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Inspection carried out on 30 January 2017

During a routine inspection

Mid Essex Hospital Services NHS Trust employs nearly 5,000 members of staff and provides local elective and emergency services to 380,000 people living in and around the districts of Chelmsford, Maldon and Braintree (including Witham).The trust provides from five sites in and around Chelmsford, Maldon and Braintree. The main site is Broomfield Hospital in Chelmsford.

Broomfield Hospital is an acute 635 bedded hospital. Broomfield hospital also provides a country-wide plastics, head and neck and gastrointestinal (GI) surgical centre to a population of 3.4 million and an internationally recognised burns service at the St Andrews Centre that serves a population of 9.8 million.

We completed a focussed inspection on the 30th January 2017 following a Statutory Notification, to ensure that the trust had implemented the action plan to mitigate the risk of a serious incident reoccurring in the peadiatric Emergency Department. The peadiatric ED department had been reconfigured in 2016 to sit within the Womens and Childrens Directorate as part of the trusts action plan.

This was undertaken by two CQC inspectors and one specialist advisor. Only peadiatric services in the Emergency department (ED) at Broomfield Hospital were inspected. We have not rated this service as it was a focused inspection to review the actions taken by the trust in respect of this incident.

The inspection team made an evidence judgement on one domain to ascertain if services were safe.

We found:

  • There was good evidence of lesson learned from incidents that had taken place and where changes had been made in practice and embeded.Due to the reconfiguration of the peadiatric ED department to the womens and childrens directorate, risks and incidents were discussed at a number of meetings and shared across the whole peadiatric pathway.
  • There was a dedicated safeguarding peadiatric lead. Safeguarding Level three training had been expanded to include all Health Care Assistants in the ED department, and 100% of staff had completed Level 1 and Level 2 safeguarding childrens training.
  • The Children’s Early Warning Tool (CEWT) training and sepsis training had been embedded in paediatric basic life support and paediatric immediate life support (PILS), which was part of the mandatory training programme, meaning that all staff (not just in paediatric ED), had been trained in the management of the unwell child.
  • The Children’s Early Warning Tool (CEWT) was in line with national guidance and in line with the observations parameters outlined in the children’s and young people observation policy.
  • There was a clear escalation pathway at the back of all observation charts, which included the use of the “SBAR” tool (situation, background, assessment and recommendation) to assist staff when escalating concerns.
  • Sepsis workshops had been rolled out to all medical and nursing staff to develop competencies in recognising and responding to children with sepsis. This included the importance of concerns raised by parents about their child’s condition.
  • Nurse vacancies had been recruited to although there was still a reliance on agency and bank staff to maintain staffing levels. Due to the reconfiguration of the peadiatric ED department to the womens and childrens directorate, staffing was reviewed daily, or as required by the peadiatric matron and clinical lead to ensure that staffing across with whole peadiatric pathway was safe.
  • There was no specialist paediatric ED consultant, however the trust was trying to recruit to this post. Between April 2015 and March 2016, the emergency department saw over 16,000 patients that were less than 17 years of age. The Royal College for Emergency Medicine (RCEM) recommends that in emergency departments seeing more than 16,000 children per year there should be at least one paediatric emergency consultant. The trust does have a consultant with an interest in paediatrics, but overall the trust did not meet this standard.
  • There was ongoing recruitment to have a second peadiatric registrar to support the ED registrar 24 hours per day. Although these posts were not fully recruited to, any vacant shifts were put out for locum cover. However, during the period 2 January 2017- 29 January 2017 14 shifts for the second paediatric register had remained unfilled
  • Data on major incident training provided by the trust showed that 12 of the 14 nursing staff in the paediatric emergency department had completed this.

We noted that there were good areas of practice and also areas where the trust should continue to make improvements.

The trust should:

  • Continue to recruit the specialist paediatric ED Consultant post to be in line with the Royal College for Emergency Medicine guidance.
  • Continue to recruit to peadiatric Registrar vacancies to allow 24/7 additional support to the ED registrar.
  • To ensure that the completion of the “safe to discharge” check is completed in all patient records by the medical teams.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 14, 15, 16 June 2016 and 30 June 2016

During an inspection to make sure that the improvements required had been made

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 carried out on 13 April 2015

During an inspection to make sure that the improvements required had been made

Broomfield Hospital is part of the Mid Essex Hospital Services NHS Trust (MEHT). Broomfield Hospital is an acute district general hospital and it is the only hospital location within Mid Essex Hospital Services NHS Trust to provide accident and emergency (A&E) services. Broomfield Hospital also provides a county-wide plastics, head and neck and upper gastrointestinal (GI) surgical centre to a population of 3.4 million, and an internationally-recognised burns service in the St Andrew's Centre within Broomfield Hospital that serves a population of 9.8 million.

