You are here

Inspection Summary


Overall summary & rating

Good

Updated 1 December 2016

The Care Quality Commission (CQC) carried out a comprehensive inspection, which included an announced inspection visit to the trust locations at Broomfield Hospital and Braintree Community Hospital between the 26 and 28 November 2014. At this focused inspection on 14- 16 June 2016 with an unannounced inspection on 30 June 2016, we reviewed the location of Broomfield hospital only.

This trust is unique in that it provides a regional specialty centre for burns and plastic surgery. We therefore included these two services as core services for this inspection. As part of this inspection we did not inspect St Peter’s Hospital. The rationale for not including this service was due to the limited activity undertaken by the trust at this location. We also did not inspect critical care or childrens and young peoples services, as both of these were rated as good at out last inspection in 2014.

Prior to undertaking this inspection we spoke with stakeholders, and reviewed the information we held about the trust. Mid Essex Hospital Services NHS Trust had been rated as requiring improvement in a number of services and we included all these in our focused inspection. The trust had undergone a period of change with the former chief executive having left the trust and the chief nurse stepping in to this role in the interim. The trust received significant support from the NHS Trust Development Authority (now NHS Improvement) following our inspection in 2014. This support and the direction of the interim chief executive has driven significant improvements at the trust. A new chief executive had recently been appointed. The trust is also part of the Essex Success Regime which has sought to ensure that services in mid and south Essex are fit for the future. The new chief executive is currently joint chief executive at both Mid Essex Hospitals NHS Trust and Basildon and Thurrock Hospitals NHS Foundation Trust.

The comprehensive inspections result in a trust being assigned a rating of ‘outstanding’, ‘good’, ‘requires improvement’ or ‘inadequate’. Each core service receives an individual rating, which, in turn, informs an overall trust rating. The inspection found that overall the trust has a rating of Good.

Overall, we have found that the provision of care in each core service had improved since our last inspection. The trust was a caring organisation throughout, and staff were passionate about their work and caring towards patients. We rated effective, caring and well led as good as we saw many improvements in the leadership and delivery of care across the trust. We found that the burns and plastics service was providing outstanding care, with some of the best outcomes for patients with severe burns in the country, and the results were competitive with burns centres worldwide, which is reflected in the three outstanding ratings given. We have rated responsive overall as requires Improvement, as the emergency department, surgery and end of life care had some areas that required improvements. Overall, we have rated Broomfield Hospital as good.

