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Provider: Mid and South Essex NHS Foundation Trust Requires improvement

Reports


Inspection carried out on 5 Feb to 1 Mar 2021

During an inspection looking at part of the service


CQC inspections of services

Inspection carried out on 05 Nov to 07 Nov 2019

During a routine inspection

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

  • We found that there were regulatory breaches resulting in requirement notices and found that the organisation was performing at a level which led to the overall rating as requires improvement.
  • Overall, we rated safe and responsive as requires improvement, effective, caring and well-led as good. All ratings remained the same. In rating this trust we took into account the current ratings of the service not inspected on this occasion.
  • We rated two (urgent and emergency care and surgery) of the five core services inspected as requires improvement and three services (medical care, maternity and outpatients) as good. The well-led part of the inspection was rated as good. We previously rated maternity alongside gynaecology, therefore we cannot compare the new ratings with previous ratings. In rating the trust overall, we took into account the three core services not inspected this time.
  • The trust did not always have enough staff to care for patients and keep them safe. Not all staff had received training in key skills. Staff did not always assess risks to patients, act on them and or keep good care records. Staff were not always managing medicines well. The trust generally controlled infection risk well. The trust managed safety incidents well and learned lessons used it to improve services.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services in the trust were available seven days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The trust did not always meet people’s needs. Patients could not always access treatments in a timely manner in line with national standards. The trust was underperforming for a range of specialties to meet the national standards for the national 18 week referral to treatment times and 62 day cancer waits to treatment. The trust planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback.
  • Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The trust engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually. Not all electronic systems were integrated and reliable.

Inspection carried out on 21 November 2017

During a routine inspection

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

  • The trust had made a number of improvements in areas previously rated as ‘requires improvement’. However, some of these changes were yet to be embedded and there were still some areas for improvement. The ratings for safe for the trust remained as requires improvement because medical care (including older people) rating for safe remained the same. The aggregated rating for the trust includes ratings for previous inspections for core services that we did not inspect during this inspection. The ratings for responsive for the trust remained the same because the rating in this area for Surgery went down because there was declining performance in referral to treatment times (RTT). Responsiveness for Outpatient services remained the same.
  • Urgent and emergency care stayed as good overall. The question of safety improved from requires improvement to good. Effective, caring, responsive and well-led remained good. Service performances against national standards were variable but had improved. The department had a cohesive team and had governance processes in place for the oversight of risk, safety and quality. However, there were concerns with safety aspects relating to staffing for children’s ED, security within the department and risk assessment processes for the environment. All risks related to mental health care provision were not highlighted on the ED risk register.
  • Overall we rated medicine including older peoples care as good. The question of safe remained requires improvement, effective and responsive improved from requires improvement to good and caring and well-led remained rated good. The service managed patient safety incidents, infection risk, records of patients’ care and medicines well. The service provided care based on national guidance and staff met patients’ nutritional needs. The service monitored the effectiveness of care and treatment; staff were competent for their roles and staff of different kinds worked together as a team to benefit patients. Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005 and cared for patients with compassion. The trust provided services in a way that met the needs of local people and patients’ individual needs and treated concerns and complaints seriously. The trust had managers at all levels with the right skills and abilities to run a service with effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. The trust engaged with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively.
  • Surgery services remained rated as good overall, with safe, effective, caring and well-led rated as good. The rating for responsive went down from good to requires improvement because the referral to treatment times (RTT) were significantly lower than the England average and there was a declining picture of performance. The key question of safe improved from requires improvement to good. Safety of the service was good, with improvements noted in ward-based pharmacy provision and sepsis training compliance. Senior staff were aware of staffing issues and had responded to reduce risk. Mandatory training compliance was generally good, with some areas of variability. Staff worked together to meet patients’ needs and treatment was delivered by competent, caring staff.
  • Services for children and young people had improved from requires improvement to good overall. Safe, effective and well led had improved to good, with caring and responsive retaining a good rating. Staff now followed good practice in relation to infection prevention and control, patient documentation and incident reporting. Gillick competence awareness had improved and staff applied this proportionately when obtaining consent from young people. Staff now provided care and treatment in line with national guidelines. Our concerns around the length of time patients waited for autism spectrum disorder and epilepsy assessments remained.
  • End of life care had improved from requires improvement to good overall. Safe, effective, responsive and well-led improved to good. Caring remained the same and was rated as good. The service handled safety incidents well. The service had processes in place to measure their performance. Staff went the extra mile in caring for their patients. The service had a cohesive team and had governance processes in place for the oversight of risk, safety and quality.
  • Outpatient services were previously inspected jointly with diagnostic imaging so we cannot compare our new ratings directly with previous ratings. We rated outpatients as requires improvement for responsive. Safe, effective, caring and well-led were rated as good because there were processes in place to ensure nurse staffing levels met the needs of patients. Staff treated patients with compassion and dignity and service leaders worked cohesively with internal and external stakeholders to manage the backlog of follow-up appointments in ophthalmology and respiratory clinics.
  • On this inspection we did not inspect critical care, maternity or diagnostic imaging. As we have not previously inspected diagnostic imaging as a single core service we cannot aggregate previous ratings. The ratings we gave to critical care and maternity in the previous 2016 inspection are part of the overall rating awarded to the trust this time.