We inspected the services within the urgent and emergency services (Emergency Department (ED), Emergency Assessment Unit (EAU), Emergency Short Stay wards (ESS and the ambulatory care services) at this hospital on 13 April 2015 in response to concerns of stakeholders and information of concern received into the CQC. Concerns were raised by stakeholders around the flow of patients through the A&E department, whether timely care was being provided and whether patients received sufficient pain relief. Concerns were also raised about ambulance handover delays which resulted in patients waiting for long periods of time prior to being taken into the hospital.

This was our third inspection of the Urgent and Emergency Services due to concerns raised with us. In August 2014 our inspection raised concerns over patient safety, security for patients, especially those with mental illness and paediatric patients, incident reporting and staffing levels and training. At our comprehensive inspection in November 2014 we saw that these issues had failed to be addressed. In February 2015 we returned to the EAU as we were alerted to qualified nurses who were working without registration. Following this issue being raised by us to the trust, action was taken to ensure that only registered nurses were directing patient care in this area. We returned in March 2015 to ensure that actions taken remained in place within the EAU. The service was rated as inadequate following these inspections. We returned in April 2015 due to concerns being raised with us in respect of the care provided within the service. Overall the rating for Urgent and Emergency Services remains as ‘Inadequate’ following this inspection. The domain ratings remained the same with safety, responsiveness and well-led being rated as ‘Inadequate’ and caring being rated as ‘Good’. However the effectiveness of the service has been downgraded from ‘Requires improvement’ to ‘Inadequate’ due in part to a deterioration of the care provided for patients with pressure ulcers.

Prior to the CQC on-site inspection, the CQC considered a range of quality indicators captured through our intelligent monitoring processes. In addition, we sought the views of a range of partners and stakeholders.

This was a focused inspection undertaken by five inspectors from CQC three of whom were qualified nurses, one paramedic and one governance and risk specialist. Only the services within urgent and emergency services (Emergency Department (ED), Emergency Assessment Unit (EAU) and Emergency Short Stay wards (ESS) at Broomfield Hospital were inspected.

Our key findings were:

  • The trust has not sufficiently implemented the recommendations and requirements following our five inspections to this service and patients continue to experience a poor level of care and treatment.
  • The flow of the emergency department, staff vacancy, skill mix and triage still had an impact on the care patients received which in some cases was poor. Care in the emergency department did not always adhere to NICE guidelines, particularly around head injuries and sepsis.
  • The staffing within the EAU and ESS were appropriately trained, qualified and registered for the care they were delivering.
  • The care of patients with mental health concerns fell below the expected standard of care in the emergency department.
  • Improvements were required in terms of the reporting and learning from incidents.
  • There were staffing shortages for nurses throughout the emergency floor and there were notable medical staff shortages within the emergency department.
  • Governance structures at departmental level across the emergency department were not robust and were in significant need of improvement.
  • Good governance arrangements were not in place as there was a lack of understanding of the risks and issues within the emergency department by the senior management and executive team.
  • Assurances on governance and risk arrangements for the services were provided by the departmental leaders to the trust, with the trust believing the services protected patients from abuse and avoidable harm. however the executive team could not produce the evidence to support the safety of services.
  • The multiple changes in leadership locally had impacted on the running and morale of the services.
  • The culture within the department was poor, there was fear of the management team blaming staff locally for failure to deliver targets and reports or pressure to undertake work practices that were not safe for patients.

We observed areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • Ensure medicines are administered in a timely way, especially for patients receiving intravenous antibiotics and time critical medicines.
  • Ensure care documentation including care plans and risk assessments are undertaken in a timely way, accurately, are fully completed and reviewed when required.
  • Improve staff training and awareness on mental health so that the provision of care for patients in urgent and emergency services with mental health conditions improves.
  • Ensure patients with mental health concerns are risk assessed on arrival at the emergency department and that patients with mental health concerns are appropriately observed and monitored.
  • Review staffing levels on the reception desk in the emergency department.
  • Ensure that resuscitation trolleys are regularly checked and stocked.
  • Improve staff knowledge and understanding of what constitutes a safeguarding referral for adults.
  • Ensure that all safeguarding referrals for adults in the emergency department are completed and actioned in a timely way.
  • Improve hand washing techniques and infection control practices and techniques in the emergency department.

