Mid Essex Hospital Services NHS Trust

20190416 900885 Post-inspection Evidence appendix template v4

Mid Essex Hospital Services NHS Trust

Broomfield Hospital

Evidence appendix

Court Road,

Broomfield,

Chelmsford

CM1 7ET

Tel: 01245362000

www.meht.nhs.uk

Date of inspection visit:

5 November to 12 December 2019

Date of publication:

6 March 2020

This evidence appendix provides the supporting evidence that enabled us to come to our judgements of the quality of service provided by this trust. It is based on a combination of information provided to us by the trust, nationally available data, what we found when we inspected, and information given to us from patients, the public and other organisations. For a summary of our inspection findings, see the inspection report for this trust.

Facts and data about this trust

Mid Essex Hospital Services NHS Trust was established in 1992 and continues to provide local

elective and emergency acute medical services for adults and children for over 380,000 people

living in and around Chelmsford, Maldon, Braintree and Witham. The trust also includes Braintree

Community Hospital which covers the whole of Mid Essex and includes a variety of services

including x-rays, MRI scans, CT scans, ultrasound, day surgery, endoscopies, physiotherapy,

nursing and rehabilitation services.

In addition the trust provides a county-wide plastics, head and neck and upper gastrointestinal (GI)

surgical service to a population of 3.4 million and a supra-regional burns service to a population of

9.8 million. The trust employs over 5,000 staff and had a total turnover of £317m in 2018/19.

The trust continues to focus on performance and financial improvements, supported by NHS

Intelligence, NHS England and the CCG, to deliver their vision of becoming a financially stable,

modern health system that delivers integration and excellence in local and specialist services.

Mid Essex Hospitals NHS Trust remains a non-foundation trust. The trust began working closely

with Southend University Hospital NHS Foundation Trust and Basildon and Thurrock Hospitals

NHS Foundation trust in 2014. In 2015 the Essex Success Regime was announced and

collaborative working to have a joint clinical strategy began and continues. The leadership teams

restructure of the three trusts commenced in 2016 and was formalised as of 1 January 2017,

shared governance arrangements began in March 2017.


This vision will continue through the proposed merger in 2020 of Mid Essex Hospital Services

NHS Trust with Basildon and Thurrock University Hospitals NHS Foundation Trust, and Southend

University Hospital NHS Foundation Trust.

(Source: Routine Provider Information Request (RPIR) – Acute context tab)

Acute hospital sites at the trust

A list of the acute hospitals at Mid Essex Hospital Services NHS Trust is shown below:

Name of acute hospital

site Address

Details of any specialist

services provided at the site

Broomfield Hospital

Broomfield Hospital

Court Road

Chelmsford

CM1 7ET

Acute and community-based

services. The site hosts regional

plastics, head and neck, and

upper gastrointestinal (upper GI)

surgical services and a supra-

regional burns service.

Braintree Community

Hospital

Braintree Community Hospital

Chadwick Drive

Braintree

CM7 2AL

A range of diagnostic tests, day

surgery, endoscopies,

physiotherapy, nursing and

rehabilitation services.

St Peter’s Hospital

St Peter's Hospital

Spital Road

Maldon

CM9 6EG

Maternity unit with a range of

outpatient clinics.

St Michael’s Hospital and

Birthing Centre

St Michael’s Hospital and Birthing

Centre

Chadwick Drive

Braintree

CM7 2AL

Birthing centre and a range of

therapy services.

(Sources: Trust Website / Routine Provider Information Request (RPIR) – Sites tab)

Due to the pending merger of the three trusts in April 2020 of; Mid Essex Hospital Services NHS

Trust with Basildon and Thurrock University Hospitals NHS Foundation Trust, and Southend

University Hospital NHS Foundation Trust. The decision was made to inspect core services at Mid

Essex Hospital Services NHS Trust and Southend University Hospital NHS Foundation Trust at

the same time which meant the executive team would be interviewed once at the well led part of

the inspection. Therefore there will be similarities in the report to the well led report for Southend

University Hospital NHS Foundation Trust.


Is this organisation well-led?

Leadership

The executives of the trust had the right skills and abilities to run a service providing

sustainable care. The trust site leadership team had the appropriate range of skills,

knowledge and experience to perform its role.

The board executive team provided collaborative leadership between Mid Essex Hospital services

NHS Trust (MEHT), Basildon and Thurrock University Hospitals NHS Foundation Trust and

Southend University Hospital NHS Foundation Trust. The collaboration of the three trusts were

referred to as the MSB group which was adopted in January 2017 whilst options were considered.

In January 2018 the board approved the decision to merge, approved by NHS Improvement in

2018.

The key reasons for merging were to combine corporate services to sustain services for the local

communities, improve patient outcomes, provide further career opportunities to staff and financial

savings associated with the merger will improve services the trust delivers.

The executives were cohesive and experienced. The joint working board (JWB) consisted of a

chair, chief executive officer, chief medical officer, chief nurse, chief transformation officer, Chief

people and organisational, development director, chief finance officer, chief information officer,

chief of facilities and estates and a managing director from each trust.

The site leadership team were recruited by the executive team and are all substantive. The team

were developed under the management of the managing director. Leaders told us they had been

supported with training opportunities to enable them to do their role, and had been offered and/or

taken up external coaching.

The site leadership team at Mid Essex included a managing director, medical director, chief

operating officer, director of nursing, director of finance, head of human resources, director of

specialist services and trust secretary and director of strategy. Since our last inspection the trust

had a more stable experienced site level leadership team which enabled them to function

effectively. The site level leadership team were led by a managing director who was a member of

the JWB.

Senior leaders developed staff and in May 2019 the trust had commissioned a fifth senior staff

development programme to ensure staff were trained to take on leadership roles, there had been

positive feedback from the previous four cohorts.

The JWB met quarterly, and the executives were supported by the site leadership team.

Board Members

Of the executive board members at the trust, 8.3% were Black and Minority Ethnic (BME) and a

third (33.3%) were female.

Of the non-executive board members, 16.7% were BME and half (50.0%) were female.

Staff group BME % Female % Executive directors 8.3% 33.3% Non-executive directors 16.7% 50.0% All board members 11.1% 38.9%

(Source: Routine Provider Information Request (RPIR) – Board Diversity tab)


Leaders told us that there was recognition that the board and senior leadership team was not

representative of the local population. To address this BME nurses had started to shadow leaders

and leaders planned to start peer mentoring BME members of staff. This is a process known as

reverse mentoring. This allows senior staff to better understand the issues that BME staff face.

All members of the board and site leadership teams we spoke with, demonstrated they had the

knowledge and leadership skills required of senior leaders. Leaders told us that the site leadership

structure was embedded, and clear lines of responsibility were now in place for governance and

safeguarding. Leaders acknowledged that governance arrangements remained complex, but were

the best they could be within the legal requirements for the three separate trusts the JWB was

responsible for.

We spoke with all the board members and found them to be cohesive, with shared visions of

continually improving care for patients and promoting the wellbeing of their workforce. It was

overwhelmingly evident that the board were all proud of the staff working within the organisation.

Both the executive directors and non-executive directors (NEDs), had the relevant operational and

financial experience, and organisational knowledge.

Leaders were aware of their current priorities and challenges leading up to the merger of the three

trusts. They had identified actions required to address them, which included sharing of good

practice, staff and building on areas of joint working not only for the benefit of Mid Essex Hospitals

Trust but for all three trusts. For example, leaders from the three trusts were implementing a

consistent approach to the use of bank and agency staff to support their own workforce and to

provide safe care to patients.

Although plans for the merger had been delayed due to a referral to the Secretary of State (of

which had now been resolved), leaders had continued working towards clinical reconfiguration and

pre-merger work. Two services were due to be reconfigured and go live; some planned

orthopaedics from December 2019 and vascular surgery pathways from January 2020 and

planned orthopaedic surgery.

The trust had a fit and proper persons policy that was in date and referenced. We reviewed five

personal files of executives to determine if employment checks had been performed in accordance

with the Fit and Proper Persons Requirement (FPPR) (Regulation 5 of the Health and Social Care

Act (Regulated Activities) Regulations 2014). This process ensured that directors are fit and

proper to carry out their role. We observed that FPPR checks were in place. The employment

process also included enhanced Disclosure and Barring Service (DBS) checks, insolvency and

bankruptcy checks, disqualified director register checks and occupational health checks of

directors appointed to the board. Further checks included annual self-declarations for additional

assurance.

It was evident from speaking with staff that the site leadership team, managers and staff worked

together to deliver a shared vision and used their individual strengths to improve services.

The trust had an operational structure which had five divisions; corporate operations, medicine

and emergency care, surgical anaesthetics and theatres, women and children’s, and burns,

plastics and outpatients. The divisions were encouraged and supported by the site leadership

team to take responsibility for their own their performance. A triumvirate team, consisting of a

divisional director, an associate director of operations and a divisional head of nursing/midwifery

led each division. The triumvirate team for each division were supported at a local level by

operational managers and matrons.


The executives had appointed ten group clinical directors specifically to lead the changes of

service provision within their divisions across the three sites post-merger. All of the group clinical

directors were passionate about their role; however, some wanted more clarity of managerial

responsibilities from the executives.

The chief pharmacist (CP) we spoke with was managed by the medical director and had good

engagement with the trust executive and awareness of medicines optimisation challenges and

business plan.

Vision and strategy

The board and site senior leadership team had set a clear strategy for the forthcoming

merger. Their vision and values that were at the heart of all the work within the trust. They

were working hard to make sure staff at all levels understood the values in relation to their

daily roles.

The executive team had developed a Mid and South Essex, (MSE) strategy for the three hospital

trusts. The CEO told us: ‘Our ambition is to improve health and wellbeing through excellent,

financially sustainable services, provided by staff supported to develop, innovate and build

rewarding careers.’ The strategy had been developed with stakeholders, staff and consulted on

through engagement with the public.

There were four overarching strategic objectives:

• MSE Objective1:

Be a single, well led, high performing and innovative organisation which joins up care for

the people we serve.

• MSE Objective 2:

Deliver high quality, safe and responsive services shaped by best practice and our local

communities.


Be an employer of choice for a supported, engaged and high-performing workforce.


Be effective and efficient with all our resources, creating an organisation that residents and

staff can rely on for the long term.

We reviewed board agendas, board meeting minutes, board papers and a range of documents

including the board assurance framework. The board assurance framework is a key mechanism

which the board used to reinforce strategic focus and improve management of risk. All of which

referenced the strategic objectives which meant these were reflected during board meetings.

The trust was proud of their development of their transformation programme All the executives and

leaders we spoke with had a shared vision to integrate and reconfigure services for seamless care

and improved outcomes for patients.


There was a trust medicines optimisation strategy monitored by the chief pharmacist. This

included for example, optimisation of the pharmacy workforce. Leaders recognised the need for

staff development and training to ensure safe and effective delivery of medicines optimisation.

We reviewed board minutes from September 2019, which showed detailed minutes were taken.

We attended a board meeting during our inspection, it was apparent that non-executive directors

were confident to make appropriate challenges, for example, non-executives asked for clarity and

assurances on a number of occasions.

Culture

Leaders across the trust continued to work to promote a positive culture that supported

and valued staff.

We found an improvement in culture during our inspection. The majority of staff told us culture was

positive since the appointment of the new site leadership team. Staff were more positive of the

proposed merger and spoke positively about new opportunities and sustainable services for

patients.

At our previous inspection we found that there had been some delays in some of the human

resource processes. Staff told us that there were some continued delays with human resource

processes in regard to the recruitment of staff although there had been improvements since our

last inspection.

The trust held daily staff briefings to encourage staff engagement and share important information

with staff, for example, feedback and learning from incidents. We observed these meetings and

saw good attendance from all grades of staff.

The executive team demonstrated a shared vision and encouraged and motivated staff to improve

and succeed. The trust had a chief transformation officer and had recruited further transformation

directors to improve relations with internal and external stakeholders to facilitate improvement

projects.

Directorate leaders we spoke with were all positive about the future merger and felt confident and

supported by the site leadership team to make improvements and changes within their own

services.

Freedom to speak-up guardians (FTSUG) were introduced following Sir Robert Francis’s

‘Freedom to Speak-up Review’ (2015). Their role is to work with leadership teams to create a

culture where people can speak-up to protect patient safety. The executive team recognised the

importance for staff to have a voice and be able to speak up freely. The trust recruited an external

company to facilitate and manage whistleblowing enquiries 24 hours a day. The company reported

directly to the trust’s people and organisational development committee. The company produced a

quarterly update and an annual report, from July 2018 to July 2019, 21 cases were reported. Staff

told us they were confident to report any concerns they had.

Appraisals were in place for providing executives with high quality annual reviews which included

career development conversations and setting objectives for the next year. All executives and

senior leaders told us that they had received a meaningful appraisal.


The trust had a ‘Being Open and Duty of Candour policy’ in place. The duty of candour is a

regulatory duty that relates to openness and transparency and requires providers of health and

social care services to notify patients (or other relevant persons) of certain ‘notifiable safety

incidents’ and provide reasonable support to that person. During our core service inspection staff

explained the process and were aware of their responsibilities. We reviewed five serious incident

investigation reports and all had details that duty of candour had been followed correctly.

Staff told us throughout our core service inspection there was a no blame culture. They also stated

staff were actively encouraged to raise concerns and report incidents without fear of retribution.

Executives, the site leadership team and managers encouraged staff to be open and honest in

relation to issues arising and to challenge poor practice. We found in all serious incident reports

we reviewed that families and carers had been contacted explanations and an apology were

given. The patient and or families were invited to be part of the investigation process.

The majority of staff told us the site leadership team were approachable and visible, although they

would like the non-executive directors and executive team to be more visible. Executives were

aware of the challenges of being visible across the three trusts and had written a paper to try to

address staff concerns. Proposed improvements where the introduction of a walk about prior to

executive meetings which alternate at each trust, attending the morning team briefings and

offering mentoring and reverse mentoring to staff. To monitor compliance leaders kept a log when

the senior leaders and executives visited areas within the trust.

Staff side were active within the trust and held bi-monthly meetings with representation from the

chairs from the three trusts due to merge. The chairs met with the chief nurse, however, they

would like regular attendance from more of the executive directors. We were told that because of

this decision making and the pace of change was delayed.

Leaders told us that the non-executive directors, the executive team and the site leadership team

visited clinical and non clinical areas. Following a visit feedback was provided to the relevant

divisional teams.

Staff Diversity

The trust provided the following breakdowns of medical and dental staff, qualified nursing and

midwifery staff and qualified allied health professionals by ethnic group:

Ethnic group Medical and

dental staff (%) Qualified nursing

midwifery staff (%) Qualified allied health

professionals (%)

White British / Irish / Any other white background

25% 70% 83%

BME - British 23% 13% 4%

BME – Non-British 7% 2% 2%

Not stated 44% 15% 11%

(Source: Routine Provider Information Request (RPIR) – Diversity tab)


NHS Staff Survey 2018 results – Summary scores

The following illustration shows how this provider compares with other similar providers on ten key

themes from the survey. Possible scores range from one to ten – a higher score indicates a better

result.

The trust’s scores were significantly lower (worse) than similar trusts in the 2018 staff survey for safe environment – bullying and harassment and staff engagement and about the same for the remaining eight themes.

There were no themes where the trust’s scores were significantly higher (better) or lower (worse)

when compared to the 2017 staff survey:

(Source: NHS Staff Survey 2018)

Leaders were disappointed with the outcome of the staff survey 2018, they felt they had

implemented a robust strategy for the merger, which had incorporated staff engagement plan. The

trust had developed a comprehensive action plan to address key areas for example, improving

communication, and dignity and respect. Actions were aligned to a member of staff with

timescales to adhere to.


Leaders told us that they were proud of their teams and staff resilience was commended. Senior

managers felt that the workforce were coping well under extreme pressures. Earlier this year the

trust had a mass recruitment drive to employ over 190 overseas nurses. Although not reflected in

this survey leaders were confident that staff would feel the benefits and reduced work pressures

once all the nurses had started work.

Staff and leaders told us of regular staff engagement events to inform staff of the progress to the

merger of the three trusts. Communication to staff was in a variety of formats, face to face, by

email and social media platforms.

Workforce race equality standard

The Workforce Race Equality Standard (WRES) became compulsory for all NHS trusts in April

2015. Trusts have to show progress against nine measures of equality in the workforce.

The scores presented below are indicators relating to the comparative experiences of white and

black and minority ethnic (BME) staff, as required for the Workforce Race Equality Standard.

The data for indicators 1 to 4 and indicator 9 is supplied to CQC by NHS England, based on data

from the Electronic Staff Record (ESR) or supplied by trusts to the NHS England WRES team,

while indicators 5 to 8 are included in the NHS Staff Survey.

Notes relating to the scores:

• These scores are un-weighted, or not adjusted.

• There are nine WRES metrics which we display as 10 indicators. However, not all

indicators are available for all trusts; for example, if the trust has less than 11 responses

for a staff survey question, then the score would not be published.

• Note that the questions are not all oriented the same way: for 1a, 1b, 2, 4 and 7, a higher

percentage is better while for indicators 3, 5, 6 and 8 a higher percentage is worse.

• The presence of a statistically significant difference between the experiences of BME and

White staff may be caused by a variety of factors. Whether such differences are of

regulatory significance will depend on individual trusts' circumstances.


As of 2018, one of the ESR staffing indicators shown above (indicators 1a to 3) showed a

statistically significant difference in score between white and BME staff. Please note that statistical

analysis was not undertaken on indicator 4 (proportion of staff accessing non-mandatory training

and CPD).

2. In 2018, BME candidates were significantly less likely than white candidates to get jobs for

which they had been shortlisted (7.7% of BME staff compared to 12.9% of white staff). This

had significantly decreased by 3.5% compared to the previous year, 2017.

Of the four indicators from the NHS staff survey 2018 shown above (indicators 5 to 8), two of

the indicators showed a statistically significant difference in score between white and BME staff.

7. 62.3% of BME staff believed that the trust provided equal opportunities for career progression

and promotion (2018 NHS staff survey) which was significantly lower when compared to

85.4% of white staff. The score had decreased by 11.0% when compared to the previous

year, 2017.


8. 18.4% of BME staff experienced discrimination from a colleague or manager in the past year

(2018 NHS staff survey) which was significantly higher when compared to 5.8% of white staff.

The score had increased by 6.1% when compared to the previous year, 2017.

There was one BME Voting Board Members at the trust, which was not significantly different to the

number expected, based on the overall percentage of BME staff.

(Source: NHS Staff Survey 2018; NHS England)

In response to the survey the trust had developed a workforce standard action plan, for example,

black, Asian and ethnic minority training was given to all recruiting line managers. The trust

introduced diversity and inclusion champions as part of recruitment panels. Actions were aligned

to a lead with timelines to achieve.

Friends and Family test

The Patient Friends and Family Test asks patients whether they would recommend the services

they have used based on their experiences of care and treatment.

The trust scored between 90.0% and 93.1% from October 2017 to September 2019. The data was

stable with only expected random variation over the whole period.

Mid Essex Hospital Services NHS Trust – recommendation rates, October 2017 to

September 2019

The chart below shows the response rates at the trust from October 2017 to September 2019:


Mid Essex Hospital Services NHS Trust – response rates, October 2017 to September 2019

(Source: Friends and Family Test)

Sickness absence rates

The trust’s sickness absence levels from July 2018 to June 2019 were similar to or higher than the

England average across the period. Sickness rates were highest in the winter months, from

November 2018 to February 2019, before falling to lower levels which were more similar to the

England average from March to June 2019.

(Source: NHS Digital)


General Medical Council – National Training Scheme Survey

In the 2019 General Medical Council Survey the trust performed worse than expected for two

indicators (curriculum coverage and local teaching), and the same as expected for the remaining

16 indicators.

(Source: General Medical Council National Training Scheme Survey)

The trust had a ‘Guardian of Safe Working Hours’ for junior doctors. The guardian’s role was to

ensure that providers identify and respond to issues around safe medical staffing, to deliver quality

care and keep patients and staff safe from avoidable harm. Safeguards around working hours of

doctors in training (junior doctors) had been designed to ensure that the risk was effectively

mitigated and that this mitigation was assured. The trust guardian reported to the medical director,

reviewed themes and trends from feedback from junior doctors. Since our last inspection the

guardian told us reporting had increased from 30% to 50%. This increase was following a

campaign through engagement meetings with junior doctors, the trust provided ‘pizza and pay slip’

meetings to highlight the importance of reporting.

Governance

The trust had a structure for overseeing performance, quality and risk, with a site

leadership managing director board member representing the trust at board level. This

gave them greater oversight of issues facing the services and they responded when

services needed more support.

Leaders operated effective governance processes, throughout the trust and with partner

organisations. Staff at all levels were clear about their roles and accountabilities. Staff had regular

opportunities to meet, discuss and learn from the performance of the service.

Executives told us over the last year since the formation of the site leadership team, they have

focused on developing management, leadership and governance within the trust to enable a

strong focus on integrated governance structures.

A trust governance improvement plan was in place and the senior team had implemented a plan

which was now embedded to provide a more consistent approach to governance across the MSB

group.

There were structures and systems in place to monitor governance and accountability throughout

the organisation to support the delivery of the strategy. There were site level divisional quality and

governance meetings, which reported to the site clinical outcomes and effectiveness meeting and

the corporate governance meeting which reported to the site governance forum and into the

quality committees in common (board level for the three trusts). This structure ensured that there

was board level oversight across the three hospital trusts through input from each of the managing

directors and other senior staff at the individual hospital.

The trust had an ‘Information Governance Strategy’ which incorporated an annual information

governance work plan. An information governance staff handbook was available on the staff

intranet and a weekly staff newsletter. All information governance policies had been reviewed and

aligned which included compliance with the General Data Protection Regulation and Data

Protection Act 2018.


Governance arrangements for infection prevention control (IPC) had improved since our last

inspection. The IPC leadership team was strengthened and monitored by the director of nursing.

Leaders told us that systems have been embedded throughout the trust. The trust had recently

been reviewed by the IPC team at NHSI/E and had moved from being rated as red to green.

Papers and reports for board meetings and other committees, that we reviewed, were of a good

standard and contained appropriate information. For example, we reviewed three finance and

performance committee in common minutes from May to July 2019 and saw that the financial risks

on the BAF were discussed.

Board Assurance Framework

The trust provided their Board Assurance Framework (BAF), which details four strategic objectives

with accompanying risks. A summary of these is shown below.

1. Be a single, well led, high performing and innovative organisation which joins up care for

the people the trust serves

2. Deliver high quality, safe and responsive services shaped by best practice and the trust’s

local communities

3. Be an employer of choice for a supported, engaged and high performing workforce

4. Be effective and efficient with resources, creating an organisation that residents and staff

can rely on for the long term

ID Risk description Current

score

Target

score

Be a single, well led, high performing and innovative organisation which joins up care for

the people the trust serves

1.1 Failure to provide a conducive environment for colleagues to design,

adopt and implement innovative practices. 15 15

1.2 Failure to implement the merger of three trusts into one trust leading

to sub-optimal decision making. 16 10

1.3 Failure to demonstrate sufficiently high levels of performance to

achieve “Good” overall rating for CQC well led. Failure to deliver

agreed remedial actions in a timely manner and ensure

responsiveness when necessary.

16 8

1.4 Failure to deliver improvement national performance

targets in the agreed trajectories. 20 12

1.5 Failure to enable and empower leaders in all areas of the

organisation to create a culture of continuous improvement. 20 15

Deliver high quality, safe and responsive services shaped by best practice and the trust’s

local communities

2.1 Failure to equip colleagues to deliver a high quality safe

service against agreed trajectories. 16 12

2.2 Failure to deliver clinical service change/reconfiguration

to meet the needs of the local population currently and in

the future, against agreed timescales.

16 9

2.3 Failure to gain agreement and consensus of local 20 9


communities to changes that reflect best practice.

2.4 Failure to achieve consistent “Good” rating for CQC in Safe, Caring,

Effective and Responsive domains. Failure to implement agreed

remedial action plans in a timely fashion.

16 8

Be an employer of choice for a supported, engaged and high performing workforce

3.1 Failure to create workforce stability with vacancy and

retention rates within the top quartile for acute trusts. 20 8

3.2 Failure to be the demonstrable employer of choice for people

with right values, behaviours, skills and experience. 20 10

3.3 Failure to lead and develop colleagues to ensure they

demonstrate support, engagement and high levels of

performance in order to drive improvement.

16 12

Be effective and efficient with resources, creating an organisation that residents and staff

can rely on for the long term

4.1 Failure to deliver financial plan. 25 15

4.2 Failure to develop and fund a long-term capital plan which addresses

the clinical, estates and technology needs of the organisation. 20 15

4.3 Failure to deliver digital transformation agenda and to ensure

resilience in informatics and IT services. 20 9

4.4 Failure to deliver transformation in corporate support to create a fit

for purpose, future proofed structure. 16 10

4.5 Failure to achieve and deliver on long term financial sustainability

and effective use of resources. 20 15

4.6 Failure to consistently deliver safe, responsive and efficient patient

care in a cost-effective manner because current estate and

infrastructure is not fit for purpose.

15 9

(Source: Trust Board Assurance Framework – June 2019)

The BAF provided the executives with an assurance that risks to achieving the trust objectives

were appropriately mitigated. The executive team told us that the BAF mapped the trust’s highest

and extreme risks, and ensured controls were in place to mitigate risks whilst actions were being

implemented.

We reviewed the BAF at the time of our inspection, the four strategic ambitions were clear, and

risks were aligned to each ambition within the BAF. All risks were rated, with a named executive

lead, there were control measures, actions and each risk had a timescale to be achieved.

There was evidence of BAF reviews at the following meetings; the finance and performance

committee, the oversight committee and the boards in common.

Medicines optimisation was integrated into the trust governance structure and there was no

evidence of gaps in the reporting structure between different committees. Medicines incidents

were reported through an electronic recording system. The medication safety officer (MSO)

automatically received and reviewed notifications of medicine incidents. The MSO role was

created following a NHS England patient safety alert. Medicines optimisation was a standing

agenda at the trust group medicines optimisation committee, which reported to the quality and

safety committee that then reported to the executive team.


Following our inspection we reviewed the minutes of meetings such as but not limited to; the

mortality review group, the audit committee, the finance and performance committee in common,

and the boards in common (closed), and observed they did not follow the same format for minute

meeting templates. Attendance was good, actions were identified and allocated to staff, however,

timelines and progress were not always clearly identifiable.

Management of risk, issues and performance

Leaders and teams used systems to manage performance effectively. They identified and

escalated relevant risks and issues and identified actions to reduce their impact. They had

plans to cope with unexpected events. Staff contributed to decision-making to help avoid

financial pressures compromising the quality of care.

Governance meetings were held at service and division level which were reviewed at a monthly

division board. The division was led by a triumvirate including the divisional director, associate

director of nursing/head of midwifery and associate director. The site leadership team received risk

based exception reports, which contained for example, non-compliance to national best practice,

this meant executives monitored progress against actions implemented.

The trust had a policy for the management of incidents and serious incidents. Throughout our core

service and well led inspection we observed embedded systems within the trust to identify learning

from incidents and complaints.

All divisions produced patient and safety quality dashboards to enable reviews from ward to board

level. Wards held safety huddles to highlight any real time safety issues. The patient and safety

committee received a board performance report and provided assurance to the board.

We reviewed the trusts quality account for the year ending March 2019. It was comprehensive and

covered statements on quality, priorities for improvement and a review of quality performance from

March 2018 to March 2019. We saw quality improvements included for example, the

commencement of elective orthopaedics services and Braintree hospital which reduced the

number of cancellations and optimised the use of theatres and wards at that site.

Finances Overview

The executive team told us financial outcomes had an overarching group deficit, with the majority

belonging to Mid Essex hospital trust. Leaders recognised that their challenge was the successful

delivery of the trust’s cost improvement programme (CIP) plan and engaging clinicians to part of

the process.

Finance was discussed at local and divisional governance meetings, divisions discussed their

financial plans and delivery of their CIPs. The site leadership teams and executive team told us

that each CIP was subject to a quality assessment and would not be agreed if it compromised the

quality of patient care.

The trust had reviewed agency staffing spend and put in financial controls which capped agency

costs in the region, this had reduced spend from £17m to £18m last year to £10m this year.

Leaders were confident in reducing agency staffing spend further once all of the overseas nurses

had started work.

Financial metrics Historical data Projections


Previous Financial Year

(2017/18)

Last Financial Year (2018/19)

This Financial Year (2019/20)

Next Financial Year (2020/21)

Income £305.3m £317.3m £348.2m £356.2m Surplus (deficit) (£52.9m) (£61.3m) (£47.2m) (£40.5m)

Full costs £358.2m £352.3m £395.4m £396.7m Budget (or budget deficit)

(£55.1m) (£60.7m) (£47.2m) (£40.5m)

The budget deficit reported in 2018/19 was higher than the previous year. At the time of reporting

in August 2019, projections for 2019/20 indicated that the budget deficit would decrease to £47.2

million.