  • The leadership of the interim chief executive has driven significant improvements at the trust and this was evident during our inspection. Staff spoke positively of the Chief Nurse, and her role as the interim chief executive. A new chief executive had recently been appointed as part of the Essex Success Regime.
  • Throughout the organisation staff were dedicated, passionate and cared about patients
  • Whilst the trust had completed a successful oversees nursing recruitment programme, there still remained a high number of qualified nurse vacancies, which impacted on skill mix and the use of bank and agency. However, maternity had successfully recruited to midiwifery vacancies.
  • The emergency department was under pressure from the number of attendances. Between April 2015 and March 2016 the department had seen a 16% increase, which was double that of the England average of 8%.
  • The increased number of attendances affected the flow of the emergency department. However, the department had introduced the Early Senior Assessment & Treatment (ESAT) and the “risk stamp”and“escalation criteria for patients with a 45 minute delay off load or delay in department for more than six hours. Both of these initiatives were working to ensure that patients were triaged, placed on appropriate pathways and re assessed when delays occurred.
  • The burns service was extremely good and the service had innovative developments and plans.Their patient outcomes also show that they are one of the best burns centres in the world.
  • Access and flow throughout the burns service was seamless, and in the plastic surgery service significant improvement and action had taken to enhance seamlessness. However, there had been 795 plastics operations cancelled by the hospital in the last 12 months, though there were suitable plans in place which were being actioned to address this. Cancellation rates for trauma patients were not being monitored robustly
  • There had been significant improvements in gynaecology with the move from Writtle ward to Gosfiled ward. Although we found general surgical outliers at the time of inspection, the numbers of outliers had reduced and there was clear criteria for outlying into a gynaecology bed.
  • Overdue outpatient appointments of more than six weeks were referred to the supervising clinician for risk assessment to ensure it was safe to delay appointment. Ad hoc clinics could then be organised to meet demand.
  • The NHS Constitution sets out that patients should wait no longer than 18 weeks from GP referral to treatment.The data provided by NHS England (September 2014 – February 2016) confirmed RTT times were in line with the England average. For general surgery 82.2% of patients were seen within 18 weeks of referral, Ear,nose and throat (ENT) 91.4%, Urology 93%, oral surgery 90.6% trauma and orthopaedics 79.6%, ophthalmology 77.8% and plastic surgery 88.8%.
  • There were robust processes in place in relation to governance and risk assessment throughout all of the services inspected. The introduction of the “safety huddles” meant that staffing, risks, incidents an other patient safety issues were discussed with a view to reducing harm and improving the safety culture within the trust.
  • The trust had responded to the withdrawal of the Liverpool Care Pathway, which had previously been seen as best practice when someone reached the last days and, hours of life. The trust used a holistic document which was in line with the five priorities of care. This care plan was called the ‘Last Days of Life Care Plan’
  • Trust feedback from the 2014 / 2015 national vascular registry (NVR) showed the trust had excellent outcome figures for abdominal aortic aneurysm repairs. The standardised mortality ratio was 0.7 (national average 1) which meant that survival was more likely at the trust compared to the national average.
  • Risk of patient readmission was lower than the England national average. The standardised relative risk of readmission at Broomfield hospital was 70 for elective patients and 87 for non-elective patents (100 is the expected level of patient readmission)
  • The Sentinel National Stroke Audit Programme (SSNAP) for October to December 2015 showed the hospital achieved an overall rating of band B for both patient–centred and team-centred key performance indicators (where band A is the highest and band E the lowest).The Myocardial Ischaemia National Audit Project (MINAP) audit scores were similar to the England average in both 2012/13 and 2013/14.

We saw several areas of outstanding practice including:

  • The burns and plastics services were extremely good and ensured that services users were involved and central to the innovation in services. The directorate had recently introduced an electronic live trauma database. This meant that staff had up-to-date information about the trauma service. Outcomes for patients with serious burns were comparable among the best in the world and were consistently exceptional.
  • The ‘trigger and response team’ team were an exceptional team supporting acutely unwell patients throughout the hospital. The team were recognised throughout the hospital as being very responsive.
  • The mortuary team were innovative and passionate about providing a good patient experience at the end of life
  • The trusts upper gastro-intestinal (UGI) surgery was internationally recognised and had recently introduced leading edge robotic technology.
  • The trust had worked to decreasing caesarean rates and had run an internal project called ‘project two per cent’. The aim was to reduce caesarean section rates and promote vaginal birth. The maternity dashboard results showed that elective clinical caesarean had decreased from 12.8% in April 2016 to 8.4% in May 2016 against a target of less than 7%.This project remains on going.All staff were engaged in this project and there was clear leadership from the senior team.
  • There was a dedicated ‘birth reflections’ clinic, which helped women who had felt that they had not experienced the birth that they had planned for, or felt levels of anxiety or stress which related to the birth experience.

Importantly, the trust must:

  • The provider must ensure that HSA4 forms are sent to the Chief Medical Office, within the 14 days in line with the Abortion Act 1967.

  • The provider must ensure that patient records in orthopaedic clinic are stored securely.

  • The provider must ensure that medication, specifically paracetamol is prescribed clearly including route of administration. The provider must also ensure that patient’s weight is recorded for patient’s prescribed VTE prophylaxis and follow the National Institute of Health and Clinical Excellence (NICE) guidelines.

  • Ensure that staff are provided with appraisals, that are valuable and benefit staff development.

  • Improve mandatory training rates, particularly in the emergency department, around (but not exclusive to) advanced adult and paediatric life support in line with the Royal College of Nursing ‘Health care service standards in caring for neonates, children and young people.’