In addition the trust should:

  • Improve the incident reporting culture for staff to increase the number of incidents reported overall.
  • Ensure that recruitment plans, to increase the amount of permanent nurses, are agreed and actioned to ensure that the high usage of agency and bank staff is reduced.
  • Review mechanisms for using feedback from patients, so that there are opportunities for reviewing and improving service quality.
  • Improve patient confidentiality in the ambulance entrance particularly when staff are discussing patient care.
  • Ensure that staff are provided with feedback and informed of learning from incidents.
  • Ensure the corridor within the emergency department which leads from the ambulance doors and the resuscitation area is kept clear of obstructions at all times.
  • Improve shift and nursing handovers in the emergency department to ensure all staff are informed of the required information.
  • Safely plan and increase consultant cover in the emergency department from 11 to 16 hours per day as recommended by The Royal College of Emergency Medicine.
  • Improve patient care within the emergency department for conditions such as sepsis and head injuries in line with Royal College of Emergency Medicine guidelines.
  • Improve implementation of the escalation protocol in the emergency department.
  • Improve ambulance handover times within the emergency department.
  • Improve local staff engagement within the ED and between the EAU and ED.
  • Improve the working relationship between the ambulance service and the emergency department.

On the basis of the ratings, I have requested for the regulator of non-foundation trusts, the Trust Development Authority (TDA), to review our concerns and implement buddy and support systems for the trust to immediately drive improvement in quality, safety and governance across urgent and emergency services and at trustwide leadership level. We have also served a warning notice to this trust and requested for significant improvements to be made to the quality of healthcare provided to patients. The trust has agreed and continue to voluntarily submit information to the Care Quality Commission to demonstrate the safety of patients, as well as how effective systems and process are within urgent and emergency services.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 26th 27th, 28th November, 6th December 2014. Focused inspection 5th February and 26th March 2015.

During a routine inspection

Broomfield Hospital is part of the Mid Essex Hospital Services NHS Trust (MEHT). Broomfield Hospital is an acute district general hospital and it is the only hospital location within Mid Essex Hospital Services NHS Trust to provide accident and emergency (A&E) services. Broomfield Hospital also provides a county-wide plastics, head and neck and upper gastrointestinal (GI) surgical centre to a population of 3.4 million, and an internationally-recognised burns service in the St Andrew's Centre within Broomfield Hospital that serves a population of 9.8 million.

Broomfield Hospital is an acute hospital providing accident and emergency (A&E), medical care, surgery, critical care, maternity and gynaecology, children and young peoples services, end of life care, and outpatient and diagnostic services, which are the eight core services always inspected by the Care Quality Commission (CQC) as part of its new approach to hospital inspection. In addition to these eight core services, the hospital provides a regional centre for burns and plastic surgery. We have therefore included these as an additional core service on this scheduled inspection.

We carried out this inspection as part of our commitment to inspect all NHS trusts in England. Our rationale for choosing this service was based upon its aspirations to become a foundation trust, but also due to risks that had arisen around the non achievement of the four hour target in A&E, and also an increased number of whistleblowing and safeguarding concerns received by the Commission.

This was a scheduled and announced inspection, which took place between 26 and 28 November 2014 and on 6 December 2014 we conducted an unannounced inspection of the service. In addition, on 05 February 2015 we returned and carried out a focused unannounced inspection of the Emergency and Assessment Unit (EAU) and took enforcement action, on 26 March 2015 we returned to ensure that systems were in place to protect people from avoidable harm.

