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Provider: Mid Essex Hospital Services NHS Trust Requires improvement

Reports


Inspection carried out on 05 Nov to 07 Nov

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. The overall rating 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 six core services inspected as requires improvement and four services (medical care, maternity, gynaecology 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 our current methodology gynaecology is not aggregated in the overall ratings. Rating the trust overall, we took into account the three core service 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 fully document risk assessments of patients. Staff were not always managing medicines well.
  • 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. The trust was not externally reporting due to data validation issues.


CQC inspections of services

Inspection carried out on 4 Sep to 18 Oct 2018

During a routine inspection

Our rating of the trust went down. We rated it as requires improvement because:

  • We rated safe, effective, responsive and well-led as requires improvement, and caring as good.
  • We rated one of the trust’s six services we inspected as inadequate and five as requires improvement. In rating the trust, we took into account the current ratings of the four services not inspected this time.
  • We found inconsistencies in safety practices amongst the core services and an inconsistent approach to leadership.
  • There were not effective processes in place to ensure that learning from serious incidents was shared and embedded to minimise the risk of re-occurrence.
  • Individual teams did not have strategic plans in place to allow them to develop their services. Staff told us that this was due to the focus on plans for the potential merger with two other local NHS trusts and awaiting approval for the clinical reconfiguration. This meant that should either of the plans experience delay the services did not have clear plans for the future.
  • There had been a significant churn in the executive management team since our last inspection. This had affected the leadership’s team ability to implement their governance improvement plan.
  • There had been significant issues with the implementation of a new electronic patient management system in May 2017. This had affected the trust’s ability to deliver reliable validated information in regard to some key performance indicators.

However:

  • The trust was focussed on planning for the future in line with sustainability and transformation plans.

Our full inspection report summarising what we found and the supporting Evidence appendix containing detailed evidence and data about the trust is available on our website –

Inspection carried out on 14th 15th, 16th June and an unannounced inspection on 30th 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 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 children’s and young people’s 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 had 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, responsive, 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, which is reflected in the two outstanding ratings given. We have rated safe overall as requires Improvement, as the emergency department, medicine end of life care and outpatients 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 (The Success Regime is part of the NHS Five Year Forward View, which is a blueprint for the NHS to take decisive steps to secure high quality, joined-up care).
  • 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 midwifery 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 (time patient arrives in the emergency department and transferred from ambulance stretcher) 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.
  • 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.
  • 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 and 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.
  • 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%.
  • Following the inspection we reviewed the RTT data from March to May 2016 The data showed an improvement in RTT performance in three specialities. These were ENT (93.4%) urology (94.2%) and oral surgery (97%). General surgery (53.6%) trauma and orthopaedics (47.5%), ophthalmology (77.4%) and plastic surgery (71%) had seen a decline in RTT performance. However this was reflective of a national trend and the figures were still in line with the national average.
  • 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 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.

  • 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.

Professor Sir Mike Richards

Chief Inspector of Hospitals

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

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, and a subsequent unannounced inspection visit to Broomfield Hospital on 6 December 2014. We carried out this comprehensive inspection of the acute core services provided by the trust as part of the Care Quality Commission’s (CQC) new approach to hospital inspection. We also undertook a focused review of the Emergency Admissions Unit at Broomfield Hospital on 5 February 2015 following concerns raised to us, we took enforcement action because staffing levels were not sufficient to ensure safe care. We returned on 26 March 2015 and found that appropriate improvements had been carried out.

This trust is unique in that it provides a regional specialty centre for burns and plastic surgery, which is delivered from the St Andrew's Centre for Burns and Plastic Surgery, and is based at Broomfield Hospital in Chelmsford. 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.

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 identified as a low risk on the Care Quality Commission’s (CQC) Intelligent Monitoring system. The trust was in band 5, which is the second lowest band available.

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.

Our key findings were as follows:

  • 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 trust is on a journey to improving the services provided, and this will take some time to embed throughout the organisation.
  • 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 obtaining the correct skill mix would remain a challenge for some time.
  • Not all staff working as nurses on the emergency assessment unit (EAU) were registered with the NMC but were included in the overall ‘registered nurse’ numbers.
  • There was a blame culture and a poor culture on EAU of staff not feeling listened to when they raised concerns about safe staffing levels. Concerns raised by staff were not acted on by the management team within the EAU.
  • 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 an end of life care plan was required following the removal of the Liverpool Care Pathway in 2014.
  • The trauma service within plastic surgery, particularly on Mayflower Ward, 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 our inspection across all specialties). There was no risk assessment process in place for these 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 it was exciting to witness the innovative developments and plans that 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 were comparable with the best in the world, and were consistently exceptional. This was evidence 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’ were an exception 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 good end of life care.
  • Individual specialist staff in the trust, including the learning disability nurse, the 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), which were developed within the critical service without initial funding, have 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.

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

Use of resources

These reports look at how NHS hospital trusts use resources, and give recommendations for improvement where needed. They are based on assessments carried out by NHS Improvement, alongside scheduled inspections led by CQC. We’re currently piloting how we work together to confirm the findings of these assessments and present the reports and ratings alongside our other inspection information. The Use of Resources reports include a ‘shadow’ (indicative) rating for the trust’s use of resources.


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.