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