(Source: Routine Provider Information Request (RPIR) – Finances Overview tab)

Trust corporate risk register

The trust had a risk management strategy which provided all staff with the framework and

processes to identify, mitigate and manage risk within the trust. The executives had sight and

awareness of the most significant risks which were recorded on their corporate risk register. All

leaders we spoke with were consistent and identified the same top risk ‘high vacancy rate for

registered nurses.

The trust provided a document detailing their 11 highest profile risks. Each of these had a current

risk score of 20 or higher (out of 25) at the time of reporting.

Risk ID Risk title Risk score (current)

Risk level (target)

Review date

525 Demand for beds exceeding capacity 20 9 05/08/2019

1225 Injury from fall or jump from top floor public multi-storey car park

25 5 05/08/2019

1354 Inadequate resources to deliver the HR transactional service

20 8 31/07/2019

1369 Inability to report accurate referral to treatment information

20 9 05/08/2019

1375 High vacancy rate for registered nurses linking to CQC ‘must’ action

25 9 05/08/2019

1376 Staff recruitment and retention 20 6 31/07/2019 1377 Poor staff engagement 20 8 31/07/2019 1378 Late notification of payroll information 20 8 31/07/2019

1382 Ensure effective audit of performance, benchmarking and improvement links to CQC ‘must’ actions

20 8 30/08/2019

1386 Failure to deliver the financial annual plan including efficiencies

20 15 05/08/2019

1400 CQC Requirement Notices 20 4 05/08/2019

(Source: Trust corporate risk register - July 2019)

Information management


The trust’s information management systems had improved access to information but has

had a number of issues which have led to validation issues.

The trust collected data and analysed it. However, new IT systems had led to data not always

being robust without validation. Staff could find the data they needed, in easily accessible formats,

to understand performance, make decisions and improvements. The information systems were not

yet integrated; however, they were secure. Data or notifications were consistently submitted to

external organisations as required.

The trust had an appointed senior information risk owner (SIRO) an NHS Information Governance

(IG) measure identified to strengthen information assurance controls for NHS information assets.

The SIRO told us there was a five year strategy to align information technology at all three trusts

post-merger. The strategy and audits of the plan was monitored by the finance committee.

During 2018-19, the trust implemented an electronic patient record system which caused data

validity issues and poor quality data. With agreement from NHS England the trust were excluded

from reporting data until they had completed a review and data cleansing exercise. Leaders told

us progress was managed at site governance performance meetings, with a clear trajectory which

was monitored and discussed. All patients categorised as long waiters received harm reviews and

reported to board in common meetings.

Leaders had reviewed processes and found staff had not received adequate training prior to the

implementation of the system. A training programme was introduced staff received training and

now all staff receive this training as part of their induction programme.

Senior leaders planned to align electronic prescribing and medicines administration (EPMA)

across the three trusts to unify processes and governance for the group. The pharmacy team has

an agreed performance dashboard across the trust.

Staff told us EPMA had significantly improved audit of medicines usage, reducing medicine related

incidents. The trust was working with partners across the wider healthcare economy to improve

transfer of care.

To enhance security the trust had achieved the general data protection regulation (GDPR) and

ISO27001 information security standard (this requires businesses to take necessary technical and

organisational measures to ensure a high level of information security).

The trust reported incidents, including serious incidents as required to the NHS national reporting

and learning system (NRLS) and/or the NHS strategic executive information system (StEIS) in line

with national guidance.

The trust had implemented ‘TeleTracking’, an innovative electronic system that improves the flow

of patients through hospital by giving centralised, real-time bed status information to doctors and

nurses. Leaders told us this has ensured patients are admitted to the right ward first time and

reduced the time nurses and managers spent checking bed availability.

Engagement

The trust included and communicated effectively with staff, patients, external providers, the

public and stakeholders.

The trust had a ‘patient experience strategy 2019’, which supported the involvement of patients,

their carers and relatives. Leaders told us of the importance of utilising feedback to improve

services. Following our inspection the trust provided us with an example of public engagement.


Relatives whose loved ones had passed away attended an event to share their experiences. Both

positive and negative experiences were captured and used to feedback to staff.

Leaders and staff we spoke with told us the trust had held engagement events to inform staff of

the changes to services in advance of the merger. In addition moving forward at mid daily meeting

continued to give staff the opportunity to share information and good practice across the

organisation.

The chief nurse told us in partnership with the chief medical officer they led clinical reconfiguration

workshops, to enable staff to be part of the journey and development of services into the merger.

Leaders and clinicians told us the merger is now a reality and more staff are involved and excited

about the opportunities which will result post-merger.

The trust had a strong volunteer service, who provided administrative assistance, supported

patients on arrival to the hospital, and staff in the clinical areas.

There was evidence of working with external stakeholders, for example, Healthwatch (the

independent champion for health and social care users) attended the trust’s patient experience

group meetings.

Social media platforms were utilised by the organisation as a way of sharing information and

receiving feedback from staff, patients and the public.

The patient council told us the team undertook ward visits to speak to patients about standards of

care they receive. This was fed back to ward managers and the matrons so that concerns could

be acted upon in a timely manner.

The equality and diversity group had been relaunched and now met bi-monthly. The trust had also

instigated the rainbow badge, the NHS rainbow badge aimed to make a positive difference by

promoting a message of inclusion for patients who identify as lesbian, gay, bisexual, transgender

(LGBT).

In the summer of 2019 the trust held an event to create network groups for staff which included,

BME, LGBT, disability and armed forces

The trust had produced a one minute video to promote apprenticeships within the hospital, it

included managers and apprentice’s views. This was launched during national apprenticeship

week.

Leaders gave examples of working with external organisations, nurses and discharge coordinators

worked with local care homes to reduce the number of community acquired pressure ulcers.

We reviewed the ‘Mid and South Essex group interim people strategy 2019 – 2020’ we saw that it

was detailed and aligned to the NHS long term plan and NHS interim people plan launched

January 2019. The strategy included the four main areas of focus:

• Making the NHS the best place to work

• Improving the leadership culture

• Tackling the nursing challenge

• Delivering 21st century care

• A new operating model for workforce

The trust had developed a leaflet for patients and the public which explained why the trust was

merging, all the proposed changes to services and the benefits for patients.


Learning, continuous improvement and innovation

The leadership team worked well with the clinical leads and encouraged divisions to share

learning across the services.

Leaders had developed a number of transformational programmes and employed further directors

to encourage innovation and learning across the three trusts. The aim was to improve consistency

of practices and patient outcomes.

In line with national guidance the trust had recruited a medical examiner whose responsibility was

to review all inpatient deaths in line with the national quality board's 'learning from deaths

guidance’. The medical examiner role was to also work closely with the coroner and their

department and share learning across the trust.

The trust has had a history of raised mortality for the last three years. There had been some

coding issues which have been fixed and leaders are confident they are on a pathway of

improving mortality rates.

The pharmacy team worked with external partners and developed an audit tool that can be used

on smart phone. This provided live data to nursing staff on the wards which enabled effective

resolution and implementation of action plans in relation to safe and secure medicines audits.

The trust offered onsite functional skills maths and English classes for staff to access to promote

learning and development.

The trust implemented a scheme to retain staff known as the ‘retire to return initiative’. Staff were

given the option to stage their retirement, the process has been streamlined to enable staff to give

six months’ notice to arrange a package of flexible working to suit their needs.

The trust had signed the armed forces covenant (a promise ensuring that those who serve or who

have served in the armed forces, and their families, are treated fairly) and developed partnership

arrangements. The trust had been informed that they were to receive a military of defence silver

award for its support to the armed forces.

Complaints process overview

We reviewed a sample of complaints during the well led inspection. All patients received an

acknowledgment letter, an apology and an explanation of the trust’s complaints processes. The

final letter sensitively explained which staff were involved in the investigation, their expertise and

details of learning identified, actions and any national or local guideline where appropriate.

The trust was asked to comment on their targets for responding to complaints and current

performance against these targets for the last 12 months.

Question In days Current

performance What is your internal target for responding to complaints? 3 100%

What is your target for completing a complaint 25 65% If you have a slightly longer target for complex complaints please indicate what that is here

60 63%

Number of complaints resolved without formal process in the last 12 months?

August 2018 to July 2019 2,547


(Source: Routine Provider Information Request (RPIR) – Complaints overview tab)

Number of complaints made to the trust

From August 2018 to July 2019, the trust received a total of 594 complaints. The highest number

of complaints were received for medical care, with 27.4% of the total complaints, followed by

surgery (23.7%).

A breakdown by core service can be seen in the table below:

Core Service Number of complaints

Percentage of total

Medical care (including older people's care) 163 27.4% Surgery 141 23.7% Urgent and emergency services 83 14.0% Outpatients 50 8.4% Burns and plastics 41 6.9% Other 34 5.7% Gynaecology 28 4.7% Maternity 27 4.5% Services for children and young people 15 2.5% Diagnostics 8 1.3% Critical care 4 0.7% Total 594 100.0%

(Source: Routine Provider Information Request (RPIR) – Complaints tab)

Compliments

From August 2018 to July 2019, the trust received a total of 1,124 compliments. The highest

number of compliments were for medical care, with 28.5% of the total compliments, followed by

surgery (13.7%) and burns and plastics (12.9%).

A breakdown by core service can be seen in the table below:

Core Service Number of

compliments Percentage of total

Medical care (including older people's care) 320 28.5% Surgery 154 13.7%

Burns and plastics 145 12.9% Services for children and young people 134 11.9% Critical care 102 9.1% Urgent and emergency services 91 8.1% Outpatients 57 5.1% Provider wide 46 4.1% Diagnostics 28 2.5%

Gynaecology 21 1.9% Maternity 13 1.2% Other 13 1.2% Total 1,124 100.0%


The trust stated that most of the compliments received related to overall care along the whole

pathway, with patients and relatives thanking staff for their kindness and compassion

during difficult and stressful times. These related to all staff from housekeepers,

porters and nurses, to consultants. 

(Source: Routine Provider Information Request (RPIR) – Compliments)

Accreditations

NHS trusts are able to participate in a number of accreditation schemes whereby the services they

provide are reviewed and a decision is made whether or not to award the service with an

accreditation. A service will be accredited if they are able to demonstrate that they meet a certain

standard of best practice in the given area. An accreditation usually carries an end date (or review

date) whereby the service will need to be re-assessed in order to continue to be accredited.

The table below shows which of the trust’s services are engaged with or have been awarded an

accreditation.

Accreditation scheme name Service accredited

Joint Advisory Group on Endoscopy (JAG) • Achieved in March 2019, renewal

visit planned for October 2019 (service accredited not provided).

Gold Standards Framework Accreditation process, leading to the GSF Hallmark Award in End of Life Care

• Baddow, Feering and Braxted wards have completed the 2-year GSF programme.

• Bardfield ward will commence on the hospitals programme for GSF from October 2019.

Clinical Pathology Accreditation and its successor Medical Laboratories ISO 15189

• Microbiology, blood sciences and histology/mortuary currently accredited.

• Point of Care services is engaged with the scheme but has not yet achieved accreditation.

(Source: Routine Provider Information Request (RPIR) – Accreditations tab).


Acute services

Broomfield Hospital

Court Road,

Broomfield,

Chelmsford

CM1 7ET

Tel: 01245362000

www.meht.nhs.uk

Urgent and emergency care

Facts and data about this service

Details of emergency departments and other urgent and emergency care services:

• Broomfield Hospital accident and emergency department

• Broomfield Hospital emergency care therapy

(Source: Routine Provider Information Request (RPIR) – Sites tab)

Emergency care at Broomfield Hospital is based in the emergency village, which comprises: the

adult emergency department (ED), acute medical unit (AMU), ambulatory care unit (ACU), and

emergency short stay ward (ESS) and frailty unit.

Emergency department patients are assessed, prioritised and streamed to agreed locations such

as gynaecology assessment, ACU, surgical assessment and GP within the emergency

department.

The emergency department is part of the East of England trauma network and has four adult

resuscitation bays with 10 acute majors cubicles and eight further majors trolleys. There are five

early senior assessment and treatment (ESAT) cubicles and a mental health interview room.

AMU is the primary route of admission and assessment for GP heralded medical patients with 10

assessment trolleys, two triage rooms and 20 assessment beds, with a target length of stay of less

than 24hrs. The unit is led by acute physicians who also lead the same day emergency care

service in ACU.

The ACU is a seven day service receiving patients streamed and referred from the ED and from

GPs supporting referrals from medical wards to facilitate earlier discharge when clinically

appropriate. There is in-reach into AMU from various specialty medical teams such as cardiology,

and community teams such as hospital at home and early supported discharge admissions

avoidance and resettlement (ESDAAR).


Paediatric ED nursing sits within women’s and children’s services. Any child or young person is

triaged by a nurse, and then seen by an ED clinician, emergency nurse practitioner, GP or direct

referral to specialist services. In addition, the children's ED service has appointed four paediatric

consultants to work within the ED department.

(Source: Routine Provider Information Request (RPIR) – Acute context)

We used a variety of methods to help us gather evidence to inspect the emergency services at

Broomfield Hospital. We spoke with 40 members of staff, six patients and two relatives. We

reviewed 19 patient records during this inspection. We interviewed the department leads and we

spoke with a variety of different staff members. We observed the environment, checked the safety

and currency of equipment, we looked at records in relation to patients’ treatment and medication.

We also looked at a range of documents relevant to the service including policies, minutes of

meetings, action plans, risk assessments, and audit results.

Activity and patient throughput

From March 2018 to February 2019 there were 106,255 attendances at the trust’s urgent and

emergency care services as indicated in the chart below.

Total number of urgent and emergency care attendances at Mid Essex Hospital Services

NHS Trust compared to all acute trusts in England, March 2018 to February 2019

(Source: Hospital Episode Statistics)


Urgent and emergency care attendances resulting in an admission

The percentage of A&E attendances at this trust that resulted in an admission decreased slightly

in 2018/19 compared to 2017/18. In both years, the proportions were higher than the England

averages.

(Source: NHS England)

Urgent and emergency care attendances by disposal method, from March 2018 to February

2019

* Discharged includes: no follow-up needed and follow-up treatment by GP

^ Referred includes: to A&E clinic, fracture clinic, other OP, other professional

# Left department includes: left before treatment or having refused treatment



Is the service safe?

By safe, we mean people are protected from abuse* and avoidable harm.

*Abuse can be physical, sexual, mental or psychological, financial, neglect, institutional or

discriminatory abuse.

Mandatory training

The service provided mandatory training in key skills including the highest level of life

support training to all staff, however not everyone had completed it.

Mandatory training completion rates

Nursing staff received and kept up-to-date with their mandatory training.

The trust set a target of 85% for the completion of all mandatory training modules, with the

exception of information governance which had a target of 95%.

Broomfield Hospital

A breakdown of compliance for mandatory training courses as of August 2019 for registered

nurses in urgent and emergency care at Broomfield Hospital is shown below:

Training module name As of August 2019

Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)

Information governance 79 79 100.0% 95% Yes

Waste management 79 79 100.0% 85% Yes

Equality and diversity 77 79 97.5% 85% Yes

Hand hygiene 76 79 96.2% 85% Yes

Medicine management training 73 76 96.1% 85% Yes

Fire safety 75 79 94.9% 85% Yes

Paediatric immediate life support 8 9 88.9% 85% Yes

Health and safety 70 79 88.6% 85% Yes

Moving and handling for people handlers 63 73 86.3% 85% Yes

Adult immediate life support 60 70 85.7% 85% Yes

Moving and handling 66 79 83.5% 85% No

In urgent and emergency care at Broomfield Hospital, the targets were met for 10 of the 11

mandatory training modules for which registered nurses were eligible.

Medical staff received and kept up-to-date with their mandatory training.

A breakdown of compliance for mandatory training courses as of August 2019 for medical staff in

urgent and emergency care at Broomfield Hospital is shown below:


Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)


Information governance 27 29 93.1% 95% No


Waste management 24 29 82.8% 85% No

Medicine management training 4 5 80.0% 85% No


Moving and handling 23 29 79.3% 85% No

Fire safety 20 29 69.0% 85% No

Paediatric immediate life support 7 11 63.6% 85% No

Adult immediate life support 17 29 58.6% 85% No

Equality and diversity 16 29 55.2% 85% No

Paediatric basic life support 2 10 20.0% 85% No

In urgent and emergency care at Broomfield Hospital, the targets were met for two of the 11

mandatory training modules for which medical staff were eligible. Compliance rates ranged from

20.0% for paediatric basic life support to 93.1% for hand hygiene.

(Source: Routine Provider Information Request (RPIR) – Training tab)

Senior staff we spoke with on inspection told us that they considered the mandatory training

completion rates for medical staff were better than the data provided ahead of inspection

suggested, so we requested updated mandatory training figures. The new data showed current

completion rates for November 2019. It demonstrated an overall mandatory training compliance of

89.68% for medical staff and the trust targets were met for eight out of the 11 mandatory training

modules. Information governance, waste management and medicine management training all had

100% compliance rates. Compliance with paediatric immediate life support was 75% and adult

immediate life support stood at 73.7%. Equality and diversity training had 89.5% compliance and

paediatric basic life support had a 45.45% compliance rate.

The mandatory training was comprehensive and met the needs of patients and staff. Staff told us

that some of the mandatory training required face to face attendance and some of the training was

completed electronically via e-learning

Clinical staff completed training on recognising and responding to patients with mental health

needs, learning disabilities, autism and dementia. Staff told us that they had completed this

training; they told us that additional training was available for them to attend. For example, the

local mental health team had provided staff throughout the department with mental health training.

Managers monitored mandatory training and alerted staff when they needed to update their

training. The service had a clinical educator who monitored mandatory training for all nursing staff

throughout the department, sent reminders and booked staff onto the appropriate training courses.

A central spreadsheet was held, which provided oversight of mandatory training for all medical

staff. Evidence of training completion was requested.

Safeguarding

Staff understood how to protect patients from abuse and the service worked well with other

agencies to do so. Staff had training on how to recognise and report abuse and they knew

how to apply it.

Safeguarding training completion rates

Nursing staff received training specific for their role on how to recognise and report abuse.

The trust set a target of 95% for the completion of safeguarding modules, with the exception

of safeguarding children (level 3) which had a target of 60%.


The tables below include prevent training as a safeguarding course. Prevent works to

stop individuals from getting involved in or supporting terrorism or extremist activity. The trust set a

target of 85% for the completion of prevent awareness training modules.

Broomfield Hospital

A breakdown of compliance for safeguarding training courses as of August 2019 for registered

nurses in urgent and emergency care at Broomfield Hospital is shown below:


Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)

Safeguarding adults (level 1 77 79 97.5% 95% Yes

Safeguarding children (level 1) 77 79 97.5% 95% Yes

Prevent - basic awareness 76 79 96.2% 85% Yes

Safeguarding children (level 2) 75 79 94.9% 95% No

Safeguarding adults (level 2) 68 79 86.1% 95% No


Prevent - awareness 43 63 68.3% 85% No

In urgent and emergency care, the targets were met for four of the seven safeguarding training

modules for which registered nurses at Broomfield Hospital were eligible.

Medical staff received training specific for their role on how to recognise and report abuse.

A breakdown of compliance for safeguarding training courses as of August 2019 for medical staff

in urgent and emergency care at Broomfield Hospital is shown below:


Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)


Prevent - awareness 22 29 75.9% 85% No



Safeguarding adults (level 1 19 29 65.5% 95% No

Safeguarding adults (level 2) 19 29 65.5% 95% No


In urgent and emergency care, the targets were met for one of the seven safeguarding training

modules for which medical staff at Broomfield Hospital were eligible.

Information provided by the trust following our inspection demonstrated an improvement in

completion rates of safeguarding training modules for medical staff in November 2019. For

example, safeguarding adults level one and safeguarding children level one both had compliance

rates of 94.7%, narrowly missing the trust target. Prevent – basic awareness training had

improved to 100% compliance.

Staff could give examples of how to protect patients from harassment and discrimination, including

those with protected characteristics under the Equality Act. For example, staff told us they had

previously raised concerns surrounding possible neglect.


Staff knew how to identify adults and children at risk of, or suffering, significant harm and worked

with other agencies to protect them. From May 2019 to October 2019 the urgent and emergency

service made 176 adult safeguarding referrals and 387 children’s safeguarding referrals. Staff

throughout the service demonstrated a good understanding of safeguarding risks. Staff described

a positive working relationship with the safeguarding leads within the trust, who in turn, liaised with

other agencies where necessary.

There was a process in place in the paediatric department for any new child safeguarding

concerns to be raised with the child’s health visitor, GP and social worker where applicable.

Staff knew how to make a safeguarding referral and who to inform if they had concerns. Staff we

spoke with were familiar with the process for raising safeguarding concerns and knew who the

safeguarding leads were within the trust. Staff told us they had good working relationships with the

safeguarding leads and described them as supportive.

There was a safeguarding policy in place, which was accessible to staff through the trust’s intranet

site. Staff demonstrated a good understanding of the trust’s safeguarding policy and procedures.

Staff followed safe procedures for children visiting the ward. There was a separate emergency

department for children. Access to the department and through different areas of the department

was secured and accessed by staff electronic passes. Staff in the paediatric emergency

department had access to a flagging system that identified children with existing safeguarding

concerns.


Cleanliness, infection control and hygiene

The service controlled infection risk well. Staff used equipment and control measures to

protect patients, themselves and others from infection. They kept the premises visibly

clean, however not all equipment we observed was clean.

All areas were clean and had suitable furnishings which were clean and mostly well-maintained.

All waiting and clinical areas we inspected were visibly clean. However, some chairs in the waiting

areas were damaged and the material covering those seats was visibly torn.

The service performed well for cleanliness. The department undertook weekly hand hygiene

audits. We reviewed audit data for the last six months. Overall hand hygiene compliance met the

trust target of 95% in May, July, September and October 2019 with respective overall scores of

100%, 96.6%, 100% and 99.1%. The trust target was not met in June or August 2019 where

overall compliance was scored at 91.6%. The department undertook monthly audits which

included a decontamination of equipment audit. The results for the audit in October 2019 were

100% compliance.

Staff followed infection control principles including the use of personal protective equipment (PPE).

We saw that PPE was readily available, and staff routinely used PPE when assisting patients. We

saw good practice relating to hand hygiene, including staff bare below elbows, and use of

sanitising hand gel. There were clear signs informing people to clean their hands when entering

the department. Sanitising gel dispensers and sinks with soap were available throughout the

department and we saw staff use these routinely.

Staff we spoke with were able to describe the protocol for managing patients with possible

infectious disease. There were specific cubicles which were used for patients who may pose a risk


of cross infection. Staff knew where to locate isolation signs to be placed outside of cubicles to

identify what PPE staff were required to wear before entering the cubicle, depending on the

infection the patient had.

Information provided by the trust following inspection stated that the infection prevention and

control team undertook assurance audits in May, July, September and November 2019. These

audits included hand hygiene, cleaning and decontamination, waste management and segregation

and transmissible infections. We reviewed the audits for the paediatric emergency department

(ED) in July 2019 and the audit for the main emergency department which was carried out in May

2019. Paediatric ED had a compliance score of 93%. The main ED had a compliance score of

95%. Both were compliant as they scored above 90%. Both audits included an action plan which

included who was responsible for the action and the date of completion. This assured us that there

were processes in place to monitor whether staff cleaned equipment after patient contact and

actioned any changes that needed to be made.

We identified some equipment in the department that did not appear to have been recently

cleaned as they were visibly dusty. This was the case for four pieces of equipment we reviewed.

The items were; one cardiac monitor in resus, a cardiac monitor in majors and two suction units in

the minor assessment extension to ED. However, other equipment we reviewed was visibly clean.

We raised the dusty equipment with staff at the time of our inspection. When we reviewed the

equipment the following day, we found it had been cleaned.

Cleaning records were not always kept up-to-date. For example, documentation had not been

completed for three days of week commencing 23 September 2019 or week commencing 12

August 2019 in the majors lite area. The cleaning tasks that required documenting included

cleaning toilets, replenishing consumables, hoovering and mopping floors and emptying rubbish

bins. However, audit performance data showed that the department mostly achieved target scores

for cleanliness from 1 August to 28 October 2019. Therefore, the issue appeared to be with

documentation rather than the completion of cleaning tasks.

Environment and equipment

The design, maintenance and use of facilities, premises, vehicles and equipment kept

people safe. Staff were trained to use them. Staff managed clinical waste well.

The emergency department (ED) contained a main waiting area and reception close to the car

park where initial streaming took place. There were facilities for the assessment and treatment of

minor and major injuries and illnesses. There were 10 majors cubicles in the department, a bay

with five resuscitation spaces which included a dedicated space for paediatric patients. There was

a sixth resuscitation bay which was used for the storage of equipment. There was a separate

paediatric ED with its own waiting area. There were emergency nurse practitioner (ENP), and

general practitioner (GP) led services within the department. Early senior assessment and

treatment (ESAT) used five cubicles in majors to assess and triage patients who arrived through

the ambulance bay. There was an extended area to the emergency department which included a

minor assessment unit and two ‘fit to sit’ cubicles plus a waiting area. Patients who arrived by air

ambulance were transferred into the department via the onsite helipad.

The emergency department had a dedicated room for adult mental health patients which had been

specifically designed to meet the needs of mental health patients. The room was situated away

from the main treatment areas to offer people privacy and a safe environment with no ligature or

self-harm risks. This was in line with standards set by the Royal College of Psychiatrists


psychiatric liaison accreditation network. The room was out of use at the time of our inspection as

a glass panel needed replacing, however when we returned for the unannounced inspection the

room was in use again.

The department also used majors cubicles for patients suffering with mental health problems. The

cubicles were situated close to the nursing station which meant that staff could directly observe

patients. Staff told us that they removed all potentially unsafe items from the rooms before

admitting patients into them. Healthcare support workers were able to carry out constant

observations where required and mental health nurses were sourced via an agency as needed.

Staff completed comprehensive mental health risk assessments and we were assured that they

were able to mitigate the risks of treating mental health patients in majors cubicles.

The paediatric ED was separate from the rest of the department. It had its own waiting area and

treatment rooms. Entrance in and out of the children’s ED was controlled by a locked door which

enabled staff to monitor who was entering or leaving the department.

The ambulatory care unit and emergency short stay ward were situated close to the emergency

department. Ambulatory care is same day care which meant that patients were assessed,

diagnosed, treated and able to go home the same day, without being admitted into hospital

overnight. The ambulatory care unit had its own waiting room, separate cubicles and an area with

reclining chairs. At the time of our unannounced inspection, the ambulatory care unit had moved

nearby to a different location and had been renamed same day emergency care (SDEC) unit.

Staff carried out daily safety checks of specialist equipment. We checked three resuscitation

trolleys within the department and found that checks were completed daily.

The service had enough suitable equipment to help them to safely care for patients. All electrical

items we reviewed had evidence of regular portable appliance testing. We found one suction unit

that was out of date for electronic testing, however it was not in use. The item was removed after

we notified a staff member. Equipment was monitored by the medical equipment library. Staff told

us they could access additional equipment if necessary.

Staff disposed of clinical waste safely. Clinical and non-clinical waste was disposed of separately.

Sharps bins containing used needles and other sharp objects were correctly signed and dated

which helped staff determine when they should be replaced.

We found patients could not reach call bells in part of the extension to the emergency department

which was known as the minor assessment unit. We saw that call bells were hanging on the walls

which were not within the reach of patients. We noticed that this area was staffed at all times while

patients were present, which mitigated the risk to patients. When we returned to the department

for an unannounced inspection we found that call bells were within reach of patients.

Assessing and responding to patient risk

Staff did not always complete risk assessments for each patient swiftly. They did not

always remove or minimise risks and update the assessments. Staff did not always identify

and quickly act upon patients at risk of deterioration.

Emergency Department Survey 2016

The trust scored about the same as other trusts for all five of the Emergency Department Survey

questions relevant to safety.

Question Score RAG


Q5. Once you arrived at the hospital, how long did you wait with the ambulance crew before your care was handed over to the emergency department staff?

7.9 About the same as

other trusts

Q8. How long did you wait before you first spoke to a nurse or doctor?


other trusts Q9. Sometimes, people will first talk to a nurse or doctor and be examined later. From the time you arrived, how long did you wait before being examined by a doctor or nurse?


other trusts

Q33. In your opinion, how clean was the emergency department?


other trusts Q34. While you were in the emergency department, did you feel threatened by other patients or visitors?


other trusts

(Source: Emergency Department Survey (October 2016 to March 2017; published October 2017)

Median time from arrival to initial assessment (emergency ambulance cases only)

The median time from arrival to initial assessment was better than the overall England median in

all 12 months from July 2018 to June 2019.