Inspection carried out on 12-14 January and unannounced 24 January 2016

During a routine inspection

We undertook this inspection 12-14 January and returned unannounced 24 January 2016. The main part of the inspection was a comprehensive announced inspection. We inspected Southend Hospital and the outpatient’s service for children and young people at the Lighthouse Child Development Unit.

This service was not triggering as high risk from national data sets or as an outlier.

Southend University Hospital NHS FT is part of the Success Regime. This includes Southend, Basildon and Mid Essex trusts working together to influence system change across the health economy. This process is key to improved care in the NHS.

During the first day of the inspection the junior doctor’s strike was in progress. The trust was offered the option to cancel the inspection but declined. We noted that the trust had a clear plan for patient care during this period of industrial action.

During our inspection the trust was on a high state of escalation due to the increased number of patients coming in to the hospital. This had existed for some time before our inspection.

We rated the services offered by Southend University Hospital NHS Foundation Trust as ‘requires improvement’.

Our key findings were as follows:

  • The increase in the number of beds at the trust had put additional strain on the services, but in particular a strain on the staff.

  • Staff nurse to patient ratios were insufficient, particularly in medicine and musculoskeletal surgery.

  • High numbers of elective surgery cancellations were seen in addition to clinic cancellations all relating to the alert status, capacity and congestion within the hospital.

  • Good patient outcomes were evidenced in particular the stroke service.

  • Staff went the extra mile for patients and demonstrated caring and compassionate attitudes.

  • The trust scored above the England average for Patient-led assessments of the Care Environment (PLACE) consistently for all categories assessed. (2013-2015)

  • Cleaning undertaken by nurses and technicians for November and December 2015 of high risk equipment was 95% and 97% compliance rates. There were no MRSA cases reported and lower than the England average rates of C.Diff.

  • Mortality and morbidity meetings took place but they did not follow a consistent format, and actions to support learning lacked timescales.

We saw several areas of outstanding practice including:

  • We rated well led for the emergency department as outstanding.The local leadership and team worked well to deliver the service.There governance practices ensured risks were identified and managed. They engaged staff to ensure they remained motivated.

  • Stroke service patient outcomes received the highest rating by Sentinel Stroke National Audit Programme.CT head scanning was delivering a 20 minute door to treatment time which was a significant achievement.

  • The trust had implemented an Early Rehabilitation and Nursing team (ERAN). The ERAN Team supported the early discharge of primary hip surgery and knee surgery patients.

  • The ‘Calls for Concern’ service, allowing patients and relatives direct access to the Critical Care Outreach Team (CCORT) following discharge home.

