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Broomfield Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 30 January 2019

We did not inspect all services at this inspection but we combined previous inspection ratings for those not inspected to give an overall rating for the hospital. We inspected urgent and emergency care, medical care, surgery, children and young people’s services, outpatients and diagnostic imaging.

Our rating of services went down. We rated it them as requires improvement because:

  • We rated safe, effective, responsive and well-led as requires improvement and caring was rated as good.
  • Our rating for safe remained the same. Staffing remained a challenge for the trust and the processes to ensure that temporary staff were competent for roles was not consistently applied. There were inconsistent practices in medicines management and record keeping.
  • Our rating for effective went down to requires improvement. Local and national audits were not being utilised to drive improvements and improve patient outcomes, there was a lack of training for staff in the Mental Capacity Act, 2005.
  • Our rating for caring remained the same. However, we found in some areas of medical care services, that staffing challenges limited staff’s capacity to always deliver compassionate care.
  • Our rating for responsive went down to requires improvement. There were significant issues with access and flow throughout the hospital. Patients could not always access care and treatment in a timely manner.
  • Our rating for well-led went down to requires improvement. There were no clear strategies for individual services. Staff were unclear of how they could contribute to the development and delivery of long-term objectives. The trust was going through a period of transition and infrastructures were being developed and were yet to be implemented.

However

  • The trust had developed plans with external stakeholders for future provision of services in line with national objectives to achieve sustainable quality care.
Inspection areas

Safe

Requires improvement

Updated 30 January 2019

Effective

Requires improvement

Updated 30 January 2019

Caring

Good

Updated 30 January 2019

Responsive

Requires improvement

Updated 30 January 2019

Well-led

Requires improvement

Updated 30 January 2019

Checks on specific services

Urgent and emergency services

Requires improvement

Updated 30 January 2019

Our rating of this service stayed the same. We rated it as requires improvement because:

  • The service provided mandatory training in key skills but not everyone completed it. Staff told us that high levels of clinical demand meant that staff could not always be spared to attend training. The emergency departmental (ED) medical staff team compliance for mandatory training was below the 85% target set by the trust.
  • The ED medical and nursing staff team compliance for safeguarding training was below the 90% target set by the trust.
  • The Department of Health’s standard for emergency departments is that 95% of patients should be admitted, transferred, or discharged within four hours of arrival in the emergency department. The trust consistently failed to meet the standard and performed generally worse than the England average for the period August 2017 to July 2018.
  • The trust reported that 31.2% of patients who required mental health services were treated within 60 minutes in July and August 2018. Patients attending requiring mental health input in July and August 2018, 63.3% were treated within four hours.
  • From July 2017 to June 2018 the trust’s monthly median total time in A&E for all patients was consistently higher than the England average, with a spike in December 2017 when the trust’s monthly median total time in A&E for all patients was 232 minutes compared to the England average of 159 minutes.
  • Reception staff were not trained in recognition of red flag signs and symptoms, which allow for timely escalation of critically unwell or injured patients who self-present to the emergency department.
  • Audit and governance processes were not embedded within the department.
  • There was a dedicated room within the ED for mental health assessments, which met most of the requirements of the Royal College of Emergency Medicine (RCEM) mental health tool kit for improving care in emergency departments, which states any assessment area needs to be safe for staff, and conducive to valid mental health assessment and importantly, the assessment room must be safe for both the patient and staff. However, the environment was not in line with all requirements of (RCEM), because the doors did not open both ways, which meant if a patient barricaded the room, staff would need to use force to enter the room.

However:

  • Staff understood their responsibilities to identify and report incidents and safeguarding concerns.
  • Staff from various teams worked well together as a team to monitor and improve patient care and outcomes.
  • Patient feedback was positive, describing staff as ‘kind and caring’.
  • Staff described a developing positive culture within the emergency department, telling us they felt supported in their role.
  • To improve mandatory training compliance the trust had employed a clinical facilitator to improve access to training for ED nursing staff.
  • Staff maintained and checked resuscitation, sepsis, and airways trolleys daily, and we found these well maintained with no gaps in staff records.
  • We reviewed the notes of nine children in relation to initial assessments, staff triaged the children within fifteen minutes of arrival including the assessment of pain complying with the standards for children and young people in emergency care settings set by the Royal College of Paediatrics and Child Health (RCPCH 2012).