Overall, we have found that the ratings and provision of care in each core service varied greatly. The trust was a caring organisation throughout, and staff we observed in the majority were passionate about their work and caring towards patients. We found that the burns service was providing excellent care, with some of the best outcomes for patients with severe burns in the country, and the results were competitive with burns centres worldwide. Generally, we found the critical care and services for children and young people good, with improvements needed in medical care, surgery, end of life care and outpatient and diagnostic services. We found examples of poor care and practice in urgent and emergency services which we have rated as inadequate, and also in maternity and gynaecology and specialist burns and plastic services which required improvement. During our inspection of Broomfield Hospital EAU on 5 February 2015 we found that the safety of the emergency assessment unit (EAU) was inadequate but this did not impact on the rating for urgent and emergency services which was already rated as inadequate. However the rating for leadership within urgent and emergency services changed from requires improvement in November 2014 to inadequate. This is because the leadership of the unit did not act to ensure that appropriate and registered staff were responsible for the direct care of patients on the EAU. The leadership of the service failed to act on concerns raised by staff and the senior management team failed to have effective governance and assurances processes in place to monitor the work and roles of the staff working in adaptation posts whilst they were awaiting registration. Overall, we have rated Broomfield Hospital as a requires improvement service as whilst there are two inadequate ratings for the safe domain this only relates to one core service. We have identified areas where improvements are required.

  • It was evident that throughout the organisation staff were passionate, dedicated and cared about the work they delivered.
  • The service has had an unstable few years with management changes and this had impacted on service flows, confidence and stability. The service is on a journey to improving the services provided and this will take some time to embed throughout.
  • There were significant staffing shortages particularly for qualified nurses throughout the hospital but there was a plan in place to recruit over 200 additional nurses, though it is recognised by the trust that skill mix would remain a challenge for some time.
  • The emergency department like all throughout England in November was under pressure from a high volume of attendances.
  • The flow of the emergency department, staff vacancy, skill mix and triage did have an impact on the care patients received which in some cases was poor. Care in the emergency department did not always adhere to NICE guidelines, particularly around head injuries and sepsis.
  • The care of patients with mental health concerns fell below the expected standard of care.
  • There was no clear pathway or plan for patients who were receiving care at the end of their life. The development and implementation of this plan was required following the removal of the Liverpool Care Pathway in 2014.
  • The trauma service within plastic surgery particularly on Mayflower was disorganised and impacted directly on patient care and safety when the ward became overcrowded with patients.
  • Significant concerns were raised around Writtle ward and their high use of non-trust staff and case mix of medical outliers and women with gynaecological and early stage pregnancy concerns.
  • There were significant waiting lists in place for patients who require a follow up outpatient appointment (over 24,000 at the time of inspection across all specialties). There was no risk assessment process in place for those patients to ensure that a longer wait was acceptable.
  • Improvements were required in terms of the reporting and learning from incidents.
  • Governance structures at departmental level across the emergency department, medical care, specialist plastic surgery, maternity and gynaecology and end of life care were not robust and were in significant need of improvement.
  • The Burns service was outstanding and there innovative developments and plans the service had. Their patient outcomes also show that they are one of the best burns centres in the world. We commend them for the work that they are undertaking and their achievements to date.

We saw several areas of outstanding practice including:

  • The caring and responsive approach shown by the chaplaincy and the services provided to bereaved families by staff in the mortuary were outstanding. Staff within both services went beyond the call of duty to support families, particularly those bereaved of children and babies.
  • The burns service was outstanding with innovative and pioneering approaches to care delivery and outcomes for people with burns which had been reflected in national research papers.
  • Outcomes for patients with serious burns was comparable among the best in the world and were consistently exceptional. This was evidenced through a cohort study undertaken by St Andrew’s in 2012.
  • Pathways for breast reconstruction and hand therapy were outstanding.
  • The trust’s abscess rate following an epidural was 0% as compared to the national average of 8% which was an excellent outcome for patients.
  • 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.
  • Individual specialist staff in the trust including the learning disability nurse, specialist nurse for dementia care and the manual handling advisor were identified as being outstanding and highly responsive to patient and staff needs.
  • The nurse-led peripherally inserted central catheters (PICC) was developed within the critical care service without initial funding, it has seen great success and improved patient outcomes.
  • There were outstanding examples of local leadership and innovation in the intensive care unit.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • Ensure that only registered nurses are included in the nursing numbers and ensure that staffing numbers are maintained on the EAU by suitably qualified and registered staff.
  • Ensure that incidents are appropriately reported and investigated on the EAU.
  • Ensure that the adaptation staff working in the hospital are provided with support, supervision and competency training as well as mentor support.
  • Improve governance and assurance processes around the use of adaption staff throughout the hospital to ensure that they work within the scope of their role.
  • Immediately improve inpatient deterioration recognition across all inpatient areas, particularly on Writtle Ward.
  • Immediately work to reduce the number of patients who are on a waiting list for a follow-up outpatient appointment.
  • Reduce the number of hospital-acquired pressure ulcers.
  • Ensure medicines are administered in a timely way, especially for patients receiving intravenous antibiotics and time critical medicines.
  • Ensure care documentation, including care plans and risk assessments, are undertaken in a timely way, accurately, are fully completed, and reviewed when required.
  • Ensure that nursing handovers are robust and identify patients at risk.
  • Ensure that there are sufficient and appropriately skilled nursing and medical staff on duty at all times to meet patients’ needs in a timely manner.
  • Ensure nurses have the appropriate/specific skills to care for all the patients in their ward areas.
  • Improve treatment times for patients with prostate cancer to ensure a higher percentage of patients receive their required treatment within 62 days.
  • Improve governance systems to include formalised and minuted mortality and morbidity meetings across the directorates.
  • Ensure that systems for providing staff with feedback on incidents, and sharing learning from incidents, are embedded throughout the trust.
  • Develop a strategy for the improvement and delivery of end of life care.
  • Improve staff training and awareness on mental health, so that the provision and care for patients in urgent and emergency services with mental health conditions improves.
  • Ensure patients with mental health concerns are risk assessed on arrival at the emergency department.
  • Review staffing levels on the reception desk in the emergency department.
  • Ensure that patients are referred to in a dignified and respectful way, and not as bed numbers, particularly on Danbury Ward.
  • Ensure all items of equipment that require annual service and maintenance are maintained on time.
  • Ensure patient prescription charts for medicines are signed when medicines are administered, particularly in the emergency department and emergency assessment unit.
  • Ensure medicines cupboards are kept secure at all times.
  • Ensure that intravenous (IV) fluids are stored securely to minimise the risk of tampering.
  • Improve staff knowledge and understanding of what constitutes a safeguarding referral for adults.
  • Ensure that all safeguard referrals for adults in the emergency department are completed and actioned in a timely way.
  • Work to improve safety, and reduce incidents with a serious impact, on the labour ward.
  • Reduce the number of elective surgeries, including elective caesarean cancellations.
  • Improve hand washing techniques, and infection control practices and techniques, in the emergency department, emergency assessment unit and on Writtle Ward.
  • Ensure that only clinically appropriate patients are admitted to Writtle Ward, also ensuring that the medical outliers criteria for Writtle Ward is not breached.
  • Review the decision to lift the birth cap on the maternity service, and determine a safe way to manage the increase in the number of women attending in labour.
  • Improve the standard of 'do not attempt cardio-pulmonary resuscitation' (DNA CPR) forms completion throughout the trust.
  • Implement an approved end of life care plan and pathway for patients.
  • Review the pathology referral system to ensure that all referrals are managed safely.
  • Review the need for a dedicated link co-ordinator for the health team at HMP Chelmsford, to co-ordinate prisoner visits.
  • Improve governance arrangements and quality assurance, particularly in incident reporting, risk registers and incident investigations.

In addition the trust should:

  • Ensure quality dashboard data is consistent across the directorate and is in a format that is easily accessible to patients and relatives.
  • Provide day rooms for care of the elderly wards.
  • Decrease the number of agency and bank staff by improving recruitment and retention of nursing staff. This would improve access to training.
  • Work and balance staff skill mix across areas to ensure skilled experienced staff are on duty where possible.
  • Improve the incident reporting culture for staff trust wide to increase the number of incidents reported overall.
  • Review staffing and management structures for end of life care.
  • Ensure that recruitment plans, to increase the amount of permanent burns nurses, are agreed and actioned to ensure that the high usage of agency and bank staff is reduced.
  • Ensure that there is a paediatric trained registered nurse, consultant and anaesthetist available at all times within the Burns service.
  • Review Burns specific policies and procedures to ensure that there is evidence of regular review and ratification.
  • Review mechanisms for using feedback from patients, so that there are opportunities for reviewing and improving service quality.
  • Improve patient confidentiality throughout the wards particularly when staff are discussing patient care.
  • Ensure that cardiac monitor alarms are not muted without ensuring that patient is safe.
  • Ensure that staff are provided with feedback and informed of learning from incidents.
  • Ensure that patients with mental health concerns are appropriately observed and monitored.
  • Ensure the corridor within the emergency department which leads from the ambulance doors and the resuscitation area is kept clear of obstructions at all times.
  • Improve shift and nursing handovers in the emergency department to ensure all staff are informed of the required information.
  • Safely plan and increase consultant cover in the emergency department from 11 to 16 hours per day as recommended by The Royal College of Emergency Medicine.
  • Improve patient care within the emergency department around sepsis and head injuries in line with Royal College of Emergency Medicine guidelines.
  • Improve implementation of the escalation protocol in the emergency department.
  • Improve ambulance handover times within the emergency department.
  • Improve local staff engagement throughout all services within the hospital.
  • Safely work to reduce the number of emergency caesareans performed in maternity.
  • Consider reviewing the case mix on Danbury ward to ensure those receiving oncology and end of life care are with an appropriate patient group.
  • Consider reviewing nursing shift lengths to minimise the number of 13.5 hour shifts staff undertake.
  • Improve audit and evidence based care and treatment in maternity services.
  • Provide formal team meetings in the maternity and gynaecology wards for staff.
  • Review cultural concerns and alleged bullying culture by management within the maternity service.
  • Improve 18-week maximum referral to treatment (RTT) waiting standards for general surgery and trauma and orthopaedics.
  • Review executive and non-executive leadership arrangements for end of life care to drive the end of life care agenda through the trust.
  • Improve the incident reporting culture trust-wide.
  • Develop a maternity specific trigger list to ensure robust reporting measures.
  • Improve the culture and leadership on EAU.
  • Improve the incident reporting culture relating to safe staffing levels.

On the basis of the findings at Broomfield Hospital from our comprehensive and focused inspections the Care Quality Commission has used its enforcement powers to impose an urgent condition on the trust’s registration to ensure that patients receive care from suitably qualified and registered nurses in the EAU. The Care Quality Commission has also issued the trust with a warning notice in relation to care and welfare concerns identified for patients receiving care at Broomfield Hospital. These can be viewed in the enforcement section of this report.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 19 August 2014

During a routine inspection

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 carried out on 11 July 2013

During an inspection to make sure that the improvements required had been made

On this occasion we did not speak with anyone who used the service about the way their medicines were managed. People were protected against the risks associated with medicines because the provider had improved arrangements in place for the storage and recording of medicines.

Inspection carried out on 13, 14 June 2013

During an inspection to make sure that the improvements required had been made

We found that Mid Essex Hospital Trust had taken steps to improve the patient assessment and record keeping and they now had more accurate and consistent records on which to base clinical and nursing management decisions. However we still found areas for further improvement and the trust were aware that more work needed to be done, especially around person centred care management.

People we spoke to on the wards we visited were happy with the care that they received. One person told us: "I have drunk more water in here than I ever do at home" and another said: "I get fed up drinking all this water but I know its doing me good." One person said: "I have been well looked after in here."

Inspection carried out on 21 February 2013

During an inspection to make sure that the improvements required had been made

We visited Broomfield Hospital in July 2012. We found that the trust was not compliant with Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 in that they were not accurately assessing peoples' needs and planning care to meet people's individual needs and ensure they were receiving the support they required.

We found that the trust remained non-compliant in that people still did not have accurate or timely assessments of their needs in place, the planning and delivery of care was not robust and did not always ensure the welfare and safety of the people using the service. We also found that the trust was not adhering to recognised guidance issued by the appropriate professional and expert bodies.

We spoke to people using the service. They told us that they were happy with the food provided and the choice available. Comments included "I get enough to eat", "The food here at Broomfield is very good" and "The food is much better than the last time I was in hospital." We found that people were provided with sufficient amounts of nutritious food

and were provided with support to enable them to eat and drink. However we found that people did not always have a prompt and accurate assessment of their actual or potential risk of malnutrition and dehydration.

We found that the provider did not have proper arrangements in place for the safe storage and security of some medicines and the safe administration of medication.

Inspection carried out on 10 July 2012

During an inspection to make sure that the improvements required had been made

We did not speak to people using services on this occasion as this visit primarily focused upon record keeping.

Inspection carried out on 13 April 2012

During an inspection to make sure that the improvements required had been made

Patients we spoke told us that they were satisfied with the care and treatment they received during their hospital stay. Patients on Felsted ward told us that staff were attentive and caring. One patient told us ‘’Staff are busy and they work very hard. I always get the help I need. The doctors and nurses are wonderful. I cannot fault the care here.’’