  • The learning tool in place within Radiology allowing learning from discrepancy in a no blame environment.

  • The Mystery Shopper scheme that actively encouraged people to regularly give their feedback on clinical care and services.

  • Safe @ Southend was a new daily initiative to allow staff to share day to day clinical and operational issues with executive Directors for rapid action. An open invitation to all staff to share concerns and challenges in an open environment which often resulted in prompt action.

  • In Outpatients a patient ambassador group met to look at issues raised by patients. Solutions to issues raised had been implemented.

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

Importantly, the trust must:

  • Ensure staffing ratios comply with NICE guidelines, to ensure both patients and staff are not at increased risk.

  • Ensure duty of candour regulations are fully implemented, the trust was not able to demonstrate that they had met all parts of the requirements.

  • Ensure that clinical review is part of the process for cancelling elective surgical patients.

  • Ensure the duty of candour regulation are being met through improved root cause analysis investigations, and robust apology to patients.

To see the full list of actions the trust must and should take please see the areas for improvement section toward the end of this report.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 7 August 2014

During an inspection looking at part of the service

Southend University Hospital is an established 700 bed general hospital and provides a range of services to a local population of some 338,800 in and around Southend and nearby towns. The trust provides a range of acute services and is the South Essex centre for cancer services.

We inspected this hospital on 7 August 2014 in response to concerns of stakeholders and information of concern received into the CQC. Southend University Hospital NHS Foundation Trust was found to be in significant breach of its terms of Monitor authorisation since 2011-2012 due to their failure to demonstrate that there were appropriate arrangements in place to provide effective leadership and governance. There were also concerns around the trust’s failure to meet cancer and C. Difficile targets.

This was a responsive review undertaken by six inspectors from CQC and two specialist advisors in A&E and governance practices. Only the services within the A&E department and the governance structures at Southend Hospital location were inspected. We have not given the trust a rating as this was a focused review, a further comprehensive inspection will be undertaken in the future to determine ratings of all services within the trust.

Our key findings were as follows:

  • In all areas inspected, we found that staff were kind, caring and compassionate towards patients.
  • Good progress had been made in strengthening the executive capacity of the board and establishing a pace of change towards improving quality.
  • Evident support for the CEO’s style and influence across the trust, engendering a commitment to change and improvement.
  • Staff were proud to work for the trust.
  • The trust had worked well to improve the performance within A&E to achieve the 95% target to see patients within four hours more consistently.
  • Management of medicines, including storage was not always in accordance with national guidelines within A&E.
  • Whilst the trust was actively recruiting nursing and medical staff, we found that the levels of permanent medical and nursing levels were not sufficient.
  • Environmentally, there were concerns with the A&E not having a dedicated paediatric A&E.
  • Infection control standards and practices around cleaning and equipment in A&E were not sufficient with some items and waiting rooms found to be unclean.
  • The quality of serious incident investigations was poor and required improvement. There was also no quality assurance process in place to review investigation findings or outcomes.
  • The staff who were undertaking serious incident investigations were not all trained investigators.
  • Learning from incidents was slow and reactive.
  • Maternity services policies and procedures on the induction of labour were not reflective of current clinical practice. However the clinical practice we observed did reflect current clinical practice in this area.

Whilst we saw areas of good practice there were also areas of poor practice where the trust needs to make improvements.

  • Importantly, the trust must:
  • Improve its cleaning schedule within the A&E department.
  • Improve the security and storage of medicines within the A&E department.
  • Increase the number of permanent trained nurses, paediatric nurses and consultants within the A&E department.

    • Ensure that policies and procedures reflect current clinical practice within maternity services.
    • Improve the quality and processes of the incident investigation process and ensure that lessons are learnt at the earliest opportunity.

During this inspection we found that the essential standards of quality and safety were not being met in some areas. As a result of our findings we have issued the trust with compliance actions. We have asked the provider to send CQC a report that says what action they are going to take to meet these essential standards.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up.

Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.


Joint inspection reports with Ofsted

We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.