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 there was an inclusive and positive culture of continuous learning and improvement based on meeting the needs of patient who used services. We checked leaders proactively supported staff to deliver safe, integrated, person-centred care and to reduce inequalities.

At our last inspection, well-led was rated as requires improvement. At this assessment, the rating remained unchanged. There was a shared direction and strategy however leaders did not ensure the vision and strategy was shared with staff in all areas. Leaders reviewed risks to the service but there remained increased demand and poor flow in the department resulting in long waiting times for patients. Leaders encouraged staff to speak up with ideas for innovation and improvement, however there was no clear strategy about how to develop these or monitoring of the outcomes. Staff and leaders demonstrated a positive, compassionate, listening culture.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff we spoke with did not know about the vision or the strategy for the service. However, there was a vision across the workforce which had enhanced morale and a collective sense of purpose. The service had a medium-term strategic plan for the emergency department. Their mission was, “To ensure all patients needing our urgent and emergency services receive outstanding quality, safe care in a timely, efficient manner.”

Leaders did not ensure the vision and strategy was shared with staff in all areas. However the service’s ambition was to ensure patients are seen, treated and discharged from their ED in accordance with the 4-hour quality standard of care and ensuring smooth, safe and timely flow throughout the hospitals. Leaders were aware they were not meeting the standards.

We reviewed data obtained for the staff survey. The survey was completed in September 2024 to November 2024 and 146 out of 454 members (32.2%) of UEC staff completed the survey. The question on the staff survey for ‘Recognised and Rewarded’ was split into the sub-questions. We saw from the data provided 77% of nursing staff and 46% of medical staff agreed or strongly agreed that their immediate manager valued their work. We saw 82% of nursing staff and 54% of medical staff said they agree or strongly agree that people they worked with showed appreciation to one another. We saw 67% of nursing staff and 38% of medical staff agreed or strongly agreed that they felt recognised for good work.

We could not compare this against the trust average percentage as the data was unclear. This was the same for the data provided for the children’s emergency department. However, there was a good culture in the department with staff focused on the patients in their care. Most of the staff we spoke with said they felt the culture was good and moving in the right direction.

Leaders had effective support and opportunities to develop and maintain their skills. The roles of staff and leaders were clear, and they understood their responsibilities and accountabilities.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge and experience to lead effectively.

Nursing and medical staff across the emergency department understood the key risks to patients within the department. They could describe the challenges faced and were able to explain the improvement actions being undertaken to improve capacity and patient flow.

Leaders were visible in the service and approachable for staff. Staff told us the departmental leads and senior managers were approachable, visible, and provided them with good support. Staff were supported to improve and develop. The service held an annual matron wellbeing review/update which was held as part of the team days rostered for staff to attend. The team days were held 6 times a year. Staff were able to receive general education and learning from incidents as well as raise suggestions and ideas anonymously. Feedback was provided after the session regarding the progress of those suggestions or ideas.

Staff understood the reporting structures and leaders understood their key roles and responsibilities. Leaders were able to demonstrate how they worked as part of a multidisciplinary team within the service.

Leaders had the appropriate range of skills, knowledge, and experience to carry out their roles. There was a triumvirate leadership structure at departmental and divisional level with clinical, nursing, and operational leads. There were clear reporting structures and key roles were supported.

The service fostered a positive culture where patients felt they could speak up and their voice would be heard. Staff were aware of the policy and how to use it, however we did not see any posters or information about this displayed anywhere in the emergency department or staff areas.

When concerns were raised, leaders investigated sensitively and confidentially, and lessons were shared and acted on. Staff we spoke with felt confident to raise concerns.

The service had a freedom to speak up guardian with whom staff could raise concerns about any issues. Leaders described an open-door policy and had an eagerness to want to help and support staff. Leaders told us staff were encouraged to raise concerns via various channels including the intranet, posters and via meetings. The FTSU process was explained to new members of staff on their induction.

We saw the freedom to speak up policy which was in date and version controlled. The policy was clear on who can speak up, who to speak up to and how the issues will be investigated and resolved.