  • Ensure that rapid discharge of patients at the end of their life is monitored, targeted and managed appropriately.

In addition the trust should:

  • Consider consultant cover in the emergency department to meet 16 hours per day as recommended by The Royal College of Emergency Medicine.

  • The provider should take action to improve MRSA screening for elective and emergency patients

  • The provider should take action to reduce the number of cancelled elective plastic surgery operations and monitor cancellation rates for trauma patients

  • The provider should improve the percentage of patients receiving treatment within 62 days of referral.

  • The provider should ensure that all resuscitation equipment have identified expiry dates.

  • The provider should ensure that glucometers are checked as per hospital policy.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 1 December 2016

Effective

Good

Updated 1 December 2016

Caring

Good

Updated 1 December 2016

Responsive

Good

Updated 1 December 2016

Well-led

Good

Updated 1 December 2016

Checks on specific services

Maternity and gynaecology

Good

Updated 1 December 2016

We rated the Maternity and Gyneacology service as good overall. We found that the current safety arrangements in maternity and gynaecology services had substantially improved since our previous visit in 2014.

Staff reported incidents and there was evidence of thorough investigations and learning from incidents that was shared with staff.

The trust had successfully recruited to midwifery vacancies and had introduced a dedicated supervisory coordinator shift which ensured that an oversight of capacity and clinical need was monitored through a 24 hour period .

Complaince with mandatory training, skills and drills training, appraisals and induction for bank and agency staff were consistent high throughout the service.

There was clear engagement with both national and local audits and evidence of self-assessment to benchmark against recommendations. Guidelines were reviewed were in date and had been updated in line with changes

The trust had responded to the high level of caesarean rates, through a dedicated project to reduce the number of caesarean rates and increase the number of natural births. This project was known as “project 2%.This had been successful in reducing caesarean rates.

There were excellent examples of strong leadership both in the HoM and clinical directorate level, but also in the maternity and gynaecology teams, including gynaecology outpatients, maternity unit and early pregnancy unit

Governance meetings were well recorded and learning disseminated down to staff through newsletters and team meetings

There were good examples of public engagement for example through forums and the engagement of service users in study days

However:

There was no fast track dedicated pathway for women admitted with gynaecology problems through the emergency department.This had been identified in the previous inspection in 2014.

The number of Gynaecology incomplete pathways for May 2016 was 1020. This is higher than expected for an elective list and there were no assured plans in place to reduce this list.

HSA4 forms (used to notify government in termination of pregnancies carried out) were not sent to the Chief Medical Office, within the 14 days in line with the Abortion Act 1967. This is a breech of Regulation 17(1)(2)(c) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Good Governance

Medical care (including older people’s care)

Good

Updated 1 December 2016

We rated the medical care services at Broomfield Hospital as good overall.

We rated the medical care services at Broomfield Hospital as good overall.

  • Incident reporting was embedded amongst nursing and allied health care professionals and learning from incidents was promoted.

  • Patients were protected from avoidable harm and abuse, e and the concept of ‘safe’ was embedded in medical care service practice, for example through the implementation of “safety huddles”.

  • Standards of hand washing and cleanliness were consistently good and regularly audited. Wards were visibly clean and uncluttered. Staff were provided with personal protective equipment and we saw it being used appropriately.

  • The risk of patient readmission at Broomfield hospital was better than the England national average. The hospital participated in national audits, including Myocardial Ischaemia National Audit Project (MINAP), The Sentinel National Stroke Audit Programme (SSNAP) and the National Diabetes Inpatient Audit (NADIA), which shows the trust is monitoring its effectiveness.

  • Patients we spoke with told us that staff were caring and kept them involved and up to date with their care and treatment. Referral to treatment times (RTT) from September 2014 to February 2016 were better than the England national average and the trust had developed effective ways of caring for people living with dementia.

  • Quality improvement strategies were developed and outcomes were monitored and acted upon to ensure patients received harm free care. Complaints were used as a means to improve services and the trust was able to provide evidence of changes made as a direct result of complaints made.

  • Leadership within the medical care service was good. Clear accountable governance structures existed and risks were identified and owned by individuals who were appropriately held to account.