Medical care (including older people’s care)

Updated 31 July 2019

Services for children & young people

Updated 30 January 2019

Our rating of this service went down. We rated it as requires improvement because:

  • Systems and process that were in place to safeguard children and young people were not fully embedded and there were shortfalls in the system of engaging with local safeguarding processes.
  • Safeguarding level three training compliance was low for medical staff.
  • Medication management and oversight of the temperature requirements for medication storage was inconsistent across the service.
  • Not all policies were consistently reviewed and updated in a timely manner.
  • The service monitored the effectiveness of care and treatment through some local and national audits, however there was only limited evidence of formal action plans related to sharing the findings of the audit rather than changes to practice.
  • There was a lack of vision and strategy, specifically for children and young people’s services.
  • There was lack of awareness by the service leads regarding the inconsistent systems and lack of robust governance systems to support children safeguarding

However

  • Staff knew how to report incidents and there was evidence of sharing learning from incidents, which was shared with staff.
  • The service controlled infection risk well. Staff used control measures, which were audited, to reduce the risk of infection. We consistently observed good hand hygiene and use of personal protective equipment such as aprons and gloves.
  • Nurse staffing levels on NNU were meeting recommended levels and were sufficient to safely meet patients’ needs. Medical staffing levels and skill mix were appropriate to meet patient needs.
  • Staff had the appropriate skills and competencies to carry out their work and there were opportunities for staff to progress or develop additional competencies.
  • Compassionate care was consistently observed and noted by patients and their families, and privacy and dignity were well highlighted throughout the service.
  • There was good internal MDT working across the service. Nursing and medical teams worked well together as one team to best support children’s needs.
  • All parents and carers we spoke with were happy with the care of their child and all observations of staff interaction with patients and parents or relatives were compassionate and kind.
  • The service had a strong local leadership team. Nursing and medical staff consistently reported good relationships with service leads and described managers as approachable and supportive.
  • There was a positive, team-based culture across the service.
  • Service leads were able to explain the key risks for the service.
  • There was evidence of public and parental engagement with the service.

Diagnostic imaging

Requires improvement

Updated 30 January 2019

We previously inspected diagnostic imaging jointly with outpatients so we cannot compare our new ratings directly with previous ratings.

We rated this service as requires improvement because:

  • The service did not always have systems in place to ensure that staff were able to identify and respond appropriately to changing risks to people who used services.
  • There were staff shortages and low mandatory training and appraisal rates.
  • The service had not always ensured that checks on the environment and equipment were regularly carried out, or that cleaning was regularly carried out or documented.
  • The service was not carrying out discrepancy audits to review the quality of reports and audit activity in 2017 had been limited.
  • Patients were not always able to access diagnostic imaging services or receive imaging reports in a timely manner.
  • The management of risk and performance was not always robust.

However,

  • Storage of contrast media had improved since our last inspection
  • Staff understood their roles and responsibilities in safeguarding and under the Mental Capacity Act.
  • Patients gave consistently positive feedback about the care provided by staff.
  • Staff described cooperative, supportive and appreciative relationships with colleagues.

Outpatients

Requires improvement

Updated 30 January 2019

We previously inspected outpatients jointly with diagnostic imaging so we cannot compare our new ratings directly with previous ratings.

We rated it as requires improvement because:

  • A high level of clinical demand meant that staff could not always be spared to attend mandatory training.
  • Records were not always clear, up-to-date, and easily available to all staff providing care.
  • There was a high reliance on bank staff.
  • The storage of medicines related stationery did not always follow national guidelines.
  • Patients could not always have timely access to initial assessments, test results, diagnoses or treatment.
  • There was no separate formal strategy for outpatients and staff were not aware of the trust’s strategy and values.
  • The service did not always collect and use information well to support its activities.

Surgery

Requires improvement

Updated 30 January 2019

Our rating of this service went down. We rated it as requires improvement because:

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

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

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.

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).