The service had policies and processes in place to ensure they were inclusive and fair in the way they operated. Staff received training in equality, diversity and human rights and had a good understanding of cultural, social and religious needs of patients. Medical staffing achieved 93.75% compliance and nursing staff achieved 98.39% compliance in equality, diversity and human rights training.

The service had a centralised complaints team who operated in accordance with the trusts complaints and concerns handling policy which was version controlled and in date. The policy was compliant with diversity legislation to ensure there was no unlawful discrimination on the grounds of age, disability, gender, race, religion, belief and sexual orientation. The service used an online system to record any concerns raised through the patient and liaison service (PALS). Within the online system there were subject categories to identify the types of concerns being raised and whether this was in relation to any protected characteristics.

Leaders acted to continually review and improve the culture of the service in the context of equality, diversity and inclusion. The service produced monthly reporting on themes from complaints and PALs through its integrated patient safety and experience report, and this included thematic reviews comprising of the protected characteristics. These reviews were discussed and shared as part of the bi-monthly patient experience, co-production and carers council meeting. In addition to this, all divisional areas had regular governance meetings where themes from complaints and PALs themes were reviewed.

Leaders understood but did not always have resources and space to manage the priorities and issues the service faced. Capacity constraints within the services and across other parts of the hospital impacted on patient flow in the emergency department. However, daily safety huddles and bed management meetings enabled sharing of information and escalation of patient risks and capacity and resource issues. Risks were discussed at safety huddles, board rounds and bed management meetings and staff and leaders proactively managed and escalated any concerns. However, there remained increased demand and poor flow in the department, and this was a consequence of beds not being vacated.

The service did not have audit systems in place to provide assurance or illustrate staff acted on the results when needed. Staff did not complete risk assessments for patients allocated for corridor care. Staff were not always completing NEWS which meant there could have been missed opportunities to identify and respond to patient deterioration.

Outcomes for patients were not always positive, consistent and did not always meet expectations, such as national standards. For example, long waits in the department led to untimely care. However divisional monthly governance and quality meetings were held to discuss governance, risk, and performance. Risk registers were reviewed during these meetings. The governance and reporting processes enabled leaders to understand the key risks and challenges to the service and to identify improvement actions to address key risks, such as capacity and flow issues. Processes were in place to escalate issues to the hospital leadership team

We saw the risk management policy which was in date and version controlled. The policy was clear on everyone’s duties and responsibilities, the risk management process, assessing, rating risks, recording and the monitoring of those risks.

Risks were captured on a divisional risk register and were rated in terms of risk level, likelihood and consequence. The service had risk management processes which meant that risks were escalated from the department up to board level when required.

Staff and leaders at all levels demonstrated a good understanding of the risks within the department and the action being taken to mitigate or remove risks. We discussed the top risks for the service with the leadership team and reviewed the department risk register. We saw the top risks were, increased staff absence and the risk that patients experienced long waiting times in emergency department due to lack of patient flow.

The service had introduced ‘Be the change’, which was introduced to improve the level of care patients received, including to improve patient flow. Staff told us this initiative was central to shifting the organisational culture and moving to a more proactive service than reactive. The initiative encouraged accountability at all levels. The service measured impact by, for example, completed harm reviews, reviews of the length of stay on specific wards, handover 45 compliance and reverse boarding on wards. Staff told us they had seen less breaches and improved performance.

The service completed harm reviews and due to the increase of extended length of stay for patients within the emergency department, introduced a new role called the fundamentals of care healthcare assistant. The role was introduced to ensure the basic requirements were undertaken including regular observations, hygiene assistance, identifying pressure area concerns, etc. Staff told us this was an existing role but the healthcare assistant on shift would solely focus on the fundamentals of care delivery to patients for 6 hours. During our assessment we did not see any fundamentals of care healthcare assistants. We were not provided with any outcome data to understand if the fundamentals of care healthcare assistant role had any impact.

The service had an innovation fellowship programme. The programme was open to all staff regardless of post or seniority and both clinical and non-clinical roles. This programme allowed staff to be empowered and supported to implement new business, ways of working and innovation to lead to more efficient patient care and services. Although the service advised us of this information, we were not provided with any details of any outcomes of the fellowship programme and whether this was innovative.