However:

  • There were variable standards of record keeping across the medical wards.

  • The storage of medicines was not always satisfactory and prescribing of medicines did not always follow National Institute of Health and Clinical Excellence (NICE) guidelines

  • Compliance with safeguarding training in medical staff was not in line with the trusts target. Safeguarding adults training level 1 had been completed by 71.7% of medical staff and Safeguarding Adults at level 2 had been completed by 55.1% of medical staff
  • Results from the 2015 National Diabetes Inpatient Audit showed that trust scores have declined in 11 indicators compared with 2013.
  • The Friends and Family test results for Goldhanger Ward for in June 2016 was 67%, which is significantly worse than the England average.

Specialist burns and plastic services

Outstanding

Updated 1 December 2016

We rated the Specialist burns and plastics service as outstanding overall. The Safety and Responsive domain has been rated as good, and the effective, caring and well-led domains have all been rated as outstanding.

Safety performance since our last visit in 2014 had improved significantly in the plastic’s trauma service, and performance remained outstanding in the burns service.

Compliance with mandatory training for all staff was was well above the trust average, and there was always a sufficient number of staff on duty to meet the needs of people who used the service.Lessons were learnt following incidents and appropriate action taken to improve safety beyond the affected team.

There was an abundance of service specific policies and procedures available developed by the directorate, which reflected evidence based practice, national guidance and relevant legislation. There was dedicated research team for the directorate, and audit results showed that outcomes for people using the burns service were good.

All nursing and support staff had either completed or were working through service specific competencies.

Pain management was effective and delivered through a multidisciplinary team approach.

The Friends and Family Test (FFT) results for the directorate were consistently high and the best in the trust, and feedback from people who used the service was consistently and overwhelmingly positive.

The service was innovative in ensuring patients understood and were involved in their care.Emotional support available was extensive and tailored to individual need. Services were planned and delivered to meet the needs of people using the service, and they were constantly evolving to improve continuity, flexibility and choice of care. Formal complaints were low and managed effectively.

Access and flow throughout the burns service was seamless, and in the plastic surgery service significant improvement and action had been taken to enhance seamlessness. Leaders were quick to respond to concerns, were visible and approachable, and staff could not speak more highly of them.

We found an extensive amount of examples which demonstrated the directorate was innovative, made improvements where needed and ensured sustainability of service provision. Throughout services staff were extremely positive, energised, passionate about their role and felt involved in service development.

However :

MRSA screening for elective and emergency patients was below trust expectation, and the service was not monitoring trauma surgery cancellations.

Staff appraisal rates on some wards was below trust expectation, however we found that appropriate action was being taken to improve compliance.

The Friends and Family Test was not carried out on Mayflower ward.

Urgent and emergency services (A&E)

Requires improvement

Updated 1 December 2016

We rated the Urgent and emergency services as requires improvement overall. The caring domain has been rated as good.

The recruitment of emergency department staff remains an issue for the trust. Patient records in the emergency department were not routinely signed or dated. The trust audit results for the Royal Emergency College of Medicine (RCEM) were below the required standard. Training rates fell short of the trust’s target for both medical and nursing staff and medical staff. Staff had not received regular appraisals in the emergency department and we were not assured that skills and competences were being measured or staff development supported.

Friends and family test data has been consistently below the England average since August 2014.

Between March 2015 and March 2016, the hospital did not meet the England NHS national target for seeing, treating, admitting, or discharging 95% of patients within four hours.The percentage of patients waiting between 4-12 hours between April 2015 and May 2015 increased to 16%, which was worse than the 8% England NHS average during the same period. The average time spent by patients in the Broomfield Hospital emergency department between January 2015 and January 2016, was consistently higher than the average England NHS trust for the same period

Staff were not aware of the trust vision. The strategy for the emergency department was being developed in line with changes from the Essex Success Regime. Changes in staffing and recruitment had affected staff morale, which placed the department under increased pressure to meet the demands of the service especially over the winter months.

However:

There was a good culture of incident reporting and learning from complaints and incidents.