Patients we spoke with on Phoenix ward told us that the care was excellent. Two parents we spoke with told us that they felt confident that their children received the very best care. One patient told us ‘’The doctors, nurses and all the staff here are patient and understanding. They really take into account our fears and keep us up to date with any changes in treatment.’’ Another patient said ‘’I think the care is exceptional. There is always someone available to speak with and answer any questions I have.’’

Two patients we spoke with on Rayne ward told us that they were happy with the care they had received. One patient commented that on occasions the treatment had not been explained to them initially by the doctor. They told us that when they asked the nursing staff that they were given a full explanation of the treatment.

Patients on Danbury and Billericay wards told us that staff were polite, pleasant and helpful. They also told us that procedures were explained to them in a way that they could understand. Some patients told us that staff gave advice in a calm and reassuring way and presented them with treatment options, making them feel included in decisions about their care.

The majority of patients we spoke with told us that they were happy with the quality and choice of food available to them during their visit to Broomfield Hospital. One patient commented that, in their opinion, there were not enough vegetables served. Two patients on Felsted ward to us that there was a very good choice of hot and cold meals available. One patient on Rayne ward said that food was ‘’ok’’. Another patient told us ‘’The food is very good, much better than I expected it would be.’’ We were told, by two patients we asked, that they were provided with sufficient drinks. We were told water jugs by their bedside were replenished frequently and they were offered regular hot drinks.

Patients we spoke with told us that the hospital was clean. One person on Braxted ward told us ‘’It is very clean here, toilets and bathrooms are clean.’’ Two people on Felsted told us ‘’There are cleaners here most days. It is always very clean here." Patients we spoke with on Billericay ward and Danbury ward also said they felt the environment was clean. One person said that they felt the ancillary staff were thorough and unobtrusive.

Patients we spoke with told us that they received their medicines at the expected times during their stay in hospital. Two patients we spoke with on Rayne ward told us that where new medicines had been prescribed for them that the reasons for their use had been explained to them. Patients told us that they were given sufficient information about their medicines when they were discharged home.

Two patients we spoke with on Billericay ward told us that staff always responded promptly when they requested assistance. One patient told us that they felt there were enough staff available. They commented, however, that over the previous bank holiday weekend they felt that the ward was short staffed.

One patient on Danbury ward told us that staff usually assisted them when needed. They told us that on one occasion staff had ‘forgotten about them’ and they were left in the bathroom for 40 minutes without assistance.

Patients we spoke with on Rayne and Felsted wards told us that staff were usually available when needed. One patient told us ‘’I rarely have to wait and if I do it is usually because someone needs more urgent help. That’s only to be expected.’ ’Patients told us that they felt medical and nursing staff worked well as a team and that this gave the confidence in their care and treatment.

Patients we spoke with told us that they were happy with the care they received from staff. Patients on Felsted and Rayne wards told us that they felt staff were skilled and knowledgeable.

Inspection carried out on 22 March 2012

During a themed inspection looking at Termination of Pregnancy Services

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

Inspection carried out on 21 September 2011

During a routine inspection

People with whom we spoke told us that they were overall very satisfied with the treatment and service they received at Broomfield Hospital. People told us that staff treated them with dignity and respect. Most people commented that the treatment they received was 'very good' or 'excellent'

Some people told us that treatment was not always explained to them and that there was a lack of written information available about treatment options. We were told that overall staff were very helpful. A number of people commented that they felt there was a shortage of staff at times. They told us that on occasions staff appeared to be 'very rushed' and that staff shortages meant that they did not always receive assistance with personal care or assistance at meal times as needed.

People told us that the hospital was very clean. They told us that staff washed their hands before and after assisting them. All of the people with whom we spoke said that they had not noticed any shortage of equipment in the hospital and, in their experiences, it had been available whenever it was required. They felt that staff appeared to be trained and competent its use.

People with whom we spoke told us that they were unaware of the procedure for making a complaint and that they had not received any written information about how to complain. Most people told us that they were very satisfied overall with their hospital experience, however the majority of people said that they had not been asked to give their views or for any feedback on their stay.

Inspection carried out on 20 October 2010

During an inspection to make sure that the improvements required had been made

This section was not completed for this inspection. More information about what we found during the inspection is available in the report below.

Inspection carried out on 11 May 2010

During an inspection to make sure that the improvements required had been made

This section was not completed for this inspection. More information about what we found during the inspection is available in the report below.