In the most recent month, June 2019, the median time to initial assessment at the trust was four

minutes compared to the England average of eight minutes.

Ambulance – Time to initial assessment from July 2018 to June 2019 at Mid Essex Hospital

Services NHS Trust

(Source: NHS Digital - A&E quality indicators)

Percentage of ambulance journeys with turnaround times over 30 minutes for this trust

From August 2018 to July 2019 the monthly percentage of ambulance journeys with turnaround

times over 30 minutes at Broomfield Hospital remained relatively consistent. Performance ranged

from 69.2% in February 2019 to 76.3% in the most recent month (July 2019) for ambulance

journeys with turnaround times over 30 minutes.

Ambulance: Number of journeys with turnaround times over 30 minutes - Broomfield

Hospital


Ambulance: Percentage of journeys with turnaround times over 30 minutes - Broomfield

Hospital

(Source: National Ambulance Information Group)

Number of black breaches for this trust

A black breach occurs when a patient waits over an hour from ambulance arrival at the emergency

department until they are handed over to the emergency department staff. From August 2018 to

July 2019 the trust reported 1,080 black breaches.

Black breaches were reported in lower levels from August 2018 to October 2018 before rising in

the winter months from November 2018 to January 2019. The number of reported black breaches

fell in the three month period from February to April 2019, before falling again from May to July

2019.

There was a dramatic increase in black breaches in December 2018 and January 2019 with 162

and 188 black breaches respectively. The fewest breaches were reported in June 2019 with 23.

The trust reported that the main reason for the black breaches were spikes in ambulance

attendances, poor bed capacity and patient flow in the department.


(Source: Routine Provider Information Request (RPIR) - Black Breaches tab)

Staff used a nationally recognised tool to identify deteriorating patients and escalated them

appropriately. Staff used the National Early Warning Score (NEWS2) and the Paediatric Early

Warning Score (PEWS) to monitor and identify deteriorating patients. However, we found that

NEWS2 scores were not always completed as frequently as they should have been. We found that

50% of the documentation we reviewed on inspection did not have NEWS2 scoring completed as

frequently as required. We raised our concerns during the inspection. The trust responded to the

concerns we raised by carrying out an audit of 10 sets of patient records. The audit reflected our

inspection findings with four out of 10 observations not recorded within recommended timescales.

The trust also conducted a harm review within the audit and there was no harm identified.

The trust reported that there had been some recent issues with the electronic devices that NEWS2

scoring was captured on. We were advised on inspection that the devices were set for two hourly

observations which needed to be overridden by staff. The matron reported there had been several

incidents raised for this issue and that a further incident had been raised at the time of our

inspection which prompted a system check of the devices.

The trust policy stated that all patients in majors required observation every 30 minutes until seen

by medical staff irrespective of clinical need or presenting complaint. The trust recognised this was

not achievable or clinically indicated. The trust agreed that frequency should be at least hourly or

more frequently dependant on the individual patient acuity determined by the NEWS2. This was

reflected in an update to the ED observation policy which was also in line with Royal College of

Emergency Medicine (RCEM) and NEWS2 best practice guidance.

We checked a further seven patient records when we returned for the unannounced inspection.

Five out of those seven records had NEWS2 scoring completed appropriately. This showed that

the frequency of NEWS2 scoring had improved in comparison to our findings from the initial

inspection. The electronic devices used for capturing NEWS2 scores were not working when we

returned for the unannounced inspection, so the data was being recorded on paper. The trust

formulated an action plan following our inspection which included an update to the ED observation

policy and training for additional staff members to be ‘super users’ of the electronic devices used

for NEWS2 scoring. The configuration of the electronic recording system was to be reviewed with

fortnightly task and finish group established that reported to the patient safety group. The trust also

planned to commence a daily local ‘snapshot’ audit to provide assurance of approved timeliness of


observations. There were actions in place to improve clinical oversight by the senior team within

ED which included restructuring the nurse in charge station to clearly display NEWS2 scores.

Staff completed risk assessments for each patient on admission / arrival, using a recognised tool,

and reviewed this regularly, including after any incident. For example, staff completed

assessments of pressure areas and frailty assessments were completed where applicable.

Staff knew about and dealt with any specific risk issues. Nursing staff used the Manchester Triage

Tool (MTT) to assess patients. The MTT is used to triage patients and ascertain how critically

unwell a patient may be. Patients were treated in priority dependent on their condition. Triage

systems aimed to reduce risk by assessing patients and seeing them in order of clinical priority,

rather than order of attendance.

The reception staff were all trained in using a ‘red flag’ criteria to immediately highlight attending

patients to nursing and or medical staff, who may be seriously unwell.

We saw appropriate screening tools for sepsis used throughout the department. There was an

escalation policy in place for patients with presumed or confirmed sepsis who required an

immediate review and the service carried out monthly audits of sepsis management for a sample

of patients. The results of the audits identified the percentage of patients who required sepsis

screening that received intravenous antibiotics within one hour. The results of the audit were 91%

in August 2019, 100% in September 2019 and 75% in October 2019. The trust reported some

problems with the electronic system used for documentation, which at times meant staff had to

use paper documentation which could lead to duplication or omission of screening. Information

provided by the trust stated that this may account for some of the reduction in compliance in

October. The trust had implemented an action plan to improve compliance of the delivery of

antibiotics within one hour. Actions were assigned to individuals with completion and target

completion dates. We saw examples of patients receiving antibiotics within the recommended

sepsis pathway times.

Nurses working within the children’s ED had the necessary skills and expertise including advanced

life support. All ED healthcare support workers received paediatric basic life support training as

part of their mandatory training; and nurses received paediatric intermediate life support (PILS).

However, we were told it was not always possible to ensure there was a children’s nurse available

in the children’s ED. The service mitigated this risk by training adult nurses, and assessing and

ensuring they had the correct competencies to work in that environment.

The service had 24-hour access to mental health liaison and specialist mental health support. Staff

reported a positive working relationship with the local mental health team. Staff from the local

mental health team were based at the hospital site during the day to enable them to provide timely

support when needed.

Staff completed, or arranged, psychosocial assessments and risk assessments for patients

thought to be at risk of self-harm or suicide. Staff risk assessed all patients with a suspected

mental health condition upon arrival at the emergency department. Staff used a mental health

assessment tool that had been developed jointly with the local mental health team. It enabled staff

to calculate the level of risk that a patient presented with. Both adult and paediatric patients had a

specific risk assessment indicating their levels of risk, and any need for a referral to the local

mental health team. We saw that these assessments were detailed, comprehensive and

personalised.

Staff shared key information to keep patients safe when handing over their care to others. A

handover nurse completed a document based on situation, background, assessment,


recommendation (SBAR) when a patient was being transferred to other areas of the hospital.

SBAR is a technique used to facilitate appropriate communication. The documentation was

followed up by telephone calls when patients were transferred to other wards, or face to face

discussion when patients were transferred to the acute medical unit (AMU).

Shift changes and handovers included all necessary key information to keep patients safe. The

department held multiple meetings throughout the day involving all key staff members to ensure

key information was handed over. Nurse huddles took place two times a day which included

handovers and debriefs for all staff at the change of shift.

Nurse staffing

The service did not always have enough nursing staff with the right qualifications, skills,

training and experience to keep patients safe from avoidable harm and to provide the right

care and treatment. However, managers regularly reviewed staffing levels and skill mix, and

gave bank and agency staff a full induction.

The service did not always have enough nursing and support staff to keep patients safe. The

paediatric emergency department (ED) was almost fully established with only one whole time

equivalent (WTE) vacancy. There were nursing vacancies throughout the adult ED. The

department were advertising for two WTE band seven nurses and 1.7 WTE band six nurses.

Information provided by the trust following our inspection stated that there were 19.98 WTE band

five nursing vacancies within adult ED, however we were advised on inspection that the band five

vacancies were due to reduce to 10.5 WTE once newly recruited nurses from overseas had

completed their registration with the Nursing and Midwifery Council. The service made use of bank

and agency staff to fill staffing gaps. They gave regular lines of work to regular agency staff and

they were provided with a full induction. Staff commented that regular agency staff felt like part of

the team.

Managers accurately calculated and reviewed the number and grade of nurses, nursing assistants

and healthcare assistants needed for each shift in accordance with national guidance. Daily

meetings took place to discuss the safe staffing levels, and the department leads could adjust

staffing levels daily according to the needs of the patients and the demands in the department.

Registered children’s nurses worked in the children’s emergency department. We were told it was

not always possible to ensure there was a children’s nurse available in line with Royal College of

Nursing guidance. The service mitigated this risk by training adult nurses, and assessing and

ensuring they had the correct competencies to work in that environment.

Broomfield Hospital

The table below shows a summary of the nursing staffing metrics within urgent and emergency

care at Broomfield Hospital compared to the trust’s targets, where applicable:

Urgent and emergency care annual staffing metrics

August 2018 to July 2019 July 2018 to June

2019 August 2018 to July 2019

Staff Group

Annual average

establishment

Annual vacancy

rate

Annual turnover

rate

Annual sickness

rate

Annual bank

hours (% of

Annual agency

hours (% of

Annual unfilled

hours (% of


available hours)

available hours)

available hours)

Target 13% 12% 3.8%

All staff 190 28% 7% 3.5% Qualified nurses

73 38% 0% 3.2% 8,663 (6%)

37,887 (26%)

19,672 (13%)

(Source: Routine Provider Information Request (RPIR) – Vacancy, Turnover, Sickness and

Nursing bank agency tabs)

Nurse staffing rates within urgent and emergency care were analysed for the past 12 months and

no indications of improvement, deterioration or change were identified in monthly rates for

vacancy, turnover and bank use.

Sickness rates

The service had reducing sickness rates which was below the trust target in June 2019.

Monthly sickness rates over the last 12 months for registered nurses show an upward trend from

July 2018 to January 2019, before falling to lower levels in the final five months of the period.

(Source: Routine Provider Information Request (RPIR) – Sickness tab)

Agency staff usage

The service had reducing rates of agency nurses.


Monthly agency hours over the last 12 months for registered nurses show a downward shift from

February 2019 to July 2019, in line with decreasing sickness rates.

(Source: Routine Provider Information Request (RPIR) - Nursing bank agency tab)

Managers tried to limit the use of bank and agency staff and encouraged hospital staff to join the

hospital bank list for overtime. This helped ensure the bank staff used were familiar with the

service.

Medical staffing

The service did not always have enough medical staff with the right qualifications, skills,


care and treatment. However, managers regularly reviewed staffing levels and skill mix, and

gave locum staff a full induction.

The service did not always have enough medical staff to keep patients safe. There were vacancies

across the adult emergency department (ED); information provided by the trust following

inspection stated that the trust had 0.9 whole time equivalent (WTE) consultant vacancies, 6.12

WTE vacancies for middle career staff and 1.4 WTE vacancies for registrars. The trust had an

action plan in place to support the recruitment and retention of middle career staff within the

emergency department. All actions were allocated to an individual with completion dates and/or

target completion dates. The risks were mitigated by the use of locum staff. Consultants told us

there had been times when they worked night shifts on occasions when no other medical cover

could be sourced. There were no paediatric medical vacancies within the department and there

were four paediatric consultants.

Broomfield Hospital

The table below shows a summary of the medical staffing metrics within urgent and emergency

care at Broomfield Hospital compared to the trust’s targets, where applicable:

Urgent and emergency care annual staffing metrics




Staff Group

Annual average establishment

Annual vacancy

rate

Annual turnover

rate

Annual sickness

rate

Annual bank

hours (% of

available hours)

Annual locum

hours (% of

available hours)

Annual unfilled

hours (% of

available hours)

Target 13% 12% 3.8% All staff 190 28% 7% 3.5%

Medical staff

35 44% 0% 0.8% 16,950 (16%)

19,014 (18%)

5,922 (6%)


Medical locum tabs)

Medical staffing rates within urgent and emergency care were analysed for the past 12 months

and no indications of improvement, deterioration or change were identified in monthly rates for

vacancy, turnover and bank use.

The trust’s vacancy rate for medical staff was consistently high across the 12 month period with an

annual vacancy rate of 44% against a trust target of 13%.

Sickness rates

Sickness rates for medical staff were reducing.

Monthly sickness rates over the last 12 months for medical staff show an upward trend from July

2018 to November 2018. There was also a peak identified in February 2019.


Locum staff usage

The service had increasing rates of locum staff.


Monthly locum hours over the last 12 months for medical staff show an upward trend from March

2019 to July 2019.

(Source: Routine Provider Information Request (RPIR) – Medical locum tab)

Managers made sure locums had a full induction and understood the service.

Staffing skill mix

Broomfield Hospital

In May 2019, the proportion of registrars reported to be working at the trust was much higher than

the England average. The proportion of junior (foundation year 1-2) staff and consultants were

lower.

Staffing skill mix for the 35 whole time equivalent staff working in urgent and emergency

care at Mid Essex Hospital Services NHS Trust.

This Trust

England average

Consultant 27% 30% Middle career^ 0% 15% Registrar group~ 61% 33% Junior* 12% 21%

^ Middle Career = At least 3 years at SHO or a higher grade within their chosen specialty ~ Registrar Group = Specialist Registrar (StR) 1-6 * Junior = Foundation Year 1-2

Information provided by the trust following inspection stated that the trust had 10 whole time

equivalent (WTE) middle career staff in the emergency department. It suggests there may have

been an issue with data submission to NHS Digital, as the data suggested there were no middle

career staff working in urgent and emergency care at this trust.

(Source: NHS Digital Workforce Statistics)


The service always had a consultant on call during evenings and weekends.

Records

Staff did not always keep detailed records of patients’ care and treatment. Records were

easily available to all staff providing care.

Patient notes were not always completed comprehensively. During our inspection we reviewed 19

sets of patient records. Eight of the records we reviewed over the course of the inspection were

eligible for sepsis documentation. Of those eight, three were completed appropriately. We found

that four records did not document the time the sepsis flowchart was completed, which should be

documented to verify whether patients received their antibiotics within one hour. There was one

set of records where a sepsis flowchart had not been completed that should have been. We were

assured that patients who were deemed to be at risk of sepsis were receiving the appropriate

medication as this was reflected in their prescription charts, along with the time they were

administered. This meant that the issue was with documentation rather than patient safety.

Completion of comfort rounding was not routinely documented in patient records. Of the 19

records we reviewed, comfort rounding was documented in 10 of them. Assessments of nutritional

needs had been completed in 10 of the patient records we reviewed. Therefore, we could not be

assured that patient records were completed comprehensively.

The department carried out an audit of 10 records on 6 November 2019. The results of the audit

showed 100% compliance with documenting allergies, completion of sepsis screening and nursing

documentation. However, the audit showed 10% compliance with property being documented and

20% compliance with documentation of pain scores. Following completion of the audit, an action

plan was put in place to improve documentation standards. Actions included communication via

emails and discussion in huddles. A tissue viability link nurse role had also been identified. The

action plan had actions assigned to individuals with completion dates.

We raised concerns as records in majors were stored in document trays on cabinets behind the

nursing stations. Staff we spoke with stated that the security of the records was protected because

they were held behind the nursing station, so staff would be able to prevent anyone unauthorised

from accessing patient records.

Records were legible and contained the right details about each patients’ care including the

presenting complaint, allergies and pain. Doctors and nurses also wrote individual notes about

care.

When patients transferred to a new team, staff told us they did not experience delays in accessing

their records.

Medicines

The service used systems and processes to safely prescribe, administer, record and store

medicines.

Staff followed systems and processes when safely prescribing, administering, recording and

storing medicines. Medicines were stored in locked cabinets in locked rooms. Keys to access

medicines were held by designated, qualified members of staff.


Staff reviewed patients' medicines regularly and provided specific advice to patients and carers

about their medicines. Pharmacy staff provided support to ward staff and ensured medicines were

restocked.

Staff stored and managed medicines and prescribing documents in line with the trust’s policy. We

checked a range of medicines in different areas of the urgent and emergency department.

Medicines were stored appropriately and were within expiry date. Controlled drugs were checked

daily to help ensure stock levels were correct. There was a dedicated pharmacist allocated to the

emergency department seven days per week. They supported the checking of medicines and

were able to offer support and guidance to staff if required.

Staff followed current national practice to check patients had the correct medicines. We observed

staff checking patients’ names and dates of birth before administering medicines. Patient Group

Directions (PGDs) were in place for nursing staff. PGDs allow healthcare professionals to supply

and administer specified medicines to pre-defined groups of patients without a prescription. The

department had introduced a sepsis PGD, which meant all staff were able to administer medicines

for sepsis patients, other than those staff who were on long term leave.

The service had systems to ensure staff knew about safety alerts and incidents, so patients

received their medicines safely. Any medicines incidents and errors were recorded on incident

recording systems and any alerts were disseminated to staff during huddles.

We checked three fridges in the emergency department and found two of them had temperatures

checked daily, however, the fridge in resus had nine dates in October 2019 where the temperature

had not been checked. The trust had an action plan in place to improve compliance. Actions were

assigned to individuals with completion dates. We found the fridge temperatures were in range.

Incidents

The service managed patient safety incidents well. Staff recognised and reported incidents

and near misses and reported them appropriately. Managers investigated incidents and

shared lessons learned with the whole team and the wider service. When things went

wrong, staff apologised and gave patients honest information and suitable support.

Managers ensured that actions from patient safety alerts were implemented and monitored.

Staff knew what incidents to report and how to report them. Staff understood their responsibilities

to raise concerns and report them using the trust’s electronic reporting system. There were

processes in place for investigating incidents and staff informed us that feedback was shared at a

local level by their managers.

Staff raised concerns and reported incidents and near misses in line with trust policy. Staff could

describe the types of incidents that required reporting. A patient fall occurred in the emergency

department during our inspection. We observed a staff member call for help and staff responded.

A doctor attended shortly after to review the patient. The incident was promptly documented via

the electronic reporting system.

Never Events

The service reported no never events.

Never events are serious patient safety incidents that should not happen if healthcare providers

follow national guidance on how to prevent them. Each never event type has the potential to cause

serious patient harm or death but neither need have happened for an incident to be a never event.


From August 2018 to August 2019, the trust did not report any never events for urgent and

emergency care services.

(Source: Strategic Executive Information System (STEIS))

Breakdown of serious incidents reported to STEIS

Staff reported serious incidents clearly and in line with trust policy. Upon reviewing the service’s

monthly emergency care governance meeting minutes from August, September and October

2019, it was evident that incidents were reported appropriately. Staff told us a daily incident review

took place in the department where incidents were reviewed and allocated to an individual for

investigation where appropriate.

In accordance with the Serious Incident Framework 2015, the trust reported 29 serious incidents

(SIs) in urgent and emergency care which met the reporting criteria set by NHS England from

August 2018 to August 2019. This represented 22.8% of all serious incidents reported by the trust

as a whole.

Just under half (44.8%) of all serious incidents reported in urgent and emergency care related to a

treatment delay meeting SI criteria.

A breakdown of the incident types reported is shown in the table below:

Incident type Number of incidents

Percentage of total

Treatment delay meeting SI criteria 13 44.8% Sub-optimal care of the deteriorating patient meeting SI criteria

8 27.6%

Diagnostic incident including delay meeting SI criteria (including failure to act on test results)

4 13.8%

Apparent/actual/suspected self-inflicted harm meeting SI criteria

3 10.3%

Slips/trips/falls meeting SI criteria 1 3.4% Total 29 100.0%


Staff understood the duty of candour. They were open and transparent and gave patients and

families a full explanation if and when things went wrong. The duty of candour is a statutory duty to

be open and honest when something goes wrong that appears to have caused or could lead to

significant harm in the future. Staff told us that they invited family members to meetings at the

hospital to discuss concerns they had raised.

Staff received feedback from investigation of incidents, both internal and external to the service.

Following incidents on wards, staff told us that learning from incidents was shared at local

meetings. The department ran serious incident learning initiatives (SILI) meetings on a weekly

basis which was open for all staff to attend.

Staff met to discuss the feedback and look at improvements to patient care. Senior staff discussed

incidents during the emergency care governance meetings.

There was evidence that changes had been made as a result of feedback. One root cause

analysis investigation report we reviewed resulted in a change that patients should only be go to


the stepdown area of majors after discussion with the emergency care physician in charge (EPIC)

or the nurse in charge (NIC).

Managers investigated incidents thoroughly. Patients and their families were involved in these

investigations. We saw this was evident in a route cause analysis investigation report we

reviewed.

Managers debriefed and supported staff after any serious incident. Staff told us that they routinely

received debriefs following any serious incidents.

Safety thermometer

The service used monitoring results well to improve safety. Staff collected safety

information and shared it with staff, patients and visitors.

The Safety Thermometer is used to record the prevalence of patient harms and to provide

immediate information and analysis for frontline teams to monitor their performance in delivering

harm free care. Measurement at the frontline is intended to focus attention on patient harms and

their elimination.

Data collection takes place one day each month. A suggested date for data collection is given but

wards can change this. Data must be submitted within 10 days of the suggested data collection

date.

Data from the Patient Safety Thermometer showed that the trust reported no new pressure ulcers,

falls with harm or new urinary tract infections in patients with a catheter from August 2018 to

August 2019 within urgent and emergency care.

(Source: NHS Digital - Safety Thermometer)

Is the service effective?

Evidence-based care and treatment

The service provided care and treatment based on national guidance and evidence-based

practice. Managers checked to make sure staff followed guidance. Staff protected the

rights of patients subject to the Mental Health Act 1983.

Staff followed up-to-date policies to plan and deliver high quality care according to best practice

and national guidance. Staff were able to access internal trust policies and external clinical

guidelines on the provider’s intranet, or in reference folders located throughout the department.

We reviewed five policies and guidelines during our inspection on the trust intranet. Policies were

in date, version controlled, regularly updated and based on national guidance.

People’s care and treatment was planned and delivered in line with up to evidence-based

guidance and standards set by the National Institute of Health and Care Excellence (NICE), The

UK Resus Council and the Royal College of Emergency Medicine. The department used clinical

pathways that aligned with national guidelines, including sepsis pathways.

Managers carried out an audit programme to support and monitor implementation of NICE

guidance. For example, the trust completed audits on sepsis patients receiving treatment within

one hour. Audits of documentation were carried out as well as infection prevention and pharmacy

audits. Audits were discussed at monthly audit meetings and action plans were in place for all

audits in order to improve future outcomes.


Staff protected the rights of patient’s subject to the Mental Health Act and followed the Code of

Practice. The adult mental health assessment and referral form provided staff with clear guidance

on how to support and review mental health patients depending on their individual level of risk. It

also contained contact details for patients who required further mental health assessments,

including out of hours contact details. At handover meetings, staff routinely referred to the

psychological and emotional needs of patients, their relatives and carers.

The paediatric emergency department met the relevant standards for children in emergency care

settings set by the Royal College of Paediatrics and Child Health (RCPCH). Children were

provided with waiting and treatment areas that were separate from adult waiting areas. Access to

the paediatric emergency department was controlled in order to protect children from harm.

Nutrition and hydration

Staff gave patients enough food and drink to meet their needs and improve their health.

The service made adjustments for patients’ religious, cultural and other needs. However,

we were not assured fluid and nutrition charts were completed for all patients who required

them.

Staff made sure patients had enough to eat and drink, including those with specialist nutrition and

hydration needs. During our inspection, we saw staff offering patients food and drink at regular

intervals. Due to the nature of services provided, hot food was not routinely offered due to the

temporary patient stay within the department. However, staff told us they could request hot food

for patients if required. Onsite catering services were contacted to accommodate patients with

specific dietary requirements.

All patients we spoke with told us they had been offered hot drinks and food (where clinically

appropriate) during their time in the department. Fresh drinking water was available throughout the

department. A food vending machine was available in the adult waiting area. In addition, the trust

had an onsite restaurant and shop for visitors.


In the CQC Emergency Department Survey, the trust scored 6.7 for the question “Were you able

to get suitable food or drinks when you were in the emergency department?” This was about the

same as other trusts.


Specialist support from staff such as dieticians was available for patients who needed it. Staff

confirmed that they were able to refer directly and that referrals were responded to quickly.

We were not assured that staff always completed patients’ fluid and nutrition charts where needed.

Assessments of nutritional needs had been completed in 10 of the 19 patient records we

reviewed. Therefore, we could not be assured fluid and nutrition charts were completed for all

patients who required them.

Pain relief

Staff assessed and monitored patients regularly to see if they were in pain and gave pain

relief in a timely way. They supported those unable to communicate using suitable

assessment tools and gave additional pain relief to ease pain.


Staff assessed patients’ pain using a recognised tool and gave pain relief in line with individual

needs and best practice. We observed staff assessing patient’s pain levels early in the patient’s

pathway by different methods in line with the Faculty of Pain Medicine’s Core Standards for Pain

Management (2015). When assessing pain in adults, staff used a pain score, ten being the worst

discomfort and one being very mild discomfort. Staff used other pain assessment tools for children

dependent upon age and those with a cognitive impairment, for example using smiley or sad

faces.

Patients received pain relief soon after it was identified they needed it or they requested it. Staff

used Patient Group Directions (PGDs) which allowed staff to administer prompt pain relief to

patients. Staff reacted promptly by administering pain relief medication when patients required it.

We saw staff regularly asking patients whether they were in any pain.

Staff prescribed, administered and recorded pain relief accurately. In records we reviewed we saw

evidence that pain was discussed during initial assessment and pain relief provided.


In the CQC Emergency Department Survey, the trust scored 6.7 for the question “How many

minutes after you requested pain relief medication did it take before you got it?” This was about

the same as other trusts.

The trust scored 7.7 for the question “Do you think the hospital staff did everything they could to

help control your pain?” This was about the same as other trusts.


Patient outcomes

Staff monitored the effectiveness of care and treatment. They used the findings to make

improvements.

The service participated in relevant national clinical audits. The service did not meet national

standards in these audits, however performance was often better than, or similar to, other trusts.

Managers used the results of national audits to improve services further. For example, the trust

had action plans in place for national audits. The action plan for the feverish child audit included

compliance with national standards, assigned and dated actions which included an internal re-

audit. Information provided by the trust stated that implementation of national clinical guidance

was reviewed by exception at clinical governance meetings on a quarterly basis.

RCEM Audit: Moderate and acute severe asthma 2016/17

In the 2016/17 Royal College of Emergency Medicine (RCEM) Moderate and acute severe asthma

audit, Broomfield Hospital’s emergency department failed to meet any of the national standards.

The department was in the upper UK quartile for two standards:

• Standard 5: If not already given before arrival to the emergency department, steroids should

be given as soon as possible as follows:

- Adults 16 years and over: 40-50mg prednisolone orally or 100mg hydrocortisone IV

- Children 6-15 years: 30-40mg prednisolone orally or 4mg/kg hydrocortisone IV


- Children 2-5 years: 20mg prednisolone orally or 4mg/kg hydrocortisone IV

o Standard 5b (fundamental): within 4 hours (moderate). This department: 61.2%; UK:

28%.

• Standard 9 (fundamental): Discharged patients should have oral prednisolone prescribed as

follows:

- Adults 16 years and over: 40-50mg prednisolone for 5 days

- Children 6-15 years: 30-40mg prednisolone for 3 days

- Children 2-5 years: 20mg prednisolone for 3 days

o This department: 76.2%; UK: 52%.

The department’s results for the remaining five standards were all within the middle 50% of

results.

• Standard 1a (fundamental): Oxygen should be given on arrival to maintain a saturation of 94-

98%. This department: 20.2%; UK: 19%.

• Standard 2a (fundamental): As per RCEM standards, vital signs should be measured and

recorded on arrival at the emergency department. This department: 26.3%; UK: 26%.

• Standard 3 (fundamental): High dose nebulised Beta 2 antagonist bronchodilator should be

given within 10 minutes of arrival at the emergency department. This department: 31.3%; UK:

25%.

• Standard 4 (fundamental): Add nebulised Ipratropium Bromide if there is a poor response to

nebulised Beta 2 antagonist bronchodilator therapy. This department: 82.8%; UK: 77%.

• Standard 5: If not already given before arrival to the emergency department, steroids should

be given as soon as possible as follows:

- Adults 16 years and over: 40-50mg prednisolone orally or 100mg hydrocortisone IV

- Children 6-15 years: 30-40mg prednisolone orally or 4mg/kg hydrocortisone IV

- Children 2-5 years: 20mg prednisolone orally or 4mg/kg hydrocortisone IV

o Standard 5a (fundamental): within 60 minutes of arrival (acute severe). This department:

32.3%; UK: 19%.