The department had introduced ESAT (Early Senior Assessment & Treatment ) streaming process. This allowed a dedicated senior nurse to assess adult patients in a timely manner and determine the most appropriate pathways for those arriving by ambulance. This ensured that patients were assessed in a timely manner.

The department had developed “risk stamp”and“escalation criteria. This was used when patients had a 45 minute delay in ambulance of load and if there was a delay in leaving the department of over 6 hours. This assessed if patient are safe to continue to be where they are or if they need assessment.

There was evidence of good multi disciplinary working in the department. Staff felt supported by senior nurses and medical staff . Staff showed a commitment to the service and demonstrated a kind, compassionate and caring approach to patients.

Surgery

Good

Updated 1 December 2016

We rated surgical services overall as good.The reponsive domain was rated as requires improvement.

Systems were in place to ensure incidents were reported, investigated and lessons learnt. Incident management was in line with ‘being open’ and the ‘duty of candour.’ The duty of candour is a regulatory duty that relates to openness and transparency and requires providers of health and social care services to notify patients (or other relevant persons) of certain ‘notifiable safety incidents’ and provide reasonable support to that person.

Staff were caring, compassionate and respectful and were positive about working in the service. Medical staffing levels and skill mix were recognised as being satisfactory within the service.

Trust wide monitoring of staffing against acuity had taken place bi-annually to determine whether current staffing levels and skill mix were appropriate for the acuity of patients who used the service. Shortfalls existed in nurse staffing levels across the service but ongoing recruitment and the introduction of new ways of working ensured sufficient staff worked within the service.

We observed good infection prevention practices by staff. Clinical equipment was serviced and generally daily checks had taken place on equipment. One exception was two glucometer machines on Lister ward whose weekend checks were not completed. Daily monitoring of resuscitation equipment had taken place.

Patient’s risks were assessed to determine their fitness for surgery. The service had protocols and guidelines in place to assess and monitor patient risk in real time. Consent processes were robust and documentation associated with these processes was adapted to the individual patient’s needs and understanding.

Patients received evidenced based care and treatment and patient outcomes had improved. Good multi-disciplinary working existed between the trust, local clinical commissioning groups and community services.

Service planning and delivery considered patients’ needs, which meant changes to the service and how it was delivered benefited the patient. Support was in place for those patients and their families who had either learning disabilities or dementia type conditions. The trust had identified a lead nurse for dementia who was also a ‘Dementia friends champion.’

The service was well led and a clear leadership structure in place. Individual management of the different areas were well led. Cultural work had taken place to strengthen the multi-disciplinary teams. Feedback from staff and patients had resulted in changes to aspects within the service.

However:

Some staff had a limited knowledge of the ‘duty of candour’ regulation

Operating theatres were established against the ‘Association for Perioperative Practice (AfPP staffing recommendations). Theatres had a vacancy rate of 62 whole time equivalent (wte) which included 42 trained nurses at band five and six and 20 theatre assistants at bands two and three. An additional recruitment event was planned for the 20 June 2016 alongside ongoing recruitment

The national referral to treatment data (RTT) target was 90%. The data provided by NHS England (September 2014 – February 2016) confirmed RTT times were in line with the England average, although the trust was not meeting standards in four out of seven specialties. These specialities included general surgery (82.2%), trauma and orthopaedics (79.6%), ophthalmology (77.8%) and plastic surgery (88.8%). The trust had identified measures to meet these standards.

Following the inspection the RTT data from March to May 2016 for these specialities was analysed to determine progress made against each speciality. The data showed a decline in RTT performance for all four specialities. The May 2016 data was general surgery (53.6%), trauma and orthopaedics (47.5%), ophthalmology (77.4%) and plastic surgery (71%).

The safeguarding training target was 95%, however, medical and nursing staff compliance rate was from 60% - 97%.

