHS organisations to offer individual care for all patients and reducing the inequality gap. This was through patient story following complaints and incident reviews.

Staff told us they were working with charities to support care on discharge and family support. The Transfer of Care Hub reported the need to work closer with social services to ensure an understanding of the system pressures and key information they required to support more timely continuity of care and promote flow, for example reduce discussion around requested packages of care.

There was a policy to support joint working with the local mental health trust to manage reviews and transfer of mental health patients admitted to Colchester General Hospital. Staff knew how to refer to the team and felt that they were supportive. However, there were long delays in transfer out of care to suitable wards for ongoing support and treatment. For example, there was a mental health patient who stayed for 84 days at the hospital, and this was due to ack of appropriate beds within the mental health trust.

We were not always assured that leaders engaged with partners to share learning with each other, or that this resulted in continuous improvements to the service. A system partner told us “Currently we do not receive information on actions taken by the hospital in response to feedback. It is difficult to assess how well patients feel their voices are heard by the hospital.”

The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. Staff did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. Staff did not always actively contribute to safe, effective practice and research.

During our previous assessment in November 2022, we found 7 breaches such as mandatory training, safe staffing, VTE risk assessment, and a safe storage of patient records. During this assessment we found repeated breaches in 4 of the same areas. This showed that leaders were not learning and improving in response to concerns raised.

Changes implemented in response to learning from incidents and complaints were not always effective. Several new systems had been introduced since 2024 to learn from incidents and complaints. However, these were not effective enough to address repeated risks identified from incidents, audits and complaints. For example, leaders had introduced a template for recording pressure ulcer damage to improve oversight following an inquest in 2024. However, pressure ulcers remained the highest reported incident type, audit data continued to show that risk assessments were not always completed on admission or updated after significant change, and the patient records we reviewed demonstrated risk assessments were not always fully completed.

Leaders told us they had made changes to safeguard patients on care of the elderly wards. However, we found these were not fully embedded, staff we spoke to had no situational awareness of any incidents or what changes had been implemented in line with the action plan.

Learning from incidents was shared through a variety of methods such as newsletters, huddles, team away days and emails. However, staff we spoke to were not aware of recent medicine events and safeguarding concerns within wards.

We reviewed an action plan which was put in place following safeguarding concerns raised by patients between December 2024 and February 2025. Clinical and non-clinical staff we spoke with reported that they were unaware of changes made. We found several changes were not yet fully implemented and embedded to safeguard patients.

The division had taken steps to drive improvement in key areas such as quality, cancer and referral to treatment times. Quality was driven through improvement projects such as the launch of ‘fundamentals of care’ and ‘every bay, every day’ and enhanced frailty services which we observed during this assessment. However, staff we spoke to told us they were understaffed on wards everyday, this impacted on their ability to deliver high quality care and reduce harm free care.

Quality improvement (QI) training was offered to staff. However, staff told us that they did not have time to carry out projects. We requested to review QI projects within medicine at Colchester General Hospital, linked to improvements. However, these did not always demonstrate long term improvements. For example, communicating medication changes to patients’ GPs following their discharge showed improvement in June 2024. We were not provided with data to demonstrate the long-term impact. However, incidents and complaints data show that this continued to be an area of concern.

The department took part in national audits to support improvement and learning. Cardiology services at Colchester General Hospital partook in national audit assessments such as National Heart Failure, National Audit of Cardiac Rhythm Management (CRM) and Myocardial Ischaemia National Audit Project (MINAP) as well as 6 NICE guidance assessments, including Stroke Rehabilitation in Adults. We were not provided with any evidence of how they were using audit outcomes to improve the service for patients.