(Source: Royal College of Emergency Medicine)

RCEM Audit: Consultant sign-off 2016/17

In the 2016/17 Consultant sign-off audit, Broomfield Hospital’s emergency department failed to

meet any of the national standards.

The department was in the lower UK quartile for two standards:


• Standard 1 (developmental): Consultant reviewed: atraumatic chest pain in patients aged 30

years and over. This department: 4.9%; UK: 11%.

• Standard 2 (developmental): Consultant reviewed: fever in children under 1 year of age. This

department: 0.0%; UK: 8%.

The department’s results for the remaining two standards were all within the middle 50% of

results.

• Standard 3 (fundamental): Consultant reviewed: patients making an unscheduled return to the

emergency department with the same condition within 72 hours of discharge. This department:

16.7%; UK: 12%.

• Standard 4 (developmental): Consultant reviewed: abdominal pain in patients aged 70 years

and over. This department: 5.9%; UK: 10%.


RCEM Audit: Severe sepsis and septic shock 2016/17

In the 2016/17 Severe sepsis and septic shock audit, Broomfield Hospital’s emergency

department failed to meet any of the national standards.

The department was in the upper UK quartile for two standards:

• Standard 5: Blood cultures obtained within one hour of arrival. This department: 68.0%; UK:

44.9%.

• Standard 8: Urine output measurement/fluid balance chart instituted within four hours of

arrival. This department: 38.8%; UK: 18.4%.

The department’s results for the remaining six standards were all within the middle 50% of results.

• Standard 1: Respiratory rate, oxygen saturations (SaO2), supplemental oxygen requirement,

temperature, blood pressure, heart rate, level of consciousness (AVPU or GCS) and capillary

blood glucose recorded on arrival. This department: 70.0%; UK: 69.1%.

• Standard 2: Review by a senior (ST4+ or equivalent) emergency department medic or

involvement of critical care medic (including the outreach team or equivalent) before leaving

the emergency department. This department: 62.0%; UK: 64.6%.

• Standard 3: O2 was initiated to maintain SaO2>94% (unless there is a documented reason not

to) within one hour of arrival. This department: 55.6%; UK: 30.4%.

• Standard 4: Serum lactate measured within one hour of arrival. This department: 70.0%; UK:

60.0%.

• Standard 6: Fluids – first intravenous crystalloid fluid bolus (up to 30 mL/Kg) given within one

hour of arrival. This department: 49.0%; UK: 43.2%.

• Standard 7: Antibiotics administered: Within one hour of arrival. This department: 52.0%; UK:

44.4%.



Trauma Audit and Research Network (TARN)

The table below summarises Broomfield Hospital’s performance in the 2018 Trauma Audit and

Research Network audit. The TARN audit captures any patient who is admitted to a non-medical

ward or transferred out to another hospital (e.g. for specialist care) whose initial complaint was

trauma (including shootings, stabbings, falls, vehicle or sporting accidents, fires or assaults).

Metrics (Audit measures)

Hospital performance

Audit Rating Met national standard?

Case Ascertainment (Proportion of eligible cases reported to TARN compared against Hospital Episode Statistics data)

28.2 – 38.3% n/a Did not meet

Crude median time from arrival to CT scan of the head for patients with traumatic brain injury (Prompt diagnosis of the severity of traumatic brain injury from a CT scan is critical to allowing appropriate treatment which minimises further brain injury.)

Not eligible n/a n/a

Crude proportion of eligible patients receiving Tranexamic Acid within 3 hours of injury (Prompt administration of tranexamic acid has been shown to significantly reduce the risk of death when given to trauma patients who are bleeding)

Not eligible n/a n/a

Crude proportion of patients with severe open lower limb fracture receiving appropriately timed urgent and emergency care (Outcomes for this serious type of injury are optimised when urgent and emergency care is carried out in a timely fashion by appropriately trained specialists.)

0.0% Lower than the

TARN aggregate

Did not meet

Risk-adjusted in-hospital survival rate following injury (This metric uses case-mix adjustment to ensure that hospitals dealing with sicker patients are compared fairly against those with a less complex case mix.)

1.4 additional survivors

As expected Met

(Source: TARN)

The trust participated in the Trauma Audit and Research Network (TARN). However, there had

been previous issues with the completeness of data which impacted on audit results and the ability

to use the results to improve patient outcomes. Information provided by the trust following our

inspection stated that the trust had completed a number of actions to address these concerns.


This included; a full time TARN administrator had been employed and received all necessary

training. Problems with coding and timely access to hospital notes had been addressed. Patients

with burns had been removed from figures as they did not meet the requirement for submission to

TARN. A dedicated team consisting of orthopaedic specialist nurses, the new TARN administrator

and band six orthopaedic nurses were deployed from June to September 2019 to reduce the

TARN data backlog.

Managers used information from the audits to improve care and treatment. They maintained action

plans with actions in place and assigned to individuals with completion and review dates where

applicable. For example, the vital signs in adults audit detailed what progress had been made

against the national standards, along with actions required to improve compliance. One action was

to include guidance in induction for new staff.

There were engagement meetings and/or follow-up of audit outliers. Meetings took place within

the service to address audit findings and monitor the implementation of action plans. Audits were

discussed at senior emergency department meetings. Improvement was checked and monitored

within these meetings.

Managers shared and made sure staff understood information from the audits. Managers told us

that specific changes to practice following audit results were communicated via email, included in

newsletters and at team meetings. Dissemination to all staff was often included in audit action

plans.

Unplanned re-attendance rate within seven days

The service had a lower than expected risk of re-attendance than the England average.

From July 2018 to June 2019, the trust’s unplanned re-attendance rate to A&E within seven days

was better than the national standard of 5% in 10 of the 12 months, excluding July 2018 and

August 2019 where performance met the national standard.

The trust performed consistently better than the England average across the 12 months. The

trust’s performance was generally consistent, ranging from 3.0% to 5.0% compared to the England

average of 7.9% to 8.5%.

Unplanned re-attendance rate within seven days - Mid Essex Hospital Services NHS Trust

(Source: NHS Digital – A&E quality indicators)


Competent staff

The service made sure staff were competent for their roles. Managers appraised staff’s

work performance and held supervision meetings with them to provide support and

development.

Staff were experienced, qualified and had the right skills and knowledge to meet the needs of

patients. The service encouraged development and told us about staff undertaking extended

training to become emergency nurse practitioners for example. Staff members had the opportunity

to take on link nurse roles which gave them access to further training which they shared with the

rest of their staff teams. For example, there were link nurses for sepsis.

Staff members in the children’s emergency department were given training and competency

booklets to work through and complete which included; cannulation, venepuncture, culture

collection, drug administration and triage training.

Managers gave all new staff a full induction tailored to their role before they started work. Staff

confirmed their attendance at the induction. Newly qualified members of nursing staff completed a

preceptorship period. This meant that staff were allocated time to transition from a student to a

qualified member of staff.

Appraisal rates

Managers supported staff to develop through yearly, constructive appraisals of their work. Staff

told us that their appraisals were up to date and that they were useful.

Broomfield Hospital

As of August 2019, 79.2% of staff within the urgent and emergency care department at Broomfield

Hospital received an appraisal compared to a trust target of 90%.

The breakdown by staff group can be seen in the table below:

Staff group

As of August 2019

Staff who received an appraisal

Eligible staff

Completion rate

Trust target

Met (Yes/No)

Medical and dental 26 27 96.3% 90% Yes

Allied health professionals 20 21 95.0% 90% Yes

Administrative and clerical 17 21 81.0% 90% No

Nursing and midwifery registered 53 70 75.7% 90% No

Additional clinical services 25 35 71.4% 90% No

Additional professional scientific and technical

0 3 0.0% 90% No

Estates and ancillary 0 1 0.0% 90% No

Total 141 178 79.2% 90% No

Medical and dental and allied health professionals in urgent and emergency care services both

met the 90% target. Only 75.7% of registered nursing staff had received an appraisal as of August

2019, however, care should be taken when interpreting the rates as this data only represents a

partial year.

(Source: Routine Provider Information Request (RPIR) – Appraisal tab)


Managers supported nursing staff to develop through regular, constructive clinical supervision of

their work. Nursing staff told us that their development needs were identified in their annual

personal development plan meetings. Managers provided ad-hoc supervision and staff told us that

managers were approachable and highly supportive.

Managers supported medical staff to develop through regular, constructive clinical supervision of

their work. Medical staff worked together across the service to provide support, learning and

debriefs to their colleagues. Junior medical staff told us they received support and supervision

from their senior colleagues.

The clinical educator supported the learning and development needs of staff. Staff were assessed

across several competencies before they were allowed to perform certain procedures. This

ensured staff were experienced, qualified and had the right skills and knowledge to meet the

needs of patients.

Managers identified any training needs their staff had and gave them the time and opportunity to

develop their skills and knowledge. Managers made sure staff received specialist training to

support staff in their role. Managers arranged clinical skills days within the service. These took

place on a six monthly basis and included skills such as cannulas, plaster and wound care.

Multidisciplinary working

Doctors, nurses and other healthcare professionals mostly worked together as a team to

benefit patients. They supported each other to provide good care.

Staff held regular and effective multidisciplinary meetings to discuss patients and improve their

care. Doctors, nurses and other healthcare professionals supported each other to provide good

care. We saw good multidisciplinary working practices within the department. Nurses and doctors

spoke highly of each other and we observed a cohesive relationship when dealing with patients.

Staff told us that they liaised with other departments when they needed to gain specialist input.

Occupational therapists and physiotherapists regularly attended the department to assess and

treat patients.

Staff worked across health care disciplines and with other agencies when required to care for

patients. During our inspection we saw staff working together as a team to assess and plan

ongoing care and treatment. We saw evidence in one set of patient notes we reviewed of a

safeguarding referral being made to the local authority.

Staff referred patients for mental health assessments when they showed signs of mental ill health,

depression. Staff described positive working relationships with the local mental health team. Staff

liaised with the local mental health team to arrange mental health act assessments when required.

Mental health staff were located within the trust premises during the day which promoted

integrated care for patients.

However, we found there were limited pathways established for patients requiring hospital stay.

Other than referring patients directly to ambulatory care, staff told us that there was a lack of clear

pathways from the emergency department. For example, staff told us that there was previously a

clear pathway from ED to gynaecology, however this was stopped following an incident. Staff told

us that re-establishing this and other pathways would be a priority.


Seven-day services

Key services were available seven days a week to support timely patient care.

Staff could call for support from doctors and other disciplines and diagnostic services, including

mental health services, 24 hours a day, seven days a week. The department had 24 hour access

to key support services, such as pathology, allowing for blood test results to be obtained at any

time. It also had 24-hour access to key diagnostic imaging tests, including x-rays, computerised

tomography (CT) scans and magnetic resonance imaging (MRI) scans.

Support from the local mental health service was available 24 hours a day, seven days a week.

Staff knew how to refer to this service and knew the processes to follow when a mental health act

assessment was required. Staff told us that the local mental health service responded promptly to

referrals.

Health promotion

Staff gave patients practical support and advice to lead healthier lives.

The service had relevant information promoting healthy lifestyles and support on wards. Varied

information was provided to patients and their relatives on a range of topics, for example, mental

health and lifestyle. Information signposted patients to other relevant agencies, where appropriate.

Staff assessed each patient’s health when admitted and provided support for any individual needs

to live a healthier lifestyle.

Consent, Mental Capacity Act and Deprivation of Liberty Safeguards

Staff supported patients to make informed decisions about their care and treatment. They

followed national guidance to gain patients’ consent. They knew how to support patients

who lacked capacity to make their own decisions or were experiencing mental ill health.

They used agreed personalised measures that limited patients' liberty.

Staff understood how and when to assess whether a patient had the capacity to make decisions

about their care. Staff demonstrated that they understood the Mental Capacity Act and how to

apply it. The trust had a Mental Capacity Act (2005) Policy for staff to follow, which included when

to assess capacity and guidance for documentation of decisions about capacity.

Staff gained consent from patients for their care and treatment in line with legislation and

guidance. We saw evidence that consent had been gained in all of the patient records we

reviewed. This was clearly recorded.

When patients could not give consent, staff made decisions in their best interest, taking into

account patients’ wishes, culture and traditions. If patients were not well enough to provide

consent, staff discussed care or treatment with relatives, or made decisions in the patient’s best

interests.

Staff understood Gillick Competence and supported children who wished to make decisions about

their treatment. Staff in the paediatric emergency department could describe the Gillick

competence and how this would be used when assessing children’s capacity. Gillick competence

is a legal principle for assessing a child’s capacity to consent to medical treatment.


Mental Capacity Act and Deprivation of Liberty training completion

The trust set a target of 95% for the completion of Mental Capacity Act (MCA) training. The

trust stated that Deprivation of Liberty Safeguarding (DoLS) training is included in the MCA

training module.

Broomfield Hospital

A breakdown of compliance for the MCA/DoLS training course as of August 2019 for qualified

nursing and medical staff in urgent and emergency care at Broomfield Hospital is shown below:

Staffing group

As of August 2019

Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)


Medical and dental 24 29 82.8% 95% No

In urgent and emergency care, the 95% target for MCA/DoLS training was not met by qualified

nursing staff or medical staff as of August 2019.


Following our inspection, we requested updated training data for MCA and DoLS training. The new

data showed current completion rates for November 2019. The data the trust provided showed

that compliance with MCA training was 85.2% for nursing staff, and 89.5% for medical staff.

Compliance with DoLS training was 93.8% for nursing staff and 89.5 for medical staff. Although

the training did not meet the trust target, it demonstrated an improvement in training compliance.

Staff understood the relevant consent and decision-making requirements of legislation and

guidance, including the Mental Health Act, Mental Capacity Act 2005 and the Children Acts 1989

and 2004 and they knew who to contact for advice.

Managers monitored the use of Deprivation of Liberty Safeguards and made sure staff knew how

to complete them. Staff we spoke with told us they have had patients admitted to the department

with DoLS in place. Staff told us they ensured patients who were subject to a DoLS came with the

correct paperwork. Staff informed the safeguarding team of any patients who arrived under DoLS

so they could support ED staff to ensure the patients’ needs were met.

Staff could describe and knew how to access policy and get accurate advice on Mental Capacity

Act and Deprivation of Liberty Safeguards.

Is the service caring?

Compassionate care

Staff treated patients with compassion and kindness, mostly respected their privacy and

dignity, and took account of their individual needs.

Staff were discreet and responsive when caring for patients. Staff took time to interact with

patients and those close to them in a respectful and considerate way. We observed two musicians

in the paediatric emergency department (ED) during our inspection. The musicians were playing

guitar to help distract children and to create a more positive environment. We observed the use of

blankets and privacy curtains throughout the department to maintain patients’ privacy and dignity.


However, in the ambulance waiting area we observed interventions being carried out without the

use of privacy screens. Staff told us the most invasive intervention they would carry out in this

area was taking bloods. We were not assured that this fully protected the privacy and dignity of

these patients. We raised our concern with the senior team who told us they would review this

practice.

Patients said staff treated them well and with kindness. All patients we spoke with told us that staff

treated them well and could not do enough for them. We observed positive interactions between

staff and patients; staff spoke to patients in a caring and respectful manner. Staff introduced

themselves and explained to patients what they were going to do before they administered any

treatment.

Friends and Family test performance

The Patient Friends and Family Test asks patients whether they would recommend the services

they have used based on their experiences of care and treatment.

Response rates for Mid Essex Hospital Services NHS Trust from July 2017 to June 2019 are

shown below. The response rates ranged from 17.4% to 20.9%.

Mid Essex Hospital Services NHS Trust – response rate July 2017 to June 2019

The chart below shows the mean friends and family test scores, with upper and lower control

limits. The width of the control limits is based on the response rates, therefore the higher the

response rates (shown by narrower control limits) the more confidence we have in the data.

The trust scored between 83.4% and 91.2% from July 2017 to June 2019.

The performance of this metric is not stable and may be subject to ongoing change.


(Source: Friends and Family Test – NHS England)

Staff mainly followed policy to keep patient care and treatment confidential. Staff were mindful

when speaking about patients’ care and treatment. Where possible, discussions took place in

private areas away from other patients and visitors. However, patient records were not locked

away. Although they were positioned behind the nursing station, we were not assured that it

provided complete confidentiality for patients.

Staff understood and respected the individual needs of each patient and showed understanding

and a non-judgmental attitude when caring for or discussing patients with mental health needs.

Staff we spoke with expressed they always held a non-judgemental attitude towards all patients.

Discussions with staff about mental health concerns demonstrated staff had understanding and a

non-judgemental attitude. We observed that staff were sensitive to all those within their care.

Staff understood and respected the personal, cultural, social and religious needs of patients and

how they may relate to care needs. Chaplaincy, pastoral and spiritual services were available for

patients and families to access when required.

Emotional support

Staff provided emotional support to patients, families and carers to minimise their distress.

They understood patients' personal, cultural and religious needs.

Staff gave patients and those close to them help, emotional support and advice when they needed

it. Patients we spoke with told us that staff were very helpful, answered any questions they had

and took any concerns they raised seriously. Patients described that they had felt well looked after

by staff.

Staff told us that the chaplaincy team visited the department daily to offer emotional support to any

patients who wished to meet with them. Staff commented that the chaplaincy team were very

supportive to patients, relatives and staff.

Staff supported patients who became distressed in an open environment and helped them

maintain their privacy and dignity. The department had a designated room for mental health


patients which was situated away from the main treatment areas to offer people privacy and a safe

environment.

Staff kept patients covered with a blanket to protect their privacy and dignity and ensured curtains

were closed when delivering any personal care.

Staff demonstrated empathy when having difficult conversations. Staff informed us that when

having difficult conversations, they went in pairs and explained things clearly yet sensitively, as

well as providing practical information. We observed that discussions patients were not rushed,

and staff asked whether they had any questions or whether there was anything else they needed.

Staff understood the emotional and social impact that a person’s care, treatment or condition had

on their wellbeing and on those close to them. Staff recognised these factors in their assessments

of patients and included that information to ensure all staff involved in their care were aware of it.

Staff provided support to patients and their relatives by signposting them to external support

agencies.

Understanding and involvement of patients and those close to them

Staff supported and involved patients, families and carers to understand their condition

and make decisions about their care and treatment.

Staff made sure patients and those close to them understood their care and treatment. We

observed that staff took time to fully explain information to patients to support discussions about

care and treatment. Staff told us they had discussions with patients and checked their

understanding. We saw this while observing staff interactions with patients.

Staff talked to patients in a way they could understand, using communication aids where

necessary. We observed staff taking time to explain to patients and their relatives and answering

their questions to ensure that they had all the information they needed.

Patients and their families could give feedback on the service and their treatment and staff

supported them to do this. They could do this through completing patient feedback cards or

through the trust website.

Staff supported patients to make informed decisions about their care by providing information and

signposting to other support services where appropriate.


The feedback from the emergency department survey test was positive.

The trust scored about the same as other trusts for all 24 of the Emergency Department Survey

questions relevant to the caring domain.

Question Trust 2016 2016 RAG Q10. Were you told how long you would have to wait to be examined?

3.4 About the same as other trusts

Q12. Did you have enough time to discuss your health or medical problem with the doctor or nurse?


Q13. While you were in the emergency department, did a doctor or nurse explain your condition and treatment in a way you could understand?


Q14. Did the doctors and nurses listen to what you had to say? 8.8 About the same as other trusts


Question Trust 2016 2016 RAG Q16. Did you have confidence and trust in the doctors and nurses examining and treating you?


Q17. Did doctors or nurses talk to each other about you as if you weren't there?


Q18. If your family or someone else close to you wanted to talk to a doctor, did they have enough opportunity to do so?


Q19. While you were in the emergency department, how much information about your condition or treatment was given to you?


Q21. If you needed attention, were you able to get a member of medical or nursing staff to help you?


Q22. Sometimes in a hospital, a member of staff will say one thing and another will say something quite different. Did this happen to you in the emergency department?


Q23. Were you involved as much as you wanted to be in decisions about your care and treatment?


Q44. Overall, did you feel you were treated with respect and dignity while you were in the emergency department?


Q15. If you had any anxieties or fears about your condition or treatment, did a doctor or nurse discuss them with you?


Q24. If you were feeling distressed while you were in the emergency department, did a member of staff help to reassure you?


Q26. Did a member of staff explain why you needed these test(s) in a way you could understand?


Q27. Before you left the emergency department, did you get the results of your tests?


Q28. Did a member of staff explain the results of the tests in a way you could understand?


Q38. Did a member of staff explain the purpose of the medications you were to take at home in a way you could understand?


Q39. Did a member of staff tell you about medication side effects to watch out for?


Q40. Did a member of staff tell you when you could resume your usual activities, such as when to go back to work or drive a car?


Q41. Did hospital staff take your family or home situation into account when you were leaving the emergency department?


Q42. Did a member of staff tell you about what danger signals regarding your illness or treatment to watch for after you went home?


Q43. Did hospital staff tell you who to contact if you were worried about your condition or treatment after you left the emergency department?


Q45. Overall 8.1 About the same as other trusts


Is the service responsive?

Service delivery to meet the needs of local people


The service planned and provided care in a way that met the needs of local people and the

communities served. It also worked with others in the wider system and local organisations

to plan care.

Managers planned and organised services so they met the needs of the local population. The trust

had a GP streaming service for patients who attended the department but did not require

assessment or treatment in the emergency department. This meant that patients could still receive

assessment and treatment rather than being advised to visit their own GP.

The trust had a winter plan in place which leads within the emergency department had been

involved in developing. The trust also worked with the local clinical commissioning group (CCG) to

develop the winter plan. The plan involved some beds being re-designated from surgical to

medical to ensure the service could meet the needs of patients at times of high demand during the

winter months.

Staff knew about and understood the standards for mixed sex accommodation and knew when to

report a potential breach. There had been no mixed sex breaches during the period from August

2018 to July 2019.

Facilities and premises were mostly appropriate for the services being delivered. The ED was

easily accessible for patients using wheelchairs and those with other mobility issues. Doorways

and corridors were generally kept free of obstacles, and allowed patients with reduced mobility

good access to all areas of the ED. There was a sufficient number of chairs in the main waiting

area and the ambulatory care unit for people during the periods of time we observed. However, we

saw the waiting area for the ‘fit to sit’ area was full one evening during our inspection, with one

patient choosing to wait outside on the floor of the corridor.

Staff could access emergency mental health support 24 hours a day 7 days a week for patients

with mental health problems, learning disabilities and dementia. The service had 24-hour access

to mental health liaison and specialist mental health support. Staff reported a positive working

relationship with the local mental health team. Staff from the local mental health team were based

at the hospital site during the day to enable them to provide timely support when needed and staff

told us they responded promptly to referrals. There were challenges at times when beds were not

available within the local mental health trust. This meant that mental health patients had to remain

in the department until a suitable bed became available.

The service had systems to help care for patients in need of additional support or specialist

intervention. The service had systems to identify patients who needed specialist support. For

example, there were alerts which flagged on the patient electronic system to identify people living

with dementia or a learning disability.

The service relieved pressure on other departments when they could treat patients in a day. The

streaming nurse assessed patients on arrival to the emergency department after they had booked

in at reception. Where possible patients could be streamed directly to the ambulatory care unit

where they could be seen and treated in one day to reduce hospital admissions.

Meeting people’s individual needs

The service was inclusive and took account of patients’ individual needs and preferences.

Staff made reasonable adjustments to help patients access services. They coordinated

care with other services and providers.


Staff made sure patients living with mental health problems, learning disabilities and dementia,

received the necessary care to meet all their needs. Staff risk assessed all patients thought to be

living with mental health problems upon arrival at the emergency department (ED). We saw that

these assessments were detailed, comprehensive and personalised to ensure patients’ needs

were fully assessed. There were pathways for both adult and children presenting to the ED with

mental health needs, and staff were appropriately trained to meet their needs and maintain their

safety.

The emergency department was not specifically designed to meet the needs of patients living with

dementia, however staff could access sensory equipment such as twiddle muffs, which provided

patients living with dementia with tactile stimulation. The trust had one whole time equivalent

dementia/delirium nurse who carried out regular ‘walk arounds’ of the emergency village to

support patients living with dementia, or to provide advice to staff when required. The

dementia/delirium nurse was also contactable via a bleep.

Staff supported patients living with dementia and learning disabilities by using ‘This is me’

documents and patient passports. Patients with a diagnosis of dementia were assessed using this

document in order to provide individualised care.

Staff understood and applied the policy on meeting the information and communication needs of

patients with a disability or sensory loss. Staff had access to sensory items which included tactile

objects patients could hold. One member of staff had put together a ‘dementia trolley’ which

contained sensory items, books and pens.

Managers made sure staff, and patients, loved ones and carers could get help from interpreters or

signers when needed. Staff told us that an interpreting service was available to help communicate

with patients whose first language was not English. This was usually provided over the telephone,

but interpreters could be sourced to aid face to face communication if required. Staff told us they

could seek support from staff members who spoke other languages to aid communication.

Patients were given a choice of food and drink to meet their cultural and religious preferences.

Staff told us that they contacted the hospital catering services when required to ensure that

individual needs were met in relation to their cultural and religious preferences.

Staff had access to communication aids to help patients become partners in their care and

treatment. Staff had access to resources such as various picture cards, including aids for pain

scoring. Hearing loops were available within the department.


The trust scored about the same as other trusts for all three of the Emergency Department Survey

questions relevant to the responsive domain.

Question – Responsive Score RAG Q7. Were you given enough privacy when discussing your condition with the receptionist?


Q11. Overall, how long did your visit to the emergency department last?


Q20. Were you given enough privacy when being examined or treated?




Access and flow

People could not always access the service when they needed it and did not always receive

care promptly. Waiting times from referral to treatment and arrangements to admit, treat

and discharge patients were not in line with national standards.

Median time from arrival to treatment (all patients)

Managers monitored waiting times but patients could not always access emergency services and

receive treatment within agreed timeframes and national targets. The leads within the department

were in the process of trialling an initiative to try to improve flow throughout the department. They

had extended the department and introduced a ‘fit to sit’ area. The area was used for patients who

were assessed as having stable conditions, did not require immediate intervention, cardiac

monitoring or high level of observation, and were deemed as low dependency. The ‘fit to sit’ area

ensured that these patients were not kept in the main waiting room but were cared for in a

dedicated area, which also supported the flow of the minors area. The trial of ‘fit to sit’ was subject

to a three month review, which was due on 4 December 2019.

There was an emergency department performance improvement plan in place which had actions

assigned to individuals and was red, amber, green (RAG) rated to indicate whether actions were

complete, on track, delayed, not complete or ongoing.

The Royal College of Emergency Medicine recommends that the time patients should wait from

time of arrival to receiving treatment should be no more than one hour. The trust did not report any

data for this quality indicator to NHS Digital from July 2018 to June 2019.


Following our inspection, we requested the median time from arrival to treatment for all patients.

Information provided by the trust stated that the median time from arrival to treatment for all

patients from 1 May 2019 to 31 October 2019 was 90 minutes. This meant that the trust did not

meet the national recommendation.

Percentage of patients admitted, transferred or discharged within four hours (all

emergency department types)

The Department of Health’s standard for emergency departments is that 95% of patients should

be admitted, transferred or discharged within four hours of arrival in the emergency department.

From August 2018 to July 2019 the trust failed to meet the standard in all twelve months. The trust

also performed consistently poorer than the England average across the same period. The trust’s

performance remained relatively consistent across the period with improvements seen in August

and October 2018 and June 2019 (88%, 87% and 84% respectively).

Four hour target performance - Mid Essex Hospital Services NHS Trust


(Source: NHS England - A&E Waiting times)

Percentage of patients waiting more than four hours from the decision to admit until being

admitted

From August 2018 to July 2019 the trust’s monthly percentage of patients waiting more than four

hours from the decision to admit until being admitted fluctuated. Performance at the trust was

worse than the England average in nine of the 12 months, excluding September 2018 and April

2019 where the trust performed better and November 2018 where performance was similar.

Percentage of patients waiting more than four hours from the decision to admit until being

admitted - Mid Essex Hospital Services NHS Trust

(Source: NHS England - A&E Waiting times).


Number of patients waiting more than 12 hours from the decision to admit until being

admitted

Over the 12 months from August 2018 to July 2019, nine patients waited more than 12 hours from

the decision to admit until being admitted. The highest number of patients waiting over 12 hours

were in January 2019 (five), followed by June 2019 (two).

(Source: NHS England - A&E Waiting times)

Percentage of patients that left the trust’s urgent and emergency care services before

being seen for treatment

The number of patients leaving the service before being seen for treatments was low.

From July 2018 to June 2019, the trust did not submit data to NHS Digital on the number of

patients that left the urgent and emergency care services before being seen for treatment.