Intensive/critical care

Good

Updated 16 April 2015

We found that the critical care service was safe, effective, caring and responsive to meet the needs of patients and relatives, and the service was well-led, with strong local leadership of the units. Medical staffing levels were in line with national guidance, Core Standards for Intensive Care Units 2013, with factors such as case mix, patient turnover and ratios of trainees considered. Nursing staffing establishment levels and skill mix were adequate across both units. The management at service level were clear about their roles and vision for the service. Staff morale was high, and a supportive environment was in place, with robust competency and training packages, small team allocations, and close working with the wider multidisciplinary team (MDT).

Services for children & young people

Good

Updated 16 April 2015

There were arrangements in place to implement good practice, learning from any untoward incidents, and an open culture to encourage a focus on patient safety and risk management practices. There were effective arrangements to identify and manage risk, and keep patients safe. We saw good examples of care being provided, with a compassionate and dignified approach.

National guidance was being implemented, and monitoring systems to measure performance were in place. The number of staff receiving mandatory training and appraisals was high. The children and young people’s service understood the different needs of the communities it serves, and acted on these to plan and design services. The paediatric department encouraged children, their relatives, and those close to them, to provide feedback about their care, and were keen to learn from experience, concerns and complaints.

End of life care

Good

Updated 1 December 2016

We rated the service as good overall. The safety, effective, caring and well-led domains have all been rated as good, and the responsive domain has all been rated as requires improvement.

End of life care to patients was good overall. The specialist palliative care team (SPCT) and the ward staff involved in end of life care were passionate, caring and maintained patients’ dignity throughout their care.

Since our last inspection visit in 2014 the completion of do not attempt cardiopulmonary resuscitation (DNACPR) forms had improved significantly.

The ‘Last Days of Life Care Plan’, a holistic document which was in line with the five priorities of care has been rolled out in all the adult wards. This document not only guides staff to consider the clinical needs of the patient but also prompts to consider and discuss the patient’s physical, emotional, spiritual, psychological and social needs.

The SPCT delivered end of life care education for medical, nursing and allied health care professionals as part of the mandatory trust induction, Preceptorship programme, Health Care Assistant and Healthcare Professionals study days, and also on the medical training programme.

The trust had put in place an end of life care facilitator which worked across the trust and each ward had a palliative/end of life care champion to support staff with any end of life training needs.

However:

Patients who had requested to be cared for in their own homes had experienced delayed discharges. There was no rapid discharge process in place.

There was no formal audit process of peoples preferred place of care/death or discharge times

Outpatients

Good

Updated 1 December 2016

We rated outpatients and diganostics as good because:

Incident reporting was well embedded and there was evidence of learning from investigation.Staff had a good understanding of duty of candour and their responsibilities in relation to the protection of vulnerable adults and children. There was appropriate safeguarding trained staff available in outpatient clinics when required.

Main outpatients and diagnostic imaging services had strong effective leadership. Specialist clinics such as urology, ophthalmology, cardiology, diabetes and pain services were well managed by their own specialist teams, with the exception of the orthopaedic and fracture clinics which lacked nursing leadership and supervision.

Staff worked to recent National Institute for Health and Care Excellence (NICE) guidance. There was evidence of working towards participation in national quality assessments such as Improving Quality in Physiological Services (IQIPs) and Imaging Services Accreditation Scheme (ISAS).

Staff provided compassionate and respectful care to patients. We observed that staff were understanding and maintained patient dignity. The majority of patient feedback that we received during our inspection was positive, and the latest Friends and Family Test (FFT) results demonstrated 82% of patients would recommend the service.

The appointment booking team had good leadership and a risk management system for follow up appointments that were overdue. The trust was performing better than the national average in seeing patients within the two-week cancer wait and the incomplete pathway targets.

There were consultant staff shortages, in diagnostic imaging, neurology and dermatology but there was a continued effort to recruit to the vacant posts. Where there were shortfalls in staffing, there were arrangements in place to access cover. Diagnostic imaging and main outpatients nursing staff shortages were in the process of recruiting.

However:

Patients waiting times in clinic were long, on average 27 minutes, and 35% of patients waited longer than this. The percentage of patients receiving treatment within 62 days of referral has continued to decline below the England standard of 85% (72.4% in February 2016).