The trust provided information following our inspection on the percentage of patients that left the

department before being seen for treatment from 01 May 2019 to 31 October 19. This figure was

2.3%.

Median total time in A&E per patient (all patients)

From July 2018 to June 2019 the trust’s monthly median total time in A&E for all patients was

higher than the England average in all 12 months, ranging from 178 minutes in August 2018 to

199 minutes in January 2019.

Performance was worst across the winter months from December 2018 to March 2019 but had

shown improvement month on month in the final three months of the period (April to June 2019).

In the most recent month, June 2019, the trust’s monthly median total time in A&E for all patients

was 185 minutes compared to the England average of 163 minutes.

Median total time in A&E per patient - Mid Essex Hospital Services NHS Trust



Managers and staff worked to make sure that they started discharge planning as early as possible.

We saw this in patients’ notes and the board meetings we attended.

Staff planned patients’ discharge carefully, particularly for those with complex mental health and

social care needs. Staff liaised with discharge coordinators, ambulance services, patients’ GPs

and social care providers when relevant to ensure that appropriate patient care was provided for

discharge.

Staff liaised with the local mental health service to support patients with mental health needs to

help plan discharges to appropriate environments, depending on the needs of the patient.

Staff supported patients when they were referred or transferred between services. Staff told us

that they completed a document based on situation, background, assessment, recommendation

(SBAR) for all patients being transferred from the emergency department to other areas of the

hospital. This ensured the patients’ needs were communicated effectively to the accepting ward or

department.

Learning from complaints and concerns

It was easy for people to give feedback and raise concerns about care received. The

service treated concerns and complaints seriously, investigated them and shared lessons

learned with all staff. The service included patients in the investigation of their complaint.

Summary of complaints

Patients, relatives and carers knew how to complain or raise concerns. All patients and relatives

that we asked told us that they knew how to raise a complaint.

The service clearly displayed information about how to raise a concern in patient areas. Leaflets

which included information on how to raise concerns were displayed in ward areas. This included

Patient Advice and Liaison Service (PALS) details on how to make a formal complaint.

Staff understood the policy on complaints and knew how to handle them. Staff told us they would

try to resolve concerns before they progressed to complaints if possible. Staff directed people to

the complaints process and provided them with the details needed to make a complaint if needed.

Managers investigated complaints and identified themes. Managers shared feedback from

complaints with staff and learning was used to improve the service. We reviewed a recent

complaint received by the service. We found that the complainant was involved in the process and

remained updated regarding the process of the investigation. Actions were identified to address

concerns and learning from the complaint was shared with staff.

Broomfield Hospital

From August 2018 to July 2019 the trust received 83 complaints in relation to urgent and

emergency care at Broomfield Hospital (14.0% of the total complaints received by the trust). The

trust took an average of 38.9 days to investigate and close complaints. This was not in line with

their complaints policy, which states complaints should be completed within 25 working days.

The 12 complaints, that had not yet been closed, had been open for an average of 30.4 working

days at the time of data submission.

A breakdown of complaints by type is shown below:


Type of complaint Number of complaints Percentage of total Clinical treatment - accident and emergency 65 78.3% Communications 5 6.0%

Clinical treatment - paediatric group 4 4.8% Values and behaviours (staff) 3 3.6% Clinical treatment - general medicine group 2 2.4% Admissions, discharge and transfer arrangements excluding delays due to absence of care package

2 2.4%

Appointments including delays and cancellations 1 1.2% Clinical treatment - obstetrics and gynaecology 1 1.2%

Total 83 100.0%


Number of compliments made to the trust

Broomfield Hospital

From August 2018 to July 2019 there were 91 compliments about urgent and emergency care at

Broomfield Hospital (8.1% of all compliments received trust-wide). Of these, 92.3% were received

by the general accident and emergency department and 7.7% were received by paediatrics.

A breakdown of compliments by department is shown below:

Department Number of


Accident and emergency 84 92.3% Paediatric accident and emergency 7 7.7% Total 91 100.0%


pathway with patients and relatives thanking staff for their kindness and compassion

during difficult and stressful times. These related to all staff from housekeepers,

porters and nurses to consultants.

Compliments and the associated learning and sharing of good practice is discussed at the patient

and carer experience group and also with individuals and their managers during appraisal. The

trust used its electronic reporting system to analyse themes from compliments.

(Source: Routine Provider Information Request (RPIR) – Compliments tab)

We spoke with staff regarding complaints that were not closed within 25 working days in line with

the trust’s policy. Staff commented that this was usually because the complaints involved other

departments, which meant it took longer to complete the complaints process.

Staff knew how to acknowledge complaints and patients received feedback from managers after

the investigation into their complaint. The trust sent feedback that addressed the entirety of

complaints and provided details to children, young people and their families of what to do if they

were not satisfied with the investigation into their complaint.

Managers shared feedback from complaints with staff and learning was used to improve the

service. Staff told us that managers shared feedback from complaints in local meetings. The

department held serious incident learning initiative (SILI) meetings on a weekly basis. Feedback

and learning from complaints was shared at these meetings as well as nursing safely huddles.


Is the service well-led?

Leadership

Leaders had the skills, knowledge, experience and integrity to run a service providing high-

quality sustainable care.

Leaders had the skills, knowledge, experience and integrity that they needed. The trust had an

executive lead for urgent and emergency care. The service was led by the clinical director, director

of operations, service manager, associate director of nursing and matrons within the department.

Leaders understood issues within the service and wider organisation and were active in their roles.

Leaders understood the challenges to quality and sustainability within the service and identified

the actions needed to address them. For example, one of the challenges within the service was

nurse staffing within the department. Leaders spoke about it as a challenge during our inspection

and it is also featured on the department’s risk register. The risk was mitigated through the use of

regular bank and agency staff, ongoing recruitment and a daily staffing review.

Staff informed us that management were approachable and supportive and also stated that the

senior leadership team were visible. The leadership team provided support to teams following any

incidents.

Senior leaders told us that sustainable, compassionate, inclusive and effective leadership was a

priority within the emergency department. The department had strong working relationships with

the local mental health team, which meant that the service had access to the appropriate mental

health expertise.

Vision and strategy

The service had a vision for what it wanted to achieve, but no service specific strategy to

turn it into action, developed with all relevant stakeholders. The vision for developing the

department was focused on prioritising patient care and aligned to local plans within the

wider health economy. Leaders and staff understood and knew how to apply them and

monitor progress.

The emergency department was within the division of medicine and emergency care. The

paediatric emergency department was within the department for women and children.

There was a divisional and trust strategy in place which included the emergency department,

however there was not a service specific strategy in place. There was a clear set of values which

prioritised patient care. The service had an emergency improvement plan which was going to be

revised in December 2019. The plan included actions to improve performance of the service with a

central focus on patient care.

The majority of staff were aware of the trust’s vision and values and could tell us what they were.

The trust’s vision was “To be a healthcare organisation that puts patient care first and whose

reputation for excellence and innovation inspires our patients, staff and the population we serve”.

The trust values were that “At our best we are a kind, professional, positive, team.” The values

statement was developed following staff listening events.


Culture

Staff felt respected, supported and valued. They were focused on the needs of patients

receiving care. The service had an open culture where patients, their families and staff

could raise concerns without fear.

The culture of the service centred on the needs and experiences of patients who used the service.

Senior staff in the department throughout our inspection told us that they were proud of the care

their staff delivered, and stated they were reliable with a positive attitude.

Staff felt supported, respected and valued. Staff spoke positively about their matrons, they told us

managers were always supportive and valued each member of staff. Staff described the service

as a positive environment to work within.

Medical and nursing staff we spoke with informed us that they had positive working relationships

with one another.

Medical staff described close working relationships within the medical team. They stated that as it

was a smaller department, they all knew each other well and felt supported by their managers.

One GP we spoke with described receiving significant support from the clinical director, despite

the fact that the GP’s were employed by the clinical commissioning group, rather than the trust.

Staff stated that the department leads had developed a cohesive working environment.

Staff we spoke with told us they felt confident that they could raise any concerns they had to their

manager and they felt they would be listened to and concerns would be acted upon.

There was a strong emphasis on staff wellbeing. The department leads told us they recently held

an emergency care wellness day. It was well supported and the leads were planning to run a

wellbeing event every six months.

Governance

Leaders operated effective governance processes, throughout the service and with partner

organisations. Staff at all levels were clear about their roles and accountabilities and had

regular opportunities to meet, discuss and learn from the performance of the service.

There were effective structures, processes and systems of accountability to support the delivery of

the strategy and a good quality sustainable service. There was a clear governance structure with

regular meetings. Emergency care governance meetings took place on a monthly basis

All levels of governance and management functioned effectively and interacted with each other

appropriately. We reviewed the minutes of the emergency care governance meetings for August,

September and October 2019. All of the minutes included whether there were any issues for

escalation to the board. Items discussed within the meetings included incidents, risks,

disseminating actions to all staff and review of the action log.

There was an integrated quality and performance report which was sent to the board. The

department leads provided data to contribute to the board report. The report included data relating

to the performance of the emergency department, including four hour performance, breaches, time

to assessment and time to treatment decision. This meant that the board had oversight of the

performance and challenges within the service.


There was a governance display board within the department which was reviewed by all staff. The

board included the department’s risk register, incident reporting themes and review of the

department’s performance against the four hour standard.

Staff at all levels were clear about their roles and accountabilities and had regular opportunities to

meet, discuss and learn from the performance of the service. All staff we spoke with were clear

about their roles and understood what they were accountable for.

There was not a standard operating procedure in place for the ‘fit to sit’ area of the emergency

department. We highlighted this during our inspection A risk assessment was completed on 7

November 2019 for the ‘fit to sit’ service provision within the identified environment. The

assessment included the environment, capacity for the location and the category and cohort of

parents suitable for the area. There was a documented process for the use of the area and an

exclusion criteria in place.


The trust had effective systems for identifying risks, planning to eliminate or reduce them,

and demonstrated the ability to cope with both the expected and unexpected.

Risks were captured on the service’s comprehensive risk register which used the red, amber,

green (RAG) system to denote the level of risk and progress in resolving the risks. There were

robust arrangements for identifying, recording and managing risks, and mitigating actions. There

was alignment between the recorded risks on the register and what staff told us was ‘on their

worry list’. The frequency that risks were reviewed depended upon the severity of the risk. The

higher risk items on the risk register were reviewed monthly, or more frequently if required. All

risks had a review date on the risk register which were all within date.

Potential risks were taken into account when planning services, for example, the ‘fit to sit’ area

was introduced for patients who were deemed as low dependency. A risk assessment was

completed prior to the introduction of this extension to the department. There were lead owners of

the risks, actions and contingency plans put in place where relevant.

There were processes to manage current and future performance. The department held a live

performance dashboard which was reviewed by department leads on a daily basis. The dashboard

included time to triage, time to treatment, ambulance waiting times and number of attendances.

This meant that leads could review the performance of the service and identify areas of learning.

Data from this dashboard was included in the report to the board.

The service had a clinical and internal audit programme to monitor quality and operational

processes, as well as systems to identify where action should be taken. There was an audit lead

for the service who coordinated the audit programme. All audits, including national and local audits

had action plans in place to improve audit results. There were plans to re-audit as appropriate to

monitor improvement. National audit results were shared with staff at the weekly serious incident

learning initiatives (SILI) meetings held within the department.

The department had a full capacity policy. There had been no reported instances of it being

repeatedly used and there were no incidents of the emergency department being closed during

the period from November 2018 to October 2019.



Appropriate and accurate information was being effectively processed, challenged and

acted upon. However, information technology systems were not always effective.

The service collected reliable data and analysed it. The service used performance dashboards to

provide assurance they had a good understanding of service performance. The live dashboard

was reviewed on a daily basis and shared in handovers with all staff. The data was measured

against key quality standards. The service manager compiled a weekly service improvement

report. This collected the data into triage streams, for example, mental health patients. The report

included rota fill and how capacity throughout the trust impacted the department. The data

collected provided service leads with good oversight of the department’s performance.

Staff had sufficient access to information about the service and challenged it appropriately. We

reviewed the minutes of the emergency department senior team meeting from 2 October, 23

October and 1 November 2019. There was evidence of scrutiny and challenge. For example, it

was documented that a consultant raised a concern about pathways for a particular patient group.

An action was agreed for a policy to be written and distributed. The action was assigned to a

specific individual and a due date was documented.

Information technology systems were not always used effectively to monitor and improve the

quality of care. During our inspection there were some issues with the electronic devices used to

calculate national early warning scores (NEWS2). The devices had been configured in a way that

required overriding manually by staff. If there were fluctuations in the internet connection, this at

times impacted the data being sent from the devices. The devices were also not working when we

returned for the unannounced inspection. Staff had raised incidents regarding the devices. The

trust had formulated an action plan which included that the configuration of the electronic

recording system was to be reviewed by a fortnightly task and finish group that had been

established. This group reported to the patient safety group.

Engagement

Leaders and staff actively and openly engaged with patients and staff to plan and manage

services. They collaborated with partner organisations to help improve services for

patients.

People’s views and experiences were gathered and used to shape and improve the service and

culture. The service participated in the friends and family test to gain feedback from patients. We

saw comments boxes were used throughout the emergency village to gain additional feedback

from patients. Feedback methods were also available via the trust website.

During our inspection, we attended one of the serious incident learning initiatives (SILI) meetings

where a previous patient provided feedback about their experience of attending the department.

They described the care they had been given and wanted to personally thank the staff involved in

their care for the treatment and support they provided.

The trust engaged with staff through a variety of methods including daily huddles, use of social

media, newsletters and emails. The service held safeguarding and wellbeing events. The

wellbeing event encouraged staff to reflect and share feedback on their experiences of working in

the department. The department leads recognised the importance of listening to staff suggestions

for improvement.

There were positive and collaborative relationships with external partners to meet the needs of the

population. Service leads engaged with the local clinical commissioning group (CCG). For


example, the trust liaised with the local CCG in the development of their winter plan to ensure the

needs of the local population could be met during a time of increased demand and pressure.


Staff were committed to continually learning and improving services. Leaders encouraged

innovation and participation in research.

Leaders and staff strived to achieve continuous learning, improvement and innovation. One

medical member of staff was in the process of developing a policy for the use of metal detector

wands for patients with mental health problems who claimed to have swallowed metal items. This

method was planned to reduce the inappropriate use of radiation for scans. Guidance was being

sought from another acute NHS trust in the development of the policy.

The introduction of the ‘fit to sit’ area in the department was a demonstration of the service’s

commitment to improving services for patients. It was still in the trial process at the time of our

inspection and was subject to a review in December 2019.

The trust continued to use serious incident learning initiative (SILI) meetings, which staff were

encouraged to attend to discuss incidents and share learning from incidents. The meeting was

embedded throughout the department as a tool for information sharing, shared learning and

improvement.


Medical care (including older people’s care)


Medical care at the trust consists of elective and non-elective services. All inpatient care is based

at Broomfield Hospital and there are 278 medical beds.

Acute medicine is based in the emergency village and consists of the acute medical unit, 20 short

stay beds (length of stay 24 hours) and 12 assessment trolleys. General practitioner (GP) referred

patients are also seen in this area. In addition, this area contains the emergency short stay ward

consisting of 10 beds with a length of stay of less than 72 hours. There is also a 7-day ambulatory

care unit.

Geriatric medicine is comprised of four wards, each with 26 beds, and a 16 bed frailty unit with

four assessment trolleys. The frailty unit provides a multi-disciplinary team seven days a week.

There are inpatient wards for gastroenterology, cardiology, respiratory and renal. Details of these

services are below:

• There is 24 hour a day seven days a week consultant cover for gastrointestinal bleed rota

and the five gastroenterology consultants provide two endoscopy sessions each week to

the endoscopy service.

• There is a dedicated 24/7 consultant led stroke service which includes a thrombolysis

service.

• There is a renal unit providing a haemodialysis service, 7am to midnight, six days a week,

and outpatient clinics.

• There is a large cardiology centre at Broomfield Hospital offering outpatient cardiac

imaging, angiography and cardio devices. Respiratory services provide inpatient non-

invasive ventilation (NIV) and outpatient lung function and sleep studies.

• Dermatology services offer consultant led and nurse led outpatient clinics and minor

operations.

• Neurology provide outpatient clinics and neurophysiology diagnostic testing.

• There is a diabetic centre providing both consultant-led and nurse-led outpatient clinics.

There is also an onsite HIV service.


The trust had 37,323 medical admissions from March 2018 to February 2019. Emergency

admissions accounted for 18,120 (48.5%), 275 (0.7%) were elective, and the remaining 18,928

(50.7%) were day case.

Admissions for the top three medical specialties were:

• General medicine: 17,547 admissions

• Medical oncology: 5,995 admissions


• Clinical haematology: 3,659 admissions


Due to the number of core services inspected, our inspection of Broomfield hospital was

announced. Prior to our inspection we reviewed data we held about the trust along with

information we requested from the trust. The medicine service was rated inadequate overall

following its last inspection in September 2018. Safe was rated as inadequate, effective, caring

and responsive were rated requires improvement and well led rated inadequate. We carried out a

focused inspection on 21 May 2019 to follow up on the concerns raised at our previous inspection

and found that the trust had made improvements to address these.

During our inspection, we spoke with 66 members of staff including doctors, nurses, therapists,

health care assistants and non-clinical staff. We visited all of the medicine wards, the endoscopy

department, acute medical assessment, frailty assessment bay, renal unit, discharge lounge,

angiography suite, day therapies and faith centre.

We reviewed 25 sets of patient records and considered other pieces of information and evidence

to come to our judgement and ratings. We spoke with nine patients and other family members to

gather their experience of the trust.

We carried out a further unannounced inspection on the 20 November 2019 in order to review

changes in the trust’s acute medical assessment centre, its frailty assessment bay and observe

staff handovers.





Mandatory training

The service provided mandatory training in key skills to all staff and made sure everyone

completed it.


The trust set a target of 85% for the completion of all mandatory training, with the exception of

information governance which had a target of 95%.

Broomfield Hospital

Nursing and medical staff received and kept up-to-date with their mandatory training.

A breakdown of compliance for mandatory training courses as of August 2019 for qualified nursing

staff in medicine at Broomfield Hospital is shown below:

Training module name As of August, 2019

Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)

Paediatric basic life support 3 3 100.0% 85% Yes Hand hygiene 257 261 98.5% 85% Yes


Waste management 256 261 98.1% 85% Yes Medicine management training 233 246 94.7% 85% Yes Information governance 246 261 94.3% 95% No

Equality and diversity 243 261 93.1% 85% Yes Fire safety 242 261 92.7% 85% Yes Health and safety 240 261 92.0% 85% Yes Moving and handling 235 261 90.0% 85% Yes Moving and handling for people handlers

222 250 88.8% 85% Yes

Adult basic life support 39 47 83.0% 85% No

Adult immediate life support 168 207 81.2% 85% No

In medicine, the trust target was met for nine of the 12 mandatory training modules for which

qualified nursing staff were eligible.


medicine at Broomfield Hospital is shown below:


Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)


Hand hygiene 132 140 94.3% 85% Yes Health and safety 132 140 94.3% 85% Yes Moving and handling 131 140 93.6% 85% Yes Information governance 130 140 92.9% 95% No Medicine management training 20 22 90.9% 85% Yes Fire safety 122 140 87.1% 85% Yes Adult basic life support 40 51 78.4% 85% No

Equality and diversity 105 140 75.0% 85% No Adult immediate life support 39 68 57.4% 85% No Paediatric basic life support 4 8 50.0% 85% No

In medicine, the trust target was met for six of the 11 mandatory training modules for which

medical staff were eligible.


The mandatory training was comprehensive and met the needs of patients and staff. Staff we

spoke with told us they had access to a wide range of mandatory training relevant to their roles.

Staff accessed additional training for example, dementia training, falls awareness and pressure

care. Nursing staff achieved 100% compliance with dementia training and medical staff achieved

99% compliance.

Nursing staff achieved 88% compliance with falls training, medical staff were not required to

complete this training.


training. Staff accessed the trust’s intranet to view and request training They completed training on

line and during face-to-face sessions. Staff told us that managers encouraged them to complete

training and they received electronic reminders when training was due for renewal.

The trust had an up to date sepsis and neutropenic sepsis policy. Staff we spoke with were aware

of the policy and had received training to identify and escalate patients who had suspected sepsis.


Data supplied by the trust following our inspection showed nursing and medical staff achieved

94% compliance with sepsis training.

Safeguarding


agencies to do so. Staff had training on how to recognise and report abuse, and they knew

how to apply it.


The trust set a target of 95% for the completion of safeguarding training modules, with the

exception of safeguarding children (level 3) which had a target of 60%.

The tables below include prevent training as a safeguarding course. Prevent works to stop

individuals from getting involved in or supporting terrorism or extremist activity. The trust set a


Broomfield Hospital

Nursing and medical staff received training specific for their role on how to recognise and report

abuse, but the trust target was not always reached.

A breakdown of compliance for safeguarding training courses as of August 2019 for qualified

nursing staff in medicine at Broomfield Hospital is shown below:


Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)

Safeguarding adults (level 1) 253 261 96.9% 95% Yes Prevent - basic awareness 249 261 95.4% 85% Yes Safeguarding children (level 1) 248 261 95.0% 95% Yes Safeguarding adults (level 2) 244 261 93.5% 95% No Safeguarding children (level 2) 241 261 92.3% 95% No Prevent - awareness 64 76 84.2% 85% No

In medicine, the trust target was met for three of the six safeguarding training modules for which



in medicine at Broomfield Hospital is shown below:


Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)


Safeguarding adults (level 1) 109 140 77.9% 95% No Prevent - awareness 14 18 77.8% 85% No Safeguarding children (level 1) 102 140 72.9% 95% No Safeguarding adults (level 2) 89 124 71.8% 95% No Safeguarding children (level 2) 81 124 65.3% 95% No Safeguarding children (level 3) 0 4 0.0% 60% No


In medicine, the trust target was met for one of the seven safeguarding training modules for which



Data supplied by the trust following our inspection showed medical staff achieved 93% compliance

with safeguarding adults’ level 1 and 92% compliance with safeguarding adults’ level 2.

Medical staff achieved 93% compliance with safeguarding children level 1, 91% compliance with

safeguarding children level 2 and 50% compliance with safeguarding children level 3.


those with protected characteristics under the Equality Act. Staff completed patient care plans

which had a dedicated section to record safeguarding issues and share key information to

safeguard patients. For example, a patient who may need additional monitoring due to ongoing

safeguarding concerns or vulnerability due to learning disability


with other agencies to protect them. Staff gave examples of safeguarding events, including

referring an allegation of patient neglect due to them coming into hospital from a local care

provider. Referring concerns over a patient alleging domestic violence and possible financial

abuse. Staff could explain the types of abuse, how to recognise and reports these, including

female genital mutilation (FGM), physical abuse and neglect amongst others.


spoke with knew the trust safeguarding lead and how to contact them and make a referral. Clear

guidance on safeguarding contacts and policies were readily available on the trust’s intranet.

Information on safeguarding was clearly displayed on notice boards within the ward areas and

corridors.

Staff followed safe procedures for children visiting the ward. Ward areas we visited were locked at

all times. Access was gained by using a buzzer. Staff gave clear guidance to visitors on who was

allowed into the ward and allowed by the patient bedside, this included ensuring children were

supervised by parents at all times on the ward.

We observed that safeguarding formed a key part of staff handover meetings throughout the day.

Staff promoted patient wellbeing during these meetings and sought the least restrictive care plans,

whilst actively seeking to encourage patients to participate in day to day activities. Where there

were concerns regarding safeguarding, staff sought to gather guidance from other professionals.

For example, safeguarding leads, social workers or general practitioners, to ensure that plans

were in place for safe discharges, and develop care plans that reflected individual needs.

The trust was reviewing its safeguarding training in line with the intercollegiate guidance Adult

Safeguarding: Roles and Competencies for Health Care Staff. The aim of the review was to

develop an action plan to ensure all staff completed the appropriate level of safeguarding training

by 2021.

The trust had an absconding patient policy, to support the care of patients who posed a risk of

absconding from a ward. We observed during our inspection a patient having their photograph

taken, to ensure staff had a visual aid if they should leave the ward. The wards were secure with

buzzer and swipe card access, this was an additional aid in the event that a patient ‘tailgated’ a

relative who may hold the door open despite requests not to do so.




protect patients, themselves and others from infection. They kept equipment and the

premises visibly clean.

Ward areas were clean and had suitable furnishings which were clean and well-maintained. All of

the wards we visited were visibly clean and free from clutter.

The service performed well for cleanliness. Hand hygiene audits for October 2019 showed all

medicine wards achieved 100% compliance. Nursing staff working within the renal unit achieved

98% compliance with infection prevention and control (IPC) training and 92% of medical staff

achieved compliance. Nursing staff within the wards achieved 100% compliance with IPC training

and medical staff achieved 95% compliance.

The medicine team had developed the role of assistant infection prevention and control

practitioner to support the wards to deliver a comprehensive infection prevention and control

service. The post-holder provided a visible presence on the wards and was accessible to clinical

teams and patients. This role had been pivotal in increasing staff awareness of IPC across the

wards through offering additional training, providing face to face guidance and supporting hygiene

audits. There was a wide range of IPC information for staff on all the wards we visited. These

included posters offering advice on hand washing, how to reduce infection risk and the trust’s IPC

policy.

Cleaning records were up-to-date and demonstrated that all areas were cleaned regularly. We

spoke with housekeeping staff and reviewed cleaning rotas. The ward managers completed a

performance improvement book (PIB) and these contained routine audits of cleaning records and

hygiene standards. We found no gaps in cleaning records between August 2019 to November

2019.


Wards we visited had a plentiful supply of PPE and we observed staff using equipment at

appropriate times. Staff were bare below the elbow and washed their hands routinely between

activities. The ward had hand sanitiser at each entrance and at key points within the ward areas.

There was clear guidance displayed to both staff and the public to cleanse their hands when

entering and leaving ward areas.

Staff cleaned equipment after patient contact and labelled equipment to show when it was last

cleaned. ‘I am clean’ stickers showed where staff had cleaned equipment and we observed staff

cleaning equipment between use. Housekeeping staff were present on the wards emptying bins,

cleaning work surfaces and equipment throughout our inspection.

For the financial year 2018/2019 there were changes to the trust’s Clostridium difficile Infection

(CDI) reporting algorithm adding a prior healthcare exposure element for community onset cases.

The trust objectives for 2019/20 were set using these two categories. Firstly, hospital acquired

healthcare associated infections: cases that are detected in the hospital two or more days after

admission. Secondly, community acquired healthcare associated infections: cases that occurred in

the community (or within two days of admission). The timeframe for reporting CDI reduced from 72

hours of admission in 2018/19 to 48 hours of admission in 2019/20.

The trust reported 26 hospital acquired CDI cases in medicine between November 2018 and

October 2019. This equated to a 0.23% infection rate against 11,269 patient admissions during the

same period.


The trust set a zero tolerance to Methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia.

The trust reported two hospital acquired cases of MRSA in medicine between November 2018 and

October 2019. This equated to a 0.02% infection rate against 11,269 patient admissions during the

same period.


The design, maintenance and use of facilities, premises and equipment kept people safe.

Staff were trained to use them. Staff managed clinical waste well.

Patients could reach call bells and staff responded quickly when called. We observed staff

ensuring that patients had call bells within reach as well as other equipment, for example walking

aids.

Staff carried out daily safety checks of specialist equipment. Resuscitation equipment on all the

wards we visited was routinely checked by staff, with no gaps, between August to November

2019. Staff had a strong focus on checking equipment and managers completed audits to ensure

checks had been completed.

The service had enough suitable equipment to help them to safely care for patients. Ward areas

had a wide range of equipment appropriate for patients including pressure care mattresses,

manual handling hoists, monitors and other equipment. The trust had an engineering team that

routinely reviewed stock and all the equipment we checked had been serviced and labelled for

next service due date.

Store rooms were visibly clean and tidy. Staff carried out stock checks routinely to ensure that

equipment was in date. We checked store rooms and found no out of date consumables on any of

the wards we visited.

Staff disposed of clinical waste safely. Sharps bins were clearly labelled and signed by staff. We

observed staff separated hazardous waste appropriately and all wards had confidential waste bins

that were locked at all times.

At the last endoscopy Joint Advisory Group on Gastrointestinal Endoscopy (JAG) accreditation in

2018, the visiting JAG authorising engineer recognised the vulnerable state of the endoscopy

equipment and recommended a replacement programme.

The three washers were 10 years old and at the limits of their life. One of the machines was out of

action one day in 25, usually because it did not meet the water quality standards. The reverse

osmosis units were built into each machine. Staff we spoke with told us the hospital engineers

usually did the repairs quite quickly, but the units were no longer fully supported by the

manufacturers, and parts were becoming harder or impossible to get. An incident report was

completed every time there was a technical failure. The trust had a business case for replacement

equipment in place.

If a washer unit failed, the endoscopes were processed by another provider, this took time, so staff

had to work late to clear up. The plan for maintaining continuity if more than one unit failed was to

use vacuum packed scopes which were usable for one month from date of sealing, and

additionally having endoscopes processed at another location. Staff told us this had only ever

happened once, some time ago.

The department also provided a cleaning service for endoscopes used for evacuation of retained

products of conception (ERCP) and in urology.


A good number of scopes were at the end of their useful clinical life. At the time of our inspection

the endoscopy team were trying to get approval for five new colonoscopes and four gastroscopes.

The trust did not have suitable facilities to meet the needs of patient families. The ward areas

lacked space for families and staff, this was noticeable on a number of occasions when families

needed to talk to staff and limited rooms were available. At the time of our inspection staff showed

us a ward that was being refurbished. This ward had additional space for patients, staff and

families and was due to open in the new year. Other wards were due to be refurbished to this

standard to provide staff with the additional space they needed to offer ongoing support to patients

and families.

Baddow and Braxted wards both had external garden spaces to enable patients to access a safe

outdoor space. The gardens had sensory areas, defined kerbs and ornaments to encourage

patients to spend time outside and enjoy the freedom of space from within the ward areas.


Staff completed and updated risk assessments for each patient and removed or minimised

risks. Staff identified and quickly acted upon patients at risk of deterioration


appropriately. The trust had made improvements from our last inspection. Staff used the National

Early Warning Score 2 (NEWS2) which improves the detection and response to clinical

deterioration in adult patients and is a key element of patient safety and improving patient

outcomes. Staff used a hand held IT tablet to record patient vital signs, and the system

automatically highlighted any patients that had an increased NEWS score and required staff

intervention.

Staff completed risk assessments for each patient on admission / arrival, using a recognised tool,

and reviewed this regularly, including after any incident. We reviewed 25 patient records and

found NEWS scores had been recorded appropriately, staff carried out patient vital signs and

venous thromboembolism (VTE) assessments on time this was an improvement from our last

inspection.

Staff knew about and dealt with any specific risk issues. Staff used the sepsis six care bundle to

identify patients whose NEWS score indicated they may have sepsis. Staff we spoke to knew how

to escalate deteriorating patients and the trust had an up to date policy to guide staff on actions to

take when patients deteriorated. The trust had a “TRIGGER” team which included key nursing

staff that responded to any patient with a NEWS score above 5. Any patient whose vital signs

indicated deterioration when recorded on the hand held IT tablets would automatically inform the

“TRIGGER” team remotely. The team would then head to the ward area and provide immediate

intervention with the sepsis bundle. The TRIGGER team were skilled in immediate and advanced

life support techniques and trained other staff in life saving skills across the trust.

Staff shared key information to keep patients safe when handing over their care to others. All staff

participated in ward handovers where key information was shared at regular intervals throughout

the day. This information included discharge planning, the patient’s current wellbeing, any

safeguarding issues, ongoing clinical needs and additional key information appropriate to the

patients care. We observed handovers between the day teams and night teams and found shift

changes and handovers included all necessary key information to keep patients safe.


The trust had a dedicated falls prevention nurse and staff followed up to date guidance to

complete falls assessments and pressure care. All the patient records we reviewed showed that

patients had been assessed by a named consultant within twelve hours of ward admission and

medical staff responded quickly if additional reviews were required, for example within the hour.

The trust had an upper gastrointestinal bleed (UGI) rota in place and clear processes to support

any patients likely to deteriorate following any endoscopy procedure. The out of hours urgent

endoscopy rota included one gastrointestinal consultant and two trained nurses. Urgent

procedures were always done in theatres. Endoscopy lists were rarely cancelled, only if, for

example, a consultant was unwell. If this happened, their subsequent lists were modified to

accommodate these patients. Additionally, another consultant or a nurse endoscopist would take

the patients onto their lists.

Staff from the medicine department attended mortality reviews, these fed into governance

meetings and information from mortality reviews was shared at team meetings. This was an

improvement from our last inspection.

Inspired by the NHS England’s “Sign UP to Safety Kitchen Table Events”, the provider’s falls

service took the kitchen table to the wards. Using the idea of a table cloth and having tea, coffee,

biscuits and sweets, staff were invited to take a five minute break and have a chat about the

services frailty harm awareness document. This was a quick glance guide to assist staff unfamiliar

with clinical frailty to consider tissue viability, medication, bone health, end of life care, falls

interventions, nutrition, delirium, dementia and avoiding deconditioning. The document was

permanently hosted on the trust falls intranet page. The mobile kitchen table also promoted

dangers of deconditioning awareness.

The services falls clinical nurse specialist (CNS) and assistant director of nursing identified that

patients within the stroke unit had a known risk of falling but sat outside of the National Institute for

Health and Care Excellence (NICE) Falls in older people: assessing risk and prevention (CG 161).

This guideline covered assessment of falls risk and interventions to prevent falls in people aged 65

and over. It aimed to reduce the risk and incidence of falls and the associated distress, pain,

injury, loss of confidence, loss of independence and mortality. In order to address this issue, and

promote safety among this patient group, the service held a weekly meeting with the matron,

senior ward sister, and thrombolysis lead to review all patients with this area with a focus on

factors contributing to falls. For example, known falls risk, current mobility, witnessed impulsivity

and opportunities to fall. The process was Plan, Do, Study Act (PDSA) assessed and lead to

stroke-specific identification of falls risks and individualised interventions, pertinent to this specific

client group, being implemented.

Data supplied by the trust following our inspection showed nursing staff achieved 82% compliance

with adult basic life support training and 85% with immediate life support.

Medical staff achieved 67% compliance with adult basic life support, 69% compliance with

immediate life support and 50% compliance with paediatric basic life support.

Nurse staffing

The service had enough nursing and support staff with the right qualifications, skills,


care and treatment. Managers regularly reviewed and adjusted staffing levels and skill mix,

and gave bank and agency staff a full induction.


The service had enough nursing and support staff to keep patients safe. During our inspection all

ward areas we visited displayed the current and expected staffing levels for each shift. All ward

areas were staffed in line with expectations.


and healthcare assistants needed for each shift in accordance with national guidance. The trust

used a safer staffing bundle to monitor staffing levels and ensure that staff were delegated

appropriately across the service. Daily safer staffing team meetings enabled the staff team to

identify any areas where staffing shortfalls occurred and managers to delegate staff accordingly.

The ward manager could adjust staffing levels daily according to the needs of patients. Staff could

request additional staffing for any patients who required additional staff resources; for example,

one to one support. We observed staff making requests for additional staffing in handover

meetings. Site managers and senior nurses responded positively to the requests for additional

staff and acted to provide additional staff where possible.

Broomfield Hospital

The table below shows a summary of the nursing staffing metrics in medicine at Broomfield

Hospital compared to the trust’s targets, where applicable:

Medicine annual staffing metrics



Staff group


Annual vacancy

rate

Annual turnover

rate

Annual sickness

rate

Annual bank

hours (% of

available hours)

Annual agency

hours (% of

available hours)

Annual unfilled

hours (% of

available hours)

Target 13% 12% 3.8%


319 44% 7% 4.4% 38,093 (8%)

111,789 (22%)

89,243 (18%)



Nurse staffing rates within medicine at Broomfield Hospital were analysed for the past 12 months


sickness.

There was an annual vacancy rate of 44% for qualified nurses compared to a trust target of 13%,

which has shown deterioration in the last six months (February to July 2019).

Vacancy rates

The service had reducing vacancy rates. The trust had a comprehensive recruitment programme

in place to address shortfalls in the nurse staffing levels. Managers assessed safe staffing levels

throughout the day and used bank and agency staff to fill any shifts. Data in relation to unfilled

shifts was used to identify any areas of regular concern and managers targeted these areas to

provide appropriate resources. The trust had been extremely successful in attracting nurses from

overseas and had an additional 40 new staff per month planned for the next three months to


address shortfalls. New nurses were supernumerary on wards until completing the required

competencies and conversion processes.

Managers we spoke with knew that staffing levels was a risk on the trust’s risk register and

actively worked with the senior team to recruit new staff and to allocate resources appropriately

across the wards. Staff we spoke with told us that staffing levels had improved since our last

inspection, they were clear on the recruitment strategy and looked forward to the new staff coming

into the service.

The trust’s electronic patient tracking system was used to support patient flow throughout the trust.

Managers could predict patient levels in various ward areas and delegate staff according to

predicted need.

Monthly vacancy rates over the last 12 months for registered nurses show a shift from February

2019 to July 2019.

(Source: Routine Provider Information Request (RPIR) – Vacancy tab)

Turnover rates

The service had reducing turnover rates. Managers had a comprehensive recruitment process and

were actively seeking to attract staff who were looking for long term careers with the trust. We met

a number of staff who had trained within the trust and managers actively promoted opportunities to

apply for additional training or roles in order to reduce turnover rates.


Monthly turnover rates over the last 12 months for registered nurses show a shift from January

2019 to June 2019.

(Source: Routine Provider Information Request (RPIR) – Turnover tab)

Bank and agency staff usage

The service had reducing rates of bank and agency nurses used on the wards. This was due to

the comprehensive recruitment programme.

Monthly bank hours over the last 12 months for registered nurses show an upward trend from

August 2018 to February 2019 followed by a downward trend from February 2019 to July 2019.

Monthly agency hours over the last 12 months for registered nurses, health visitors and midwives

show a shift from February 2019 to July 2019.


Managers limited their use of bank and agency staff and requested staff familiar with the service.

The trust was piloting a bank staffing ‘app’ designed by the trust. This innovation differed from

other staffing apps as it was skills-based and used the data to identify where skill gaps were, and


the likelihood of shifts being filled. The pilot had reduced the trust spending on agency staff and

increased the shift fill rate to near 100%.

Managers made sure all bank and agency staff had a full induction and understood the service.

We reviewed twenty staff competency check lists and founds these to be up to date at the time of

our inspection. Managers we spoke with, explained the process for checking bank and agency

staff competencies prior to them starting their shifts. Managers completed audits against the

competency checklist and recorded these within the ward PIB. Managers only allowed bank and

agency staff to work with patients when they had completed the appropriate competencies.

Checking the competency checklist enabled managers to deploy the staff safely within the ward

and match their skills to the patient needs.

Medical staffing

The service had enough medical staff with the right qualifications, skills, training and

experience to keep patients safe from avoidable harm and to provide the right care and

treatment. Managers regularly reviewed and adjusted staffing levels and skill mix and gave

locum staff a full induction.

The service had enough medical staff to keep patients safe. At the time of our inspection medical

staffing met the planned requirements on each ward. Rotas were planned to ensure adequate

numbers of medical staff. Medical staff we spoke with told us that there were sufficient staffing

levels and a willingness for staff to cover each other at times of absence or due to holidays and

training.

Broomfield Hospital

The table below shows a summary of the medical staffing metrics in medicine at Broomfield


Medicine annual staffing metrics

August 2018 to July

2019 July 2018 to June 2019 August 2018 to July 2019

Staff group

Annual average

establishment

Annual vacancy

rate

Annual turnover

rate

Annual sickness

rate

Annual bank

hours (% of

available hours)

Annual locum

hours (% of

available hours)

Annual unfilled

hours (% of

available hours)

Target 13% 12% 3.8%

All staff 948 26% 10% 4.4% Medical staff

151 18% 6% 1.8% 27,037 (7%)

41,141 (11%)

2,150 (1%)


Medical locum tabs)

Medical staffing rates within medicine at Broomfield Hospital were analysed for the past 12 months


vacancy, turnover, bank and locum use.


The trust had a consultant clinical champion for medicine medical staffing. A senior consultant met

a minimum of three times a week with the co-ordinator for medicine to review the medical rotas of

all grades of doctors. This was to provide advice and guidance regarding allocation of staff and

cover for rota gaps. The consultant also advised the rota co-ordinator on the allocation of junior

doctors across the medical wards and assessed safe minimum medical staffing levels when there

were staff shortages.

Managers could access locums when they needed additional medical staff. Rotas showed locum

staff were used when needed, especially during the winter escalation months.

Managers made sure locums had a full induction to the service before they started work. Locum

staff we spoke with said the trust was supportive of their role and ensure they completed

orientation and competencies, prior to working unsupervised on the wards.

Sickness rates

Sickness rates for medical staff were reducing. Medical staff we spoke with said that the trust was

responsive to staff wellbeing and provided support at times of sickness. The medical staff team

used a social media app to share shifts and cover sickness if necessary.

Monthly sickness rates over the last 12 months for medical staff show a downward trend from July

2018 to January 2019.


Staffing skill mix

The service had a good skill mix of medical staff on each shift and reviewed this regularly.

Managers reviewed medical staffing levels frequently and ensure appropriately qualified medical

staff were available.

In May 2019, the proportion of registrars and consultant staff reported to be working at the trust

was higher than the England average. The proportion of middle career and junior (foundation year

1-2) staff was lower than the England average.


Staffing skill mix for the 126 whole time equivalent staff working in medicine at Mid Essex

Hospital Services NHS Trust

This Trust

England average

Consultant 49% 45%

Middle career^ 2% 7%

Registrar group~ 33% 28%

Junior* 16% 20%


(Source: NHS Digital - Workforce Statistics - Medical (01/05/2019 - 31/05/2019)

The trust always had a consultant on call during evenings and weekends. Consultants conducted

daily ward rounds Monday to Friday. At weekends staff could ask for consultants to review

patients. Medical and nursing staff were confident that they knew who would be on duty or on call

at any time. There was effective communication between the staff teams to ensure effective cover

was in place at all times.

Records

Staff kept detailed records of patients care and treatment. Records were clear, up-to-date,

stored securely and easily available to all staff providing care.

Patient notes were comprehensive, and all staff could access them easily, this was an

improvement from our last inspection. Throughout our inspection we found staff took great care in

securing patient records and maintaining these to a high standard. All entries were

contemporaneous, contained a detailed care plan, the date and signatures of the staff responsible

for the patients care and treatment plan.

Records contained the patient assessment of need, care and treatment plans with clear

references to any additional needs for example a learning disability, dementia or existing co-

morbidities; for example, Parkinson’s disease. All records showed a clear patient diagnosis by

medical staff. Multidisciplinary (MDT) staff completed patient records and we found these

complemented the care plans for patients, encouraging staff to follow best practice when

supporting patient care.

When patients transferred to a new team, there were no delays in staff accessing their records.

The trust had ward administrators who supported staff to access records quickly and ensure

records were maintained to an appropriate standard.


Records were stored securely. Patient nursing records were stored at the end of the patient’s bed

in a closed folder and medical records were stored in a locked cabinet with key pad entry.

Medicines


medicines.


storing medicines. Patient records we reviewed showed allergies clearly documented and all

records were signed and dated by a clinician or nurse in charge of the patient’s care.

Staff reviewed patients’ medicines regularly and provided specific advice to patients and carers

about their medicines. Patient medication was reviewed daily during the ward rounds. Pharmacy

staff visited the wards to review patients, complete medication reconciliation and to arrange tablets

to take home.

Patients were provided with advice and information about their medications. We spoke with one

patient who explained how staff had guided them through their medications routine and explained

the way the medicines worked and any side effects.

Staff stored and managed medicines and prescribing documents in line with the provider’s policy.

We reviewed the controlled drugs records on the wards we visited. These demonstrated that staff

comprehensively reviewed and signed for controlled drugs in line with the trust’s medications

policy. On the ward’s medications were stored in a locked cupboard within a locked room. Access

to this room was limited to named roles and the key pad password was regularly changed. Staff

recorded ambient medication room temperatures and refrigeration temperatures accurately on all

the wards we visited. Records showed that between August 2019 to November 2019 checks were

completed daily. This was an improvement from our last inspection.

Staff followed current national practice to check patients had the correct medicines. Staff ensured

that the right patient had the right medications. All patients had barcodes on their wrist bands that

staff scanned prior to medication administration to ensure that the right patient was getting the

right medicine, right dose, at the right time and by the right route. Staff wore orange tabards whilst

undertaking medication rounds, which clearly stated, ‘do not disturb during medicine rounds’ to

minimise medication errors due to staff distraction.


received their medicines safely. Any medication safety alerts were shared at clinical governance

meetings, with the information shared through the hospital’s hot topic of the day, or during staff

handovers.

Decision making processes were in place to ensure people’s behaviour was not controlled by

excessive and inappropriate use of medicines. Staff ensured that patient behaviour was not being

controlled by inappropriate use of medicines, this was in line with the trust’s medication policy.

Staff discussed patient medicines and medication reviews during handovers and could seek

additional guidance from the trust’s pharmacy team. Staff recorded all medicines administered,

including those given PRN, which means “As needed”, to ensure patients were not taking

excessive amounts.


Incidents


and near misses. Managers investigated incidents and shared lessons learned with the

whole team and the wider service. When things went wrong, staff apologised and gave

patients honest information and suitable support. Managers ensured that actions from

patient safety alerts were implemented and monitored.

All staff knew what incidents to report and how to report them. Staff we spoke with gave us a

variety of examples of the types of incidents to report and were familiar with the trust’s electronic

incident reporting system.

Staff raised concerns and reported incidents and near misses in line with the services policy. We

reviewed three incident reports as part of the inspection process and found staff escalated

incidents in line with policy and that thorough root cause analysis took place.

Never Events

The service reported no never events on any wards.

Broomfield Hospital




From August 2018 to August 2019, the trust reported no incidents that were classified as a never

event in medicine.



Broomfield Hospital

Staff reported serious incidents clearly and in line with service policy. In accordance with the

Serious Incident Framework 2015, the trust reported 40 serious incidents (SIs) in medicine at

Broomfield Hospital which met the reporting criteria set by NHS England from August 2018 to

August 2019. This represented 31.5% of all serious incidents reported by the trust as a whole.


Incident type Number of incidents Percentage of total Slips/trips/falls meeting SI criteria 14 35.0% Pressure ulcer meeting SI criteria 10 25.0%

Sub-optimal care of the deteriorating patient meeting SI criteria

4 10.0%

VTE meeting SI criteria 4 10.0% Diagnostic incident including delay meeting SI criteria (including failure to act on test results)

3 7.5%

Medication incident meeting SI criteria 2 5.0% Environmental incident meeting SI criteria 1 2.5% Treatment delay meeting SI criteria 1 2.5% Surgical/invasive procedure incident meeting SI criteria

1 2.5%


Total 40 100.0% (Source: Strategic Executive Information System (STEIS))


families a full explanation if and when things went wrong. Managers we spoke with had a good

understanding of the duty of candour and its importance in supporting patients and families when

things went wrong. We reviewed three incident reports and noted duty of candour had been

followed. Once a serious incident was declared, an initial duty of candour letter was sent including

an apology, confirming details of the investigation and providing contact details. Once the

investigation was complete, the investigating officer contacted the patient or family.


Feedback from incidents and improvements to patient care were discussed at clinical governance

meetings and mortality reviews. Handover meetings were used to share learning, as well as

newsletters and hot topics.

Staff met to discuss the feedback and look at improvements to patient care. The staff teams held

regular team meetings and discussed incidents. Individual staff members involved in incidents had

the opportunity to get feedback and to have active involvement in any improvements they could

make to their day to day practice.

There was evidence that changes had been made as a result of feedback. The trust had

introduced competency check lists for agency and bank staff as a result of an incident involving

medications.


investigations. We reviewed the last three root cause analysis reports and noted they were

investigated thoroughly, with clear root cause analysis completed and actions to minimise further

incidents of the same nature.

Managers debriefed and supported staff after any serious incident. Staff who had been involved in

incidents told us they were supported by the leadership team and their peers. Staff were

encouraged to use reflective practice and discuss incidents openly, in order to minimise future

events. Staff could also access the chaplaincy team for additional support, if they felt they needed

to talk to someone about their experiences.

Safety thermometer



Safety thermometer data was displayed on wards for staff and patients to see. The trust used the

green safety cross system to display the number of falls, IPC incidents and pressure ulcers.

The safety thermometer is used to record the prevalence of patient harms and to provide



their elimination.

Staff used the safety thermometer data to further improve services. Performance on the safety

thermometer was discussed as part of the clinical governance process, at handover meetings and

hot topics could be addressed at handovers, for example if there was an increase in falls related


incidents. The trust had a comprehensive focus on reducing pressure ulcers, called “Reveal the

heal”. Posters and guidance explaining how to reduce pressure ulcers combined with additional

training and the use of patient care records had seen a recent reduction in the number of hospital

acquired pressure sores.

Data collection takes place one day each month – a suggested date for data collection is given but


date.

Data from the patient safety thermometer showed that the trust reported 27 new pressure ulcers,

14 falls with harm and 21 new urinary tract infections in patients with a catheter from August 2018

to August 2019 for medical services.

Prevalence rate (number of patients per 100 surveyed) of pressure ulcers,

falls and catheter acquired urinary tract infections at Mid Essex Hospital

Services NHS Trust

1

Total

Pressure

ulcers

(27)

2

Total Falls

(14)

3

Total

CUTIs

(21)

1 Pressure ulcers levels 2, 3 and 4 2 Falls with harm levels 3 to 6 3 Catheter acquired urinary tract infection level 3 only

(Source: NHS Digital - Safety Thermometer)








and national guidance. We reviewed eight policies on the trust’s intranet and they were all up to

date. Staff had access to up to date clinical guidance and the intranet provided a wide range of up

to date care pathways and advice for practitioners.

The trust had a process in place to identify new guidance published on the National Institute for

Health & Care Excellence (NICE) website monthly. This was directed to the relevant clinical

speciality lead. The lead carried out a baseline assessment who reviewed current practice against

the guidelines. Based on this assessment, the specialty lead agreed with the divisional triumvirate

any required implementation plan. The trust’s clinical effectiveness group received and monitored

the NICE internal compliance dashboard.

The trust had a dementia strategy which related to various best practice guidance including NICE

Quality Standard: Dementia (QS184), 2019. NICE Quality Standard: Delirium (QS63), 2014. NICE

Guideline: Dementia: assessment, management and support for people living with dementia and

their carers (NG97), 2018 and the Prime Minister’s Challenge on Dementia, 2020.

Staff protected the rights of patients subject to the Mental Health Act and followed the Code of

Practice. Staff were aware of patient rights under the Mental Health Act and knew how to reach

the mental health team to ensure patient care was being given appropriately. However, staff said

the response times for mental health support varied greatly.

At handover meetings, staff routinely referred to the psychological and emotional needs of

patients, their relatives and carers. Staff comprehensively discussed patient emotional and

psychological needs during handovers. This ensured that appropriate referrals to specialist staff

for example speech and language, occupational therapy, physiotherapy or the mental health team

were actively managed.

The renal service had measures in place for continued assessment of a patient’s vascular access

for example arteriovenous fistula and line rates, and processes for regular monitoring of vascular

access function. Managers maintained dialysis staff competency training records to ensure they

followed standard operating procedures to minimise the risk of infection. For example, electrolyte

imbalance, symptomatic dialysis-related hypotension and accidental venous needle/line

disconnection. The trust also provided clear pictorial guides for staff and patients to reduce

accidental venous needle/line disconnection.



They used special feeding and hydration techniques when necessary. The service made

adjustments for patients religious, cultural and other needs.

Staff made sure patients had enough to eat and drink, including those with special nutrition and

hydration needs. Patients on the medical wards had protected meal times to ensure that they had

time to eat and drink in a calm environment. Staff helped patients to eat when they were unable to


on their own. Patients on specialist diets had this highlighted on the board above their bed and

care plans reflected individual patient’s dietary needs.

Staff fully and accurately completed patient’s fluid and nutrition charts where needed. We

reviewed 25 patient records and found that four of these had not had their fluid chart updated,

which we drew to staff’s attention at the time of the inspection.

Staff used a nationally recognised screening tool to monitor patients at risk of malnutrition. Of the

21 patient care records we reviewed, all had the malnutrition universal screening tool completed.

There was clear guidance for staff to follow, to promote patient wellbeing in relation to nutrition and

hydration.

Specialist support from staff such as dieticians and speech and language therapists were available

for patients who needed it. The multidisciplinary (MDT) worked alongside staff to identify patients

who needed any additional support and to provide best practice guidance, for example the use of

additional food supplements, meal sizes or to increase fluid levels.

All the wards we visited had volunteers at meal times who made a positive impact on supporting

patients, providing additional support and care during meal times. All food was prepared in

kitchens on the wards. This meant food was always hot when necessary and ready to serve.

There was a wide range of menu choices and staff provided additional finger food for patients who

wanted small snacks. Patients had access to water at all times, fresh fruit, tea and coffee.

The trust had a dementia nutrition pathway and staff could signpost patients to other teams, for

example the speech and language therapy teams for additional support.

Pain relief




Staff assessed patients pain using a recognised tool and gave pain relief in line with individual

needs and best practice. Staff used a smiley face tool to assess pain levels and we observed staff

routinely checked patients pain levels and gave pain relief as required. The trust had a specialist

pain team which staff sent referrals to, for patients suffering with a lot of pain or chronic (long term)

pain.

Patients received pain relief soon after requesting it. Patients we spoke with during our inspection

told us they received pain relief quickly and that staff responded positively to additional requests

for pain relief. We observed staff carrying out medication rounds and asking patients for their level

of pain, if their pain relief was effective and if they wanted to discuss their pain relief with medical

staff. On the respiratory ward we observed a nurse offering pain relief to a patient. The patient

wasn’t satisfied with the level of pain relief, the nurse immediately referred the patient to be seen

by the medical staff on duty.

Staff prescribed, administered and recorded pain relief accurately. From the 25 patient records we

reviewed we noted pain relief was prescribed, administered and recorded appropriately.

Patient outcomes



improvements and achieved good outcomes for patients.

Managers and staff carried out a comprehensive programme of repeated audits to check

improvement over time and the service participated in relevant national clinical audits. The trust

participated in a range of national audits and shared its outcomes with staff and external

stakeholders.

Outcomes for patients were positive, consistent and met expectations, such as national standards.

For example, the trust took part in the quarterly Sentinel Stroke National Audit programme. On a

scale of A-E, where A is best, the trust achieved grade A in latest audit, covering the period from

January to March 2019. The hospital has achieved an overall grade A in each of the last four data

collection periods.

Managers and staff used the results to improve patient outcomes. The trust used audit data to

improve services, for example ongoing recruitment of consultant oncologists to support

assessment and delivery of treatment to patients with cancer in response to the National Lung

Cancer Audit.

Relative risk of readmission

Elective Admissions - Broomfield Hospital

From February 2018 to January 2019, patients at Broomfield Hospital had a lower than expected

risk of readmission for elective admissions when compared to the England average.

• Patients in medical oncology and clinical haematology had a lower than expected risk of

readmission for elective admissions compared to the England average.

• Patients in general medicine had a higher than expected risk of readmission for elective

admissions compared to the England average.

Note: Ratio of observed to expected emergency readmissions multiplied by 100. A value below

100 is interpreted as a positive finding, as this means there were fewer observed readmissions

than expected. A value above 100 represents the opposite. Top three specialties for specific site

based on count of activity.

Non-Elective Admissions - Broomfield Hospital

From February 2018 to January 2019, patients at Broomfield Hospital had a similar to expected

risk of readmission for non-elective admissions when compared to the England average.

• Patients in general medicine had a similar to expected risk of readmission for non-elective



• Patients in geriatric medicine had a higher than expected risk of readmission for non-

elective admissions compared to the England average.

• Patients in stroke medicine had a lower than expected risk of readmission for non-elective





based on count of activity.

(Source: Hospital Episode Statistics - HES - Readmissions (01/02/2018 - 31/01/2019))

Sentinel Stroke National Audit Programme (SSNAP)

Broomfield Hospital

Broomfield Hospital took part in the quarterly Sentinel Stroke National Audit programme. On a

scale of A-E, where A is best, the trust achieved grade A in latest audit, covering the period from

January to March 2019. The hospital has achieved an overall grade A in each of the last four data

collection periods.

The trust achieved either a grade A or grade B for all indicators in the audit other than the indicator

relating to the stroke unit where the hospital was awarded a grade C.

Overall Scores

Apr 18 -

Jun 18

Jul 18 -

Sep 18

Oct 18 -

Dec 18

Jan 19 -

Mar 19

SSNAP level A A A A

Case ascertainment band A A A A

Audit compliance band A A A A

Combined total key indicator level A A A A


(Source: Royal College of Physicians London, SSNAP audit)

Lung Cancer Audit

The table below summarises Mid Essex Hospital Services NHS Trust’s performance in the 2018

National Lung Cancer Audit.


Trust performance

Comparison to other Trusts

Met national standard?

Patient centred performance

Apr 18 -

Jun 18

Jul 18 -

Sep 18

Oct 18 -

Dec 18

Jan 19 -

Mar 19

Domain 1: Scanning A A A A

Domain 2: Stroke unit C↓ B C↓ C

Domain 3: Thrombolysis A B↓ C↓ B↑

Domain 4: Specialist assessmentsA A A A

Domain 5: Occupational therapy C↓ A↑↑ A A

Domain 6: Physiotherapy B A↑ A B↓

Domain 7: Speech and language

therapyC↓ C B↑ B

Domain 8: Multi-disciplinary team

workingB B B B

Domain 9: Standards by dischargeA A A A

Domain 10: Discharge processes B↓ A↑ A A

Patient-centred total key indicator

levelA A A A

Team centred performance

Apr 18 -

Jun 18

Jul 18 -

Sep 18

Oct 18 -

Dec 18

Jan 19 -

Mar 19

Domain 1: Scanning A A A A

Domain 2: Stroke unit B↑ B C↓ C

Domain 3: Thrombolysis A B↓ C↓ B↑

Domain 4: Specialist assessmentsA A A A

Domain 5: Occupational therapy C↓↓ A↑↑ A A

Domain 6: Physiotherapy C↓ A↑↑ A B↓

Domain 7: Speech and language

therapyC C B↑ B

Domain 8: Multi-disciplinary team

workingB B B B

Domain 9: Standards by dischargeA A A A

Domain 10: Discharge processes A A A A

Team-centred total key indicator

levelA A A A


Crude proportion of patients seen by a cancer nurse specialist (Access to a cancer nurse specialist is associated with increased receipt of anticancer treatment)

81.3% Does not meet the audit aspirational

standard Did not meet

Case-mix adjusted one-year survival rate (Adjusted scores take into account the differences in the case-mix of patients treated)

30.6% Within expected range No current standard

Case-mix adjusted percentage of patients with Non-Small Cell Lung Cancer (NSCLC) receiving surgery (Surgery remains the preferred treatment for early-stage lung cancer; adjusted scores take into account the differences in the case-mix of patients seen)

16.1% Within expected range Did not meet

Case-mix adjusted percentage of fit patients with advanced NSCLC receiving systemic anti-cancer treatment (For fitter patients with incurable NSCLC anti-cancer treatment is known to extend life expectancy and improve quality of life; adjusted scores take into account the differences in the case-mix of patients seen)

45.0% Worse than expected Did not meet

Case-mix adjusted percentage of patients with Small Cell Lung Cancer (SCLC) receiving chemotherapy (SCLC tumours are sensitive to chemotherapy which can improve survival and quality of life; adjusted scores take into account the differences in the case-mix of patients seen)

60.1% Within expected range Did not meet

(Source: National Lung Cancer Audit)

The trust participated in the Lung Cancer Audit and published its executive summary report in May

2019. The audit showed results were better than expected in five areas and the trust had an action

plan to address any shortfalls in the one remaining area.

National Audit of Inpatient Falls

Broomfield Hospital

The table below summarises Broomfield Hospital’s performance in the 2017 National Audit of

Inpatient Falls. The audit reports on the extent to which key indicators were met and grades

performance as red (less than 50% of patients received the assessment/intervention), amber

(between 50% and 79% of patients received the assessment/intervention) and green (more than

80% of patients received the assessment/intervention.




Audit’s Rating

Met national aspirational standard?

Does the trust have a multidisciplinary working group for falls prevention where data on falls are discussed at most or all the meetings?

Yes N/A Met

Crude proportion of patients who had a vision assessment (if applicable) (Having a vision assessment is indicative of good practice in falls prevention)

48.3% Red Did not meet

Crude proportion of patients who had a lying and standing blood pressure assessment (if applicable) (Having a lying and standing blood pressure assessment is indicative of good practice in falls prevention)


Crude proportion of patients assessed for the presence or absence of delirium (if applicable) (Having an assessment for delirium is indicative of good practice in falls prevention)


Crude proportion of patients with a call bell in reach (if applicable) (Having a call bell in reach is an important environmental factor that may impact on the risk of falls)

100.0% Green Met

(Source: National Audit of Inpatient Falls)

The National Audit of Inpatient Falls (NAIF) is transitioning from its previous methodology,

snapshot audit in 2015 and 2017, to a new methodology to enable continuous audit. The trust took

part in those audits at that time.

The new audit focuses on patients who sustain a hip fracture while in hospital. The scope of this

audit will widen to include acute hospitals, community and mental health hospitals. The trust

planned to implement the continuous audit incrementally and begin data collection on the 1

January 2019. The results were likely to be published in March 2020.

Chronic Obstructive Pulmonary Disease Audit

Broomfield Hospital did not participate in the 2018/19 Chronic Obstructive Pulmonary Disease

Audit.

(Source: Chronic Obstructive Pulmonary Disease Audit)

National Audit of Dementia

Broomfield Hospital

The table below summarises Broomfield Hospital’s performance in the 2017 National Audit of

Dementia.



Audit’s Rating Met national standard?

Percentage of carers rating overall care received by the person cared for in hospital as Excellent or Very

95.1% Better No current standard


Good (A key aim of the audit was to collect feedback from carers to ask them to rate the care that was received by the person they care for while in hospital) Percentage of staff responding “always” or “most of the time” to the question “Is your ward/ trust able to respond to the needs of people with dementia as they arise?” (This measure could reflect on staff perception of adequate staffing and/or training available to meet the needs of people with dementia in hospital)

82.9% Similar No current standard

Mental state assessment carried out upon or during admission for recent changes or fluctuation in behaviour that may indicate the presence of delirium (Delirium is five times more likely to affect people with dementia, who should have an initial assessment for any possible signs, followed by a full clinical assessment if necessary)


Multi-disciplinary team involvement in discussion of discharge (Timely coordination and adequate discharge planning is essential to limit potential delays in dementia patients returning to their place of residence and avoid prolonged admission)

68.6% Worse No current standard

(Source: National Audit of Dementia)

The trust published its executive summary report to the national audit if dementia in September

2019. The trust’s score for nutrition in round four was 100%, above the national score of 89% and

an improvement from round three score of 93.8%. Notable areas included protected mealtimes,

carers allowed to visit anytime (including mealtimes) and provision of finger foods and snacks.

The trust’s score for assessment in round four was 88.3%, above the national score of 87% and

an improvement from the round three score of 86.3%. Notable areas included assessment of

mobility, nutritional status, pressure ulcer risk, continence and pain, which were all at 94% or

above. The mental state assessments however, scored markedly lower and the trust carried out a

gap analysis and developed an action plan to address areas of weakness. The trust did not

perform as well as the previous round in the carer rating of communication (round 4: 71% down

from round 3: 80.7%) and carer rating patient care (round 4: 87.9% down from round 3: 93.3%).

The trust had actions to address this in the action plan, including relaunching the carers’ packs,

the patient surveys and promoting open visiting.

Managers used information from the audits to improve care and treatment. In May 2019, the trust

participated in the National Diabetes Inpatient Audit – Harms. This audit measured the quality of

care provided to people with diabetes when they were admitted to hospital and aimed to support


quality improvement. The 2018 audit involved only reporting harms which occurred whilst the

patient was in hospital; for example, hypoglycaemia needing rescue treatment and hospital

acquired foot ulcer. As a result of the audit the trust applied to the National Treatment and Care

group for funding for an additional inpatient specialist nurse to support inpatient diabetes care. The

bid was successful, and the trust recruited to this post to enhance care to its patients.

Managers and staff investigated outliers and implemented local changes to improve care and

monitored the improvement over time. Consultants reviewed each medical patient on non-medical

wards; known as outliers, on a daily basis and ensured care and treatment plans were in place to

manage their condition.

Managers shared and made sure staff understood information from the audits. Staff we spoke with

during our inspection said they received updates from audits at team meetings, from newsletters

and safety huddles.

Improvement was checked and monitored. The trust was proactive in conducting audits, gathering

evidence to show improvement or decline in services. Where improvements were identified these

were celebrated and further work done to improve performance. Any gaps in service or areas for

improvement were shared with the staff team and the trust completed a gap analysis and

developed action plans in order to drive change.

The trust’s endoscopy department was accredited by ‘The Joint Advisory Group on

Gastrointestinal Endoscopy’ (JAG).

Competent staff

The service made sure staff were competent for their roles. Managers appraised staffs’

work performance and held supervision meetings with them to provide support and

development.


patients. Staff had the right skills and had completed additional competencies as needed for their

roles, this was an improvement on our last inspection. Examples of extra competencies included

dementia study days and sepsis sessions.

Managers gave all new staff a full induction tailored to their role before they started work. We

reviewed twenty agency and bank staff competency and orientation checklist and found these

comprehensive, covering a wide range of core competencies, for example medication

administration. Staff checked the competencies of any bank or agency staff prior to them starting

their shift and only allowed them to complete tasks in line with the competencies they had

completed. Ward managers recorded checks against the staff competencies and orientation within

the performance improvement book (PIB). This was an improvement on our last inspection.

The trust had a virtual dementia tour for staff. This was an eight minute immersive experience

enabling staff to gain empathy and greater understanding when interacting with patients living with

dementia. All staff could enrol onto the course as any staff member potentially was likely to have

contact with people living with dementia. Staff we spoke with said this was extremely positive and

told us this gave them increased understanding of what it is like for patients living with dementia.


Appraisal rates

Broomfield Hospital

As of August 2019, 84.1% of required staff in medical care at Broomfield Hospital received an

appraisal, which was below the trust target of 90%.

A breakdown by staff group can be found in the table below.

Staff group

As of August 2019


Eligible staff

Completion rate

Trust target

Met (Yes/No)

Additional clinical services 181 195 92.8% 90% Yes Allied health professionals 15 17 88.2% 90% No Administrative and clerical 47 54 87.0% 90% No Medical and dental 99 117 84.6% 90% No Healthcare scientists 57 69 82.6% 90% No Nursing and midwifery registered 177 230 77.0% 90% No

Estates and ancillary 6 9 66.7% 90% No Additional professional, scientific and technical

0 1 0.0% 90% No

Total 582 692 84.1% 90% No

Staff working in additional clinical services met the 90% trust target. Allied health professionals,

administrative and clerical, medical and dental staff and healthcare scientists all had appraisal

completion rates above 80% as of August 2019. Care should be taken when interpreting the rates

as this data only represents a partial year.


Appraisal data supplied by the trust following our inspection showed medical staff achieved 92%

appraisal compliance and nursing staff 81% compliance.

Managers supported nursing and medical staff to develop through regular, constructive clinical

supervision of their work. Staff we spoke with valued the opportunity to discuss their performance

and development during supervision.

The clinical coach supported the learning and development needs of staff. The trust employed a

clinical coach within the medicine division, who worked 22.5 hours per week covering three wards.

The role included working with the senior nursing team to ensure the pre-registration and newly

qualified nurses had the best possible experience to maintain safe patient care. The clinical coach

also facilitated staff development plans including training and education, apprenticeships,

supported staffs’ continuing professional development and nurse revalidation.

Managers made sure staff attended team meetings or had access to full notes when they could

not attend. The trust promoted team meetings. Records we reviewed from August, September and

October 2019 showed that the wards held regular team meetings with opportunities to discuss

staff development and learning from incidents.


develop their skills and knowledge. Training needs were identified through a variety of sources

including learning from incidents, appraisals and through staff requesting additional training at their

supervision sessions.


Staff had the opportunity to discuss training needs with their line manager and were supported to

develop their skills and knowledge. Staff we spoke with said they valued their appraisals and

opportunities to discuss their training. Staff told us their line managers were supportive in

developing their skills and that they felt confident in requesting additional training.

Managers made sure staff received any specialist training for their role. Staff who required

specialist training for their role received this in order to carry out their roles, for example additional

dementia training for dementia support workers.

Managers recruited, trained and supported volunteers to support patients in the service.

Throughout the inspection we met dedicated and highly motivated volunteers that were focused on

providing additional support to the patients on the wards. Volunteers went through a strict

induction process and covered key areas of training required for their safety and in order to

understand the needs of patients, for example safeguarding and dementia care.


Doctors, nurses and other healthcare professionals worked together as a team to benefit

patients. They supported each other to provide good care.


care. We noted the trust held regular multidisciplinary (MDT) ‘red to green bed day’ meetings, with

input from nursing staff, medical staff, allied health professionals, mental health colleagues and

social care staff. Red and green bed days are a visual management system to assist in the

identification of wasted time in a patient’s journey in hospital. Applicable to in-patient wards in both

acute and community settings, this approach is used to reduce internal and external delays as part

of the “SAFER” patient flow bundle.


patients. Staff we spoke with gave numerous positive examples of cross sector working with

district nurses, social care and the clinical commissioning groups (CCGs) in order to care for

patients. A big focus of the MDT was the patient discharge process, this was an improvement from

our last inspection.

Staff referred patients for mental health assessments when they showed signs of mental ill health,

depression. Staff we spoke with during our inspection were aware of the mental health liaison

teams and could provide examples of cases where they referred patients to them.

Patients had their care pathway reviewed by relevant consultants. Consultants conducted daily

ward rounds Monday to Friday. At weekends staff could ask for medical staff to review patients.

Seven-day services


Consultants led daily ward rounds on all wards. Patients were reviewed by consultants depending

on their care pathway. Consultant services were available seven days a week, out of hours an on-

call consultant was available. Specialist consultants were available on-call for gastrointestinal

bleeds, cardiologist pacing, haematology and microbiology.


Consultant ward rounds on the general medicine wards occurred daily Monday to Friday. On

Saturday and Sunday consultants reviewed any new patients, any patients needing to be

discharged and any unstable patients.

Staff could call for support from doctors and other disciplines, including mental health services and

diagnostic tests, 24 hours a day, seven days a week. The pharmacy was open Monday to Friday

8.45am to 5.15pm, and Saturdays and bank holidays 10am to 4pm. Out of hours an on-call

pharmacist was available. Diagnostic tests, for example, CT, MRI and x-rays were available 24

hours a day, seven days a week.

Physiotherapists provided an on call respiratory service seven days a week, via on call out of

hours service.

Health promotion


The service had relevant information promoting healthy lifestyles and support on wards/units. On

all the wards we visited we noted information available to guide patients and families on healthy

life styles. Information was available on a range of subjects, which included, but was not limited to,

managing healthy diets, diabetes, mental health and smoking cessation.


to live a healthier lifestyle. Patients were weighed and had a medical history taken on admission to

the ward. Medical history could include information such as smoking and recreational drug use.

The cardiac rehabilitation service gave patients information, knowledge and tools to be able to

make healthier lifestyle choices. The patients were then invited to an eight-week cardiac

rehabilitation course consisting of exercise (individualised to the patient), and education, including

diet, stress management and benefits of exercise.

The alcohol liaison team visited all of the wards to give staff training on how to helpfully discuss

alcohol usage with patients and give leaflets and guidance. The trust had updated its inpatient

nursing booklets to make it easier for staff to assess patient alcohol and tobacco usage. Patients

in the stroke unit and transient ischaemic attack (TIA) clinics were offered verbal and written

advice about smoking, alcohol, diet and exercise.



followed national guidance to gain patients consent. They knew how to support patients


They used measures that limit patients liberty appropriately.


about their care. Staff were familiar with the test for identifying whether patients had mental

capacity to make decisions about their activities of day to day living, care and treatment. Staff

were able to explain factors that could affect capacity, whether capacity was fluctuating or affected

by delirium. Staff handovers had a keen focus on patients who lacked capacity and the decisions

that had been made in the patients best interest. Staff understood least restrictive care planning

and when to seek advice from the dementia specialist nurse or safeguarding team for additional

advice.



guidance. Patients we spoke with during our inspection and records we reviewed showed that

consent was gained prior to any patient treatment.

When patients could not give consent, staff made decisions in their best interest, taking into

account patients wishes, culture and traditions. Staff were familiar with best interest decision

making and how to ensure care plans were as least restrictive as possible. Capacity was routinely

discussed at handover meetings and care plans routinely updated where patient capacity

fluctuated or if patients displayed distress or confusion.

Staff made sure patients consented to treatment based on all the information available. We

observed staff discussed the risks and benefits of treatment plans with patients so that they could

give informed consent where appropriate.

Staff clearly recorded consent in the patients records. Out of the 25 patient records we reviewed,

staff had recorded patient consent where required.


(Nursing) staff received and kept up to date with training in the Mental Capacity Act and

Deprivation of Liberty Safeguards.

The trust set a target of 95% for the completion of Mental Capacity Act (MCA) training. The trust

stated that Deprivation of Liberty Safeguarding (DoLS) training was included in the MCA training

module.

Broomfield Hospital

A breakdown of compliance for the MCA/DoLS training course as of August 2019 for registered

nurses and medical staff in medicine at Broomfield Hospital is shown below:

Staffing group As of August, 2019

Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)

Medical and dental 113 124 91.1% 95% No Nursing and midwifery registered 156 174 89.7% 95% No

In medicine, the 95% trust target was not met for the MCA/DoLS module by registered nurses and

medical and dental staff. Training compliance was above 89% for staff groups.


Clinical staff received and kept up to date with training in the Mental Capacity Act (MCA) and

Deprivation of Liberty Safeguards (DoLS). Data supplied by the trust following our inspection

showed medical staff achieved 92% compliance with MCA and DoLS training and nursing staff

achieved 90% compliance.


guidance, including the Mental Health Act, Mental Capacity Act 2005 and they knew who to

contact for advice. Staff were familiar with the legislation regarding consent and the differences

between MHA and MCA legislation.


Act and Deprivation of Liberty Safeguards. Staff told us they contacted the safeguarding lead if

they had any concerns or needed any advice in relation to MCA or DoLS. MCA and DoLS were


discussed at all team handovers we observed, and staff had ample opportunity to advocate for

patients to ensure their needs were being met.

Managers monitored the use of Deprivation of Liberty Safeguards and Mental Capacity Act and

made sure staff knew how to complete them. Ward managers knew all patients who were subject

to a DoLS and ensured that applications were completed on time and reviewed where necessary.

Staff implemented Deprivation of Liberty Safeguards in line with approved documentation. We

reviewed MCA and DoLS assessments within patient records and found these were completed

appropriately and used least restrictive care practices.


Compassionate care

Staff treated patients with compassion and kindness, respected their privacy and dignity,

and took account of their individual needs.


patients and those close to them in a respectful and considerate way. Throughout our inspection

we observed positive interactions between staff members and patients and relatives. Staff

knocked on doors before entering toilets, introduced themselves and spoke kindly to patients and

their relatives.

Patients said staff treated them well and with kindness. We spoke with nine patients and other

family members. Eight of the patients gave positive feedback on the service saying that staff

always treated them or their relatives with kindness. One patient stated that the staff had not

followed their exercise plan and they had raised a complaint about this to the service.

Staff followed policy to keep patient care and treatment confidential. Staff understood the

importance of keeping patient care and treatment confidential. However, on one ward we

observed a patient handover at 7.15am that occurred at the end of a patient’s bed, with other

patients present in the bay. Staff told us this was based on feedback from managers who had told

them handover must be done in view of the patient, so they could physically see the patient’s

condition. This had arisen due to a previous safety concern.

We were concerned about the confidentially and privacy of patients in this area as well as all the

patients being woken up at the same time and staff switching all the lights on within the bay. At

one point there were ten staff handing over in the bay, with complex and often confused patients

present. We raised this issue with a senior member of staff, who said they would review the

practice.

On our follow up inspection on 21 November 2019 we again revisited a number of wards to

observe handovers. There had been no change in the handover process following our previous

inspection and the inconsistencies in practice remained.

On other wards handovers took place in side rooms, patients were asleep with lights off and staff

were calmly supporting patients to wake up and prepare for the day. This gave a calm and

reassuring environment for the patients and one that respected the individuality of the patients and

their complex needs.



We observed consistently positive interaction between patients and staff, who were non-


judgemental despite patients often showing distressed behaviour. Staff showed great patience and

empathy. One patient demonstrated some particularly distressed behaviour, staff provided

consistently positive reassurance, used distraction techniques and reassured other patients to

promote their safety. All staff spoke respectfully about patients and showed empathy and

understanding when discussing patients with mental health needs.

The trust had introduced pet therapy on its renal unit. A dog visited the unit once a week, providing

renal patients with a welcome distraction from the monotony of dialysis. Staff noticed a significant

difference to patient’s body language and mood on the days when the dog visited the unit.


how they may relate to care needs. Staff understood and appreciated the varying social, economic

and religious needs of their patients and took this into account when care planning.


The Friends and Family Test response rate for medicine at the Mid Essex Hospital Services NHS

Trust was 27.6% which was better than the England average of 24.0% from July 2018 to June

2019.

A breakdown of FFT performance by ward for medical wards at Broomfield Hospital is shown

below. The percentage of respondents that said they would recommend the ward to family or

friends was 75% or higher for all medical wards for these 12 months overall.

1. The total responses exclude all responses in months where there were less than five

responses at a particular ward (shown as gaps in the data above), as well as wards where

there were less than 100 responses in total over the 12-month period.

2. Sorted by total response.

3. The formatting above is conditional formatting which colours cells on a grading from highest to

lowest, to aid in seeing quickly where scores are high or low. Colours do not imply the passing

or failing of any national standard.

(Source: NHS England Friends and Family Test)


Emotional support


They understood patients personal, cultural and religious needs.


it. Staff provided patients and relatives with emotional support when they needed it. Staff

explained how they helped patients understand their condition and signposted them to

organisations to help them manage their condition. For example, dementia or Parkinson’s self-help

groups. We spoke with one family who said the staff had been exceptionally understanding of their

personal situation. Staff had listened to their concerns and given additional time and care to them

as a family.


maintain their privacy and dignity. Staff were aware of the importance of maintaining patients

dignity and privacy, especially if they were distressed or confused. We spoke to the night team

who told us a patient with confusion had become upset and removed their clothes. Staff provided

support in a none judgmental way, saying, “That could be my family or a friend, it’s our role to

provide them with care and support, not judge them”.

Staff undertook training on breaking bad news and demonstrated empathy when having difficult

conversations. During our inspection we observed staff discussing the need to speak with patients

and their families regarding end of life care. In staff handovers staff demonstrated great empathy

and understanding for the patients and families, discussing plans in a sensitive and professional

manner. Staff prioritised patients with end of life plans and ensured they spoke to the patients and

families without any additional delays, so they were clear on the choices they could make. We

asked staff how they coped personally with having to have these conversations, they explained

they could always speak to colleagues or their line managers for additional support. On one

occasion we noted one of the medical staff having three of these conversations in the same shift.

They conducted themselves this with the utmost of dignity and professionalism putting the patient

and family needs first.


on their wellbeing and on those close to them. Staff explained that for many patients the ward was

a strange environment, they tried wherever possible to make it feel homely and encouraged

families to bring in small items form home to help orientate patients to their bed space. During

handover meetings staff routinely discussed the social and emotional impact of the patient’s

condition and how they could plan a discharge appropriate to the patient’s needs.


Staff supported patients, families and carers to understand their condition and make

decisions about their care and treatment.

Staff made sure patients and those close to them understood their care and treatment. Patients

we spoke with told us that staff fully involved them in their care. One patient said, “They have been

brilliant, I know exactly what’s going to happen to me next and I am going home soon”. Another

patient said, “There is a routine on here, so the days go quite quickly, the staff tell me everything

they can, and give me time to ask questions”.

Staff talked with patients, families and carers in a way they could understand, using

communication aids where necessary. Staff had access to pictorial symbols to encourage


communication with patients who were unable to speak. We observed staff used language that

patients understood and gave patients time to ask questions if they were unsure about anything.

Staff interacting with confused patients showed genuine empathy, gave patients extra time and

reassurance. Staff showed insight into the patient perspective and how it would feel to have a

sensory or physical impairment themselves.


supported them to do this. Patients and their relatives provided feedback via the FFT and through

the complaints and compliments procedure. We noted rafts of thank you cards displayed on the

wards we visited. One card said, “Thank you so much for all the care to my dad, you made such a

difference”. Another card said, “Thank you so much for your kindness”.

Staff supported patients to make advanced decisions about their care. Staff we spoke with told us

they spoke to patients and families about the importance of making advanced decisions so that

they could have control over what happened to them. We noted in patient records that advanced

decisions were made about subjects such as resuscitation status and care planning for the future.

Staff supported patients to make informed decisions about their care. Staff spoke openly with

patients about the risks and benefits of procedures and treatment plans, so they could make

informed decisions about their care. We noted where patients lacked capacity that family members

had been involved in decision making and staff had a good understanding of the need to involve

families and those close to the patient in their care.





to plan care.

Managers planned and organised services, so they met the changing needs of the local

population. Since our last inspection the trust had developed the frailty assessment bay (FAB)

which was a seven-day, multidisciplinary service that included a consultant geriatrician, junior

medical staff, frailty nurses, therapists, a social worker and dedicated dementia support. We

carried out a follow up unannounced inspection on 20 November 2019 and found the trust had

reconfigured the FAB to a standalone unit, no longer attached to the AMU. This was in response

to feedback from staff and service planning to reduce unnecessary patient admissions and focus

on coordinated and efficient discharges.


aim of FAB was for frail old people to be seen quickly and undergo a comprehensive

multidisciplinary assessment early on in their admission. The team assessed, treated, and

diagnosed patients with a discharge plan, in rapid succession, to avoid admission to the hospital.


report a potential breach. There were three mixed sex breaches reported in January 2019, within

the discharge lounge. During periods when capacity across the trust and particularly within the

emergency department was challenged to the point that OPEL 3 triggers (The highest level of risk

due to patient capacity and flow through the trust), the trust escalation protocol allowed for


decision making that minimised risk to patients. The trust would, at that point, declare a mix sex

breach to maintain patient safety.

Facilities and premises were appropriate for the services being delivered. The facilities and

premises provided adequate accommodation for the services being provided. Some areas of the

hospital were aged, some wards lacked storage space for equipment and there was a lack of

meeting/side rooms for patient activities. The trust was refurbishing one ward to improve these

areas and had additional plans to make similar changes across its existing wards.

Staff could access emergency mental health support 24 hours a day 7 days a week for patients

with mental health problems, learning disabilities and dementia. A mental health team worked on

site, employed by an external provider. The team operated an on-call system and staff from the

mental health team visited the ward for reviews of patients when required.


intervention. The trust employed dementia support workers on the elderly care wards. The

dementia support workers worked alongside the staff team to provide additional support to

patients living with dementia. They supported the dementia champions to update staff on new

skills and advice on supporting patients and their families. The trust also had access to dementia

specialist nurses, falls specialists, mental health staff and infection prevention and control (IPC)

staff.


The service was inclusive and took account of patients individual needs and preferences.




received the necessary care to meet all their needs. Activity boxes containing puzzles, books and

‘twiddlemuffs’ (a hand muff designed to provide sensory stimulation) were put together for patients

living with dementia to assist with agitation or confusion. Staff had purchased reminiscence

therapy in the form of interactive computers which provided additional stimulation to patients living

with dementia.

Staff promoted the use of “serene side rooms”. This process involved staff using a side room, if

one was free, for patients who may be confused or agitated. Staff used aromatherapy, serene

lighting and activity boxes to distract patients and provide a calm environment to reduce anxiety.

Wards were designed to meet the needs of patients living with dementia. Patient ward areas were

colour coded with male and female bays. Each bed had a famous person’s picture or a famous

brand on display above the patient’s bed. This was to encourage the patient to recognise their bed

space and orientate themselves on the ward.


documents and patient passports. Staff used patient passports and “This is me” documents to help

staff know more about the patients likes, dislikes past experiences and their medical conditions

and how best to care for them. Often the books were completed by relatives or care home staff

and contained individual details, for example food preferences or particular actions staff could

follow if the patient became distressed.



patients with a disability or sensory loss. Staff we spoke with knew how to meet the

communication needs of patients with a disability and where to go for more assistance if

necessary. Staff told us they would speak to the dementia nurse, learning disabilities nurse or

speech and language therapy staff if they were unsure how to communicate with patients.

The service had information leaflets available in languages spoken by the patients and local

community. All leaflets on display in the hospital were printed in English. Staff told us that the trust

could print them in other languages if required but they were not readily displayed or available.

Managers made sure staff, patients, loved ones and carers could get help from interpreters or

signers when needed. Staff could access a translation service for patients whose first language

was not English.

Patients were given a choice of food and drink to meet their cultural and religious preferences. The

service provided menus to patients each day so that they could make food choices that met their

cultural and religious preferences. Staff encouraged patients to actively make choices and be

involved in their menu options.


treatment. Staff had access to pictorial symbols as an aid to communication with patients who

were unable to speak or were cognitively impaired. The medicine team had developed a game for

patients with called "either, neither or both" to help initiate conversations with patients. Staff

providing one to one care or meaningful time with a patient used this game to enhance

conversation and stimulate dialogue. There was a pocket pack of 100 cards with a choice of two

subjects on the cards that staff used as an aid for conversation and getting to know patients better.

The service had a shared care programme in renal replacement therapies (DIY Dialysis). The

shared care (formerly self-care) programme was non-compulsory. The new programme allowed

patients to gain a better understanding of their chronic condition and a better understanding of

their treatment. Patients who signed up encouraged others to get involved to improve overall

health and well-being and 50 out of the 139 patients eligible had signed up at the time of our

inspection

The red bag scheme was launched within Mid-Essex to identify patients from care homes and to

improve two-way communication for this cohort of patients. The bags were held in the care homes

and when a patient was transferred to an acute trust the red bag was sent with all relevant

paperwork, medication and some personal belongings. The bag stayed with the patient all the way

through their hospital journey and ensured that vital information related to the patients, for

example, do not attempt cardiopulmonary resuscitation status (DNACPR) was shared with all

clinical teams and any updated status returned with the patient on discharge.

The wards had access to the chaplaincy team and faith centre. The chaplaincy team supported

those of all faiths and none and was a key part of providing both pastoral and spiritual support to

the patients and relatives.

Access and flow

People could access the service when they needed it and received the right care promptly.

Waiting times from referral to treatment and arrangements to admit, treat and discharge

patients were in line with national standards.


Managers monitored waiting times and made sure patients could access services when needed

and received treatment within agreed timeframes and national targets.

Average length of stay

Broomfield Hospital – elective patients

From March 2018 to February 2019 the average length of stay for medical elective patients at

Broomfield Hospital was 4.3 days, which was lower than the England average of 5.9 days.

Average length of stay for elective specialties:

• The average length of stay for elective patients in general medicine at the trust was 7.3 days.

The average for England was 7.6 days.

• The average length of stay for elective patients in pain management at the trust was 1.2 days.


• The average length of stay for elective patients in gastroenterology at the trust was 3.2 days.


Note: Top three specialties for specific site based on count of activity.

Managers and staff worked to make sure patients did not stay longer than they needed to. During

our inspection the trust was in the process of reconfiguring its acute medical unit (AMU),

emergency short stay unit, (ESSU) and frailty assessment bay (FAB). We carried out a follow up

unannounced inspection on 20 November 2019 and found the trust had implemented the changes.

The FAB was reconfigured into a standalone unit, no longer attached to the AMU and was open

Monday to Friday 9am to 6pm. The FAB received referrals from all specialities, for patients who

required treatments or investigations, but did not require an overnight stay.

The FAB was collocated with the short stay frailty unit. The short stay frailty unit was open 24

hours a day seven days a week for overnight assessment and treatment. The FAB and short stay

frailty unit had access to a multidisciplinary team of physiotherapists, occupational therapists,

medical staff and nurses as well as social care and community based teams. The aim of the FAB

was for frail old people to be seen quickly and undergo a comprehensive multidisciplinary

assessment early on in their admission. The team assessed, treated, and diagnosed patients with

a discharge plan, to avoid admission to the hospital.

The acute medical unit had increased from 33 beds to 44 and was co-located with the emergency

short stay unit and open 24 hours a day seven days a week. Patients were referred from the

trust’s emergency department, local general practitioners (GP) or care homes. The patients were


actively triaged to stream them to the appropriate trust, for example the FAB to avoid admission,

or alternatively to a ward to be seen by a speciality team for further investigations or treatment.

Broomfield Hospital – non-elective patients

From March 2018 to February 2019 the average length of stay for medical non-elective patients at

Broomfield Hospital was 4.9 days, which was lower than the England average of 6.1 days.

Average length of stay for non-elective specialties:

• The average length of stay for non-elective patients in general medicine at the trust was 4.7

days. The average for England was 5.6 days.

• The average length of stay for non-elective patients in stroke medicine at the trust was 7.7


• The average length of stay for non-elective patients in geriatric medicine at the trust was 7.8




Referral to treatment (percentage within 18 weeks) - admitted performance

We could not gain accurate assurances that people could access the service when they needed it

and receive the right care promptly. Waiting times from referral to treatment (RTT) were not

externally reported at the time of our inspection. From 2018 to 2019, the trust implemented an

electronic patient record system which caused data validity issues and poor quality data. With

agreement from NHS England the trust were excluded from reporting data until they had

completed a review and data cleansing exercise.

Locally, managers told us waiting times were being monitored. However, at the time of our

inspection local leaders were unable to provide us with data to evidence the percentages of harm

reviews or whether the service were meeting the national targets.

Following our inspection we requested data from the senior leadership team We reviewed the data

that was provided, we were not able to analyse trends on unvalidated data. Senior leaders told us

patients that were not able to access services within national targets, received a harm review and

were reported to board in common meetings. They also told us that until they returned to reporting

(scheduled April 2020) ‘shadow reporting’ was in place, which included monthly review meetings

with NHS Improvement/England and commissioners.



We asked the trust for additional data against national RTT standards. The trust told us they were

not currently reporting against this standard and therefore not in a position to formally respond to

our additional data requests. The trust has not reported against national 18 week RTT standards

since January 2018.

The decision to discontinue reporting was triggered by the identification of a number of data quality

issues, linked with the implementation of a new Electronic Patient Record (EPR) in May 2017.

Issues identified included migration of data, internal and external reporting, training and

operational processes.

Following the agreement of the trust board, a programme of work was established, with a

dedicated programme management team, reporting through the trust’s elective care group (ECG)

as a sub group of the senior management group (SMG). Key workstreams included validation,

data quality, training, demand and capacity.

From its implementation the programme had been supported by a dedicated resource from the

NHS Improvement Elective Intensive Support Team (IST). Ongoing support was in place (1 day

per week) until the trust returns to reporting. Regular gateway and progress reviews have been

undertaken between the trust and NHS England/Improvement and Clinical Commissioning Group

(CCG) colleagues, with all partners providing assurance of the current position. The latest meeting

was 24 October 2019. This issue was on the medicine risk register and an RTT recovery plan was

in place.

Patient moving wards per admission

The trust stated that the systems they have in place do not differentiate between clinical and non-

clinical reasons for patients moving wards and therefore this data is not recorded.

(Source: Routine Provider Information Request (RPIR) – Ward moves tab)

Patient moving wards at night

Staff did move patients between wards at night. From August 2018 to July 2019, there were 2,936

patients moving wards at night within medicine at Broomfield Hospital. The ward with the highest

number of ward moves at night was the acute medical unit with 2,247. This was followed by the

emergency short stay ward (203 ward moves) and the frailty unit (139 ward moves).

(Source: Routine Provider Information Request (RPIR) – Moves at night tab)

Managers monitored that patient moves between wards/ services were kept to a minimum.

Managers we spoke with were aware of patients being moved between wards at night and that

this could be detrimental to their care. Staff we spoke with told that patients who were very unwell

or nearing the end of their life would not be moved unless absolutely necessary.

At the time of our inspection the trust had implemented a tele tracking system across the three

trusts to embed new ways of working that automated and streamlined essential services in order

to improve patient outcomes.

The system had a shared control centre in Billericay, to aim to improve management of patient

flow across the three trusts. The key objective was to increase bed capacity across the group by

identifying and eliminating ‘idle bed time’ and reducing waste, resulting from structural

inefficiencies in hospital operations and implement a bed management model. Tele tracking

worked closely with each trust to agree improved work flows, reduce waste, and ensure every

patient was assigned the right bed, first time. Clinical and operational teams from each trust were

involved in the design process, ensuring the system was tailored to their pathways and work flows.


The real time technology and system detected electronic badges and bracelets worn by patients. It

provided staff with visibility to all beds and patients across the trust. The system provided real time

bed status, patients that need to be allocated to a bed and housekeeping of portering

requirements to support staff to clean a bed or help transport a patient.


Throughout our inspection we found that staff had a strong focus on the patient discharge process,

this was an improvement from our last inspection. All patients were given an expected discharge

date recorded in their notes, staff aimed to hit this date. We noted the trust held ‘red to green bed

day’ meetings, with input from nursing staff, medical staff, allied health professionals, mental

health colleagues and social care. Red and green bed days were a visual management system to

assist in the identification of wasted time in a patient’s journey. Applicable to in-patient wards in

both acute and community settings, this approach was used to reduce internal and external delays

as part of the SAFER patient flow bundle.

The trust held a daily medically fit patient review which took place in the operations centre. The

nurse in charge or patient flow co-ordinator from each ward had an opportunity to meet and get a

two-way update with representatives from the integrated discharge team to ensure all complex

discharge patients had a clear plan. This improved planning around patients and the added benefit

of supporting the education of the clinical teams around discharge pathways and processes

available to the patients.

The system was a key tool within the site status/capacity meetings and utilised to allocate the

elective and non-elective flow into confirmed and pending discharges, as well as further plan for

capacity throughout the day and into the next 24 and 48 hours.

Staff planned patients discharge carefully, particularly for those with complex mental health and

social care needs. Staff ensured that patients were discharged to a safe location and care

packages were in place, if required. Following our last inspection, the trust had trialled the role of a

flow coordinator on three of the wards as part of improving the safer patient flow bundle and safe

discharge. The flow co-ordinators played a pivotal role in supporting the nurse in charge with

planning robust daily patient discharge and acted as a link between the clinical team and the

integrated discharge team. The trust told us that the wards with flow co-ordinators had more

discharges before midday as all processes required were in put into place in a timely manner.

Following the trial, funding had been identified to appoint flow coordinators onto all medical wards.

This was an improvement on our last inspection.

The trust employed a trusted assessor to work with local community care providers and carry out

patient assessments to support the discharge process. This meant that care home staff no longer

needed to come into the hospital and hospital staff could assess patients to ensure the discharge

was safe and the preferred place of care could meet the patient’s needs.

Managers monitored the number of delayed discharges, knew which wards had the highest

number and acted to prevent them. We noted patients on several wards who were waiting for care

packages to be finalised so that they could be safely discharged. ‘Stranded patient’ reviews

happened twice a week, where staff discussed patients who had been admitted for longer than

seven, 14 and 21 days. The reviews led to increased activity with the local clinical commissioning

group (CCG) and social services to ensure these patients had a supportive discharge. The trust

closely motored patient discharge and had assigned additional resources to this area to improve

patient flow and safety. The use of the electronic patient tracking system had improved flow and

enabled staff to identify patients who were ready for discharge and to move patients to the most

appropriate area of the hospital, for their care and discharge planning.


Discharge was affected by a number of factors including lack of social care locally, family

decisions, treatment plans changing and patients deteriorating or needing longer in hospital to

prevent an unsafe discharge.

Staff supported patients when they were referred or transferred between services. We observed

that staff explained why patients were being moved between services and accompanied them to

their new ward if needed. Ward administrators worked alongside the teams to ensure patient

records and details went with the patients to minimise any delays in communication of the patient’s

needs.

Managers made sure they had arrangements for medical staff to review any medical patients on

non-medical wards. Consultants reviewed each medical patient on non-medical wards; known as

outliers, on a daily basis and ensured care and treatment plans were in place to manage their

condition.

Managers worked to minimise the number of medical patients on non-medical wards. One of the

functionalities of the tele tracking system was the internal transfer worklist. The list incorporated

internal transfers that were to be moved from one speciality to another, which proactively

supported the movement of the patient into the right speciality bed. Should a patient be in an

outlying speciality ward the system highlighted these patients for ongoing movement.

From the 2nd December 2019 the tele tracking system will show a new “SNAP CAP”. This is a

capacity snap shot report generated from all three NHS trusts that will incorporate the outliers in

beds across all three sites. During our inspection outliers were discussed at every site meeting,

although the trust did not generate a report to view the quantity of outliers.






Patients, relatives and carers knew how to complain or raise concerns. Patients and families, we

spoke with confirmed that they knew who to contact if they had a complaint or wanted to raise any

concerns. One patient told us they had been unhappy with their care regime and had made a

complaint to the staff.

The service clearly displayed information about how to raise a concern in patient areas.

Information was displayed on the wards we visited that explained how to make a complaint and

how to contact the complaints team.

Staff understood the policy on complaints and knew how to handle them. Staff we spoke with were

familiar with the trust’s complaints policy and knew how to access it. Staff were confident in

dealing with complaints and escalating them where necessary.

Broomfield Hospital

Managers investigated complaints and identified themes. However, the investigations and

subsequent closure of individual complaints, did not comply with the service target.

From August 2018 to July 2019, the trust received 163 complaints about medicine (27.4% of the

total complaints received by the trust). The trust took an average of 41.3 days to investigate and


close complaints. This was not in line with their complaints policy which states complaints should

be completed within 25 working days. However, the trust explained they spent the additional time

dealing with complex cases, this prevented revisiting complaints that may have been closed to

early. Some complaints couldn’t be closed within the 25 working days. Were this happened the

complainant was kept informed and the trust set agreed dates for any complaint extensions.


Type of complaint Number of complaints Percentage of total Clinical treatment - general medicine group 72 44.2% Clinical treatment - accident and emergency 27 16.6% Clinical treatment - surgical group 18 11.0% Clinical treatment - clinical oncology 17 10.4% Admissions, discharge and transfer arrangements excluding delays due to absence of care package

10 6.1%

Communications 9 5.5% Values and behaviours (staff) 5 3.1% Privacy, dignity and wellbeing (including property and expenses)

4 2.5%

Appointments including delays and cancellations

1 0.6%

Total 163 100.0%



Broomfield Hospital

From August 2018 to July 2019 there were 320 compliments about medicine at Broomfield

Hospital (28.5% of all compliments received trust-wide). The highest number of compliments were

received by the Stroke unit (31.9%), followed by Felstead ward (19.1%) and Baddow ward

(10.9%).

A breakdown of compliments by department is below:

Department Number of compliments Percentage of total Stroke unit 102 31.9% Felsted ward 61 19.1% Baddow ward 35 10.9% Goldhanger ward 20 6.3% Bardfield ward 17 5.3%

Dermatology 10 3.1% Cardiac department 10 3.1% Rheumatology 8 2.5% Endoscopy unit 7 2.2% Terling ward 6 1.9% Emergency short stay 6 1.9% Oncology 5 1.6%

Braxted ward 5 1.6% Acute medical unit 5 1.6% Medicine specialty 4 1.3% PICC Trust 3 0.9% Feering ward 3 0.9%


Neurology department 3 0.9% Ambulatory care 3 0.9% Danbury ward 2 0.6%

Writtle ward 2 0.6% Renal/dialysis unit 2 0.6% Chemotherapy suite 1 0.3% Total 320 100.0%


pathway with patients and relatives thanking staff for their kindness and compassion during

difficult and stressful times. These related to all staff from housekeepers, porters and nurses to

consultants.

Compliments and the associated learning and sharing of good practice was discussed at the

patient and carer experience group and also with individuals and their managers during appraisal.

The trust used its electronic reporting system to analyse themes from compliments.



the investigation into their complaint. Staff told us they initially verbally acknowledged complaints

and tried to resolve them at ward level. If the complaint was more serious staff knew how to

escalate the concerns to their manager and understood the role of the complaints team in

investigating complaints.


service. Changes were made to the service as a result of feedback and complaints. Staff told us

that complaints were discussed at team meetings, and we noted records of team meetings

showed complaints had been on the agenda.

Complaints were also discussed as hot topics, at governance meetings and handovers to ensure

staff understood shared learning from complaints to improve performance.


Leadership

Leaders had the integrity, skills and abilities to run the service. They understood and

managed the priorities and issues the service faced. They were visible and approachable in

the service for patients and staff. They supported staff to develop their skills and take on

more senior roles.

The medical division was led by the divisional lead, who was a consultant geriatrician, associate

director of nursing and the associate director of operations. At local level matrons oversaw multiple

wards and assisted ward managers. Staff spoke positively about the leadership team and said that

over the last few months leadership of the wards had got stronger.

All staff we spoke with spoke very highly of the executive team, saying that they were visible,

approachable and new staff members’ names.

Vision and strategy


The service had a vision for what it wanted to achieve and a strategy to turn it into action,

developed with all relevant stakeholders. The vision and strategy were focused on

sustainability of services and aligned to local plans within the wider health economy.

Leaders and staff understood and knew how to apply them and monitor progress.

The trust had a vision that was to be a health care organisation that puts patient care first and

whose reputation for excellence and innovation inspires our patients, staff and the population we

serve. The staff values were based on, “We are a kind, professional positive team”.

The medical wards had their own philosophy of care displayed on each ward. This was a

philosophy that encouraged staff to work towards every day excellence in the service to provide

care to patients.

Throughout our inspection we noted that staff displayed behaviours which met the trust’s vision

and ward philosophies.

All wards displayed their improvement journeys on notice boards. These demonstrated

achievements towards achieving the trust’s vision and improvements.

Culture

All staff we spoke with said that there was a positive culture within the medicine division. Staff felt

supported and cared for and developed strong professional relationships with colleagues.

Staff knew the trust had freedom to speak up guardians but told us they felt able to speak up if

they felt something was wrong, or they felt something was not fair.

There was a culture of mutual respect amongst the multidisciplinary staff teams, with staff

respecting each other professional knowledge and how this could be best used to serve the

patient’s needs.

On all the wards we visited we found staff with positive attitudes, who were welcoming and

friendly, were proud to show us what they did and tell us how they were going to improve. Patients

benefited from a culture where staff were prepared to listen to each other and share ideas to

improve patient care.

Staff handovers were patient focused. We never heard staff on the wards talking about bed

capacity, they focused on the patients and their needs. Staff were focused on safe discharges and

finding the right treatment pathways to enable patients to leave the hospital safely and quickly.

Governance




The trust had effective governance systems in place, this was an improvement from our last

inspection. Each division had a governance meeting monthly which reported into their divisional

board, chaired by the divisional director. The meetings focussed on the overarching finance,

performance, quality and workforce issues for their division. The divisional board informed the

monthly performance and accountability meetings held with the senior leadership team, as well as

the quality meetings held at service level. For example, risk and compliance, patient safety, patient

experience and clinical effectiveness all reported into the site governance forum.


Safety and quality were a key part of the board agenda and agreed quality measures, based on

local and national priorities, were reviewed by the board through the integrated performance board

report. With effect from February 2019, following the trust merging with two other NHS trusts they

shared a quality committee across the three sites. This functioned as the trust’s umbrella clinical

governance committee, providing the board with assurance that the trust was delivering a quality

trust against each of the dimensions set out in High Quality Care for All (2008) for all and

enshrined in the Health and Social Care Act 2012.

In order to ensure that the non-executive directors had sufficient opportunity to scrutinise

performance in their respective trust’s, each site had a site governance forum (SGF). The SGF’s

were able to escalate issues to the committees and boards across the three sites on an exception

risk-basis. Patient stories were shared and discussed at Boards and SGF’s, and directors made

site visits to wards for additional assurance on quality and safety.

We reviewed governance meeting minute records from September and October 2019 and found

these to be comprehensive and covered areas of quality linked to performance, including mortality,

training and development, risk and strategy.


Leaders and teams had systems to manage performance. They identified and escalated

relevant risks and issues or identify actions to reduce their impact. They had plans to cope

with unexpected events. Staff contributed to decision-making to help avoid financial

pressures compromising the quality of care.

During our inspection we reviewed the trust’s risk register. The risk register was monitored within

the governance framework and regularly reviewed.

Managers that we spoke with were aware of risks within the medicine service and mitigating

actions to reduce these.

Risks included nurse staffing levels, lack of physical bed space and patient flow through the

hospital. The trust was actively using data and technology to increase flow, maximise on patient

bed space and reduce delayed discharges to improve flow throughout the wards.

The recruitment strategy and appointment of key staff, for example flow coordinators, trusted

assessors and specialist staff for dementia and falls, contributed significantly to responding to risks

across the trust in order to improve patient care.

Staff used data routinely to improve performance. The investment in the patient tele tracking

system meant that staff could use live data to improve performance across the wards and manage

flow to reduce delays and improve patient outcomes.

Audits were routine, staff used data to improve performance and identify any additional risks or

areas that required improvement within the trust.


The service collected reliable data and analysed it. Staff could find the data they needed, in

easily accessible formats, to understand performance, make decisions and improvements.

The information systems were integrated and secure. Data or notifications were

consistently submitted to external organisations as required.


In May 2017, a new electronic patient record system led to problems with accurately tracking

patients and capturing validated accurate referral to treatment (RTT) data. At the time of our

inspection, RTT formal data submission was not taking place (ceased in January 2018 with the

support from NHS England), however, the trust had implemented a number of local measures to

monitor RTT times. All patients who did not meet RTT were reviewed for harm.

The trust intranet provided staff a wealth of up to date policies and guidance to help them plan,

deliver and monitor patient care and outcomes.

Staff were aware of how to use and store confidential information.

The trust used a combination of paper and electronic records for recording patient observations.

Staff also accessed key data from hand held IT tablets that were used to monitor patients

conditions and alert them to any deteriorating patients.

The trust had arrangements in place which ensured data was submitted to external providers as

required for example, serious incidents and never events.

Engagement

Leaders and staff actively and openly engaged with patients, staff, equality groups, the

public and local organisations to plan and manage services. They collaborated with partner

organisations to help improve services for patients.

Staff we spoke with said they could attend a wide range of meetings to participate in engagement

with managers and the senior team.

The 2018 staff survey showed 67% of staff felt supported by their immediate manager and 67% of

staff felt managers were invested in their health and wellbeing, and the hospital took positive

action in this area.

Stakeholders could provide feedback about their experience through the friends and family test

(FFT). The FFT was undertaken through text messaging (SMS) or intelligent voice messaging

(IVM). The trust also used hard copy questionnaires to supplement response rates in care of the

elderly wards.

The trust had a patient experience group with a diverse membership, who provided feedback

through this forum. Patient advice and liaison services (PALS) posters were displayed around the

wards which advised patients on how to give feedback or make a complaint. Patients could also

complete a ‘thank you’ card or feedback via websites, including Care Opinion or NHS Choices as

well as through social media forums.

The trust had a patient council that carried out regular patient surveys where the views and

opinions of patients were canvassed. Patients, relatives, and carers could feedback about their

experience to the local Health Watch.

The trust had a schedule of 'In Your Shoes' patient listening events, this previously included a

listening event for the bereaved. Patients were invited into the trust where they shared their

experience of the care that they had received.

When a patient died, their next of kin were sent a survey where they could give feedback about

theirs and their loved one’s experience.

The trust had a newsletter to share key information to staff.



All staff were committed to continually learning and improving services. They had a good

understanding of quality improvement methods and the skills to use them. Leaders

encouraged innovation and participation in research.

The medicine team had developed a game for patients with called "Either, neither or both" to help

initiate conversations with patients. Staff providing one to one care or meaningful time with a

patient used this game to enhanced conversation and stimulate dialogue. There was a pocket

pack of 100 cards with a choice of two subjects on the cards that staff used as an aid for

conversation and getting to know their patients better.

Inspired by the NHS England’s “Sign up to Safety Kitchen Table Events”, the provider’s falls

service took the kitchen table to the wards. Using the idea of a table cloth and having tea, coffee,

biscuits and sweets, staff were invited to take a five minute break and have a chat about the the

trust’s frailty harm awareness document. This was a quick glance guide to assist staff unfamiliar

with clinical frailty to consider tissue viability, medication, bone health, end of life care, falls

interventions, nutrition, delirium, dementia and avoiding deconditioning. The document was

permanently hosted on the trust’s falls intranet page. The mobile kitchen table also promoted the

dangers of deconditioning.

The trust introduced a virtual dementia tour for staff. This was an eight minute immersive

experience enabling staff to gain empathy and greater understanding when interacting with

patients living with dementia. All staff could enrol onto the course as any staff member potentially

could have contact with people living with dementia. Staff we spoke with were extremely positive

and told us this gave them increased understanding of what it was like for patients living with

dementia.

The trust had a consultant clinical champion for medicine medical staffing. A senior consultant met

a minimum of three times a week with the rota co-ordinator for medicine, to review the medical

rotas of all grades of doctors to provide advice and guidance regarding allocation of staff and

cover for rota gaps. The consultant also advised the rota co-ordinator the allocation of junior

doctors across the medical wards and assessed safe minimum medical staffing levels, when there

were staff shortages due to sickness.

Following our last inspection, the trust had trailed the role of a flow coordinator on three of the

wards as part of improving the safer patient flow bundle compliance and safe discharge. The flow

co-ordinators played a pivotal role in supporting the nurse in charge with planning patients

discharge and acted as a link between the clinical team and the integrated discharge team. The

trust told us that the wards with flow co-ordinators had more discharges before midday as all

processes were in place in a timely manner. Following the trial, funding had been identified to

support the introduction of patient flow coordinators onto all medical wards, to work alongside the

clinical teams to deal with all escalations around patient discharge pathways.

The medicine team had developed the role of an assistant infection prevention and control

practitioner to support the wards to deliver a comprehensive infection prevention and control trust.

The post-holder provided a visible presence and was accessible to clinical teams, patients and

trust users. They took an active role within the infection prevention and control trust, providing

support to clinical and non-clinical staff within the trust to help ensure that patients are cared for in

a clean and safe environment.

The trust had a shared care programme in renal replacement therapies (DIY Dialysis). The shared

care (formerly self-care) programme was non-compulsory. The new programme allowed patients


to gain a better understanding of their chronic condition and a better understanding of their

treatment. Patients who signed up, encouraged others to get involved, to improve overall health

and well-being and 50 out of the 139 patients eligible had signed up at the time of our inspection

The trust had introduced pet therapy on its renal unit. A dog visited the unit once a week, providing

renal patients with a welcome distraction from the monotony of dialysis. Staff noticed a significant

difference to patient’s body language and mood on the days the dog visited the unit.

The trust’s falls clinical nurse specialist (CNS) and assistant director of nursing, identified that

patients within the stroke unit had a known risk of falling but sat outside of the National Institute

for Health and Care Excellence (NICE) Falls in older people: assessing risk and prevention

(CG 161). This guideline covered assessment of fall risk and interventions to prevent falls in

people aged 65 and over. It aimed to reduce the risk and incidence of falls and associated

distress, pain, injury, loss of confidence, independence and mortality.

In order to address this issue, and promote safety among this patient group, the trust held a

weekly meeting with the matron, senior ward sister, and thrombolysis lead, to review all patients

with this area with a focus on factors contributing to falls. For example, known falls risk, current

mobility, witnessed impulsivity and opportunities to fall. The process was plan, do, study act

(PDSA) assessed and lead to stroke-specific identification of falls risks and individualised

interventions pertinent to this specific client group being implemented.

The red bag scheme was launched within Mid-Essex to identify patients from care homes to

improve two-way communication for this cohort of patients. The bags were held in the care homes

and when a patient was transferred to an acute trust the red bag was sent with all relevant

paperwork, medication and some personal belongings. The bag stayed with the patient all the way

through their journey and ensured that vital information related to the patients, for example, do not

attempt cardiopulmonary resuscitation status (DNACPR) was shared with all clinical teams and

any updated status returned with the patient on discharge.

We noted the trust held ‘red to green bed day’ meetings, with input from nursing staff, medical

staff, allied health professionals, mental health colleagues and social care. Red and green bed

days are a visual management system to assist in the identification of wasted time in a patient’s

journey. It was applicable to in-patient wards in both acute and community settings, this approach

was used to reduce internal and external delays as part of the SAFER patient flow bundle.

The trust held a daily, medically fit patient review, which took place in the operations centre. The

nurse in charge or patient flow co-ordinator from each ward had an opportunity to meet and get a

two-way update with representatives from the integrated discharge team to ensure all complex

discharge patients had a clear plan. This improved planning around patients but and the added

benefit of supporting the education of the clinical teams around discharge pathways and

processes available to the patients.

The trust was piloting a bank staffing ‘app’ designed by the trust to work across organisations and

across care sectors. This innovation differed from other staffing apps by being skills-based and

used the data to identify where skill gaps were, and the likelihood of these shifts being filled. The

pilot has demonstrated that agency spends were reduced and there was an increased shift fill rate

to near 100%.


Surgery


The trust’s surgical division at Broomfield Hospital has six divisions: specialist surgery

(ophthalmology, which is now a Mid and South Essex (MSE) group managed specialty, oral

maxillofacial surgery (OMFS), ear, nose and throat (ENT) and audiology), musculoskeletal

services (trauma and orthopaedics and rheumatology), surgical specialties with endoscopy

(upper/lower gastrointestinal, colorectal, breast, vascular and urology) and theatres, and critical

care including anaesthetics and pain.

Operating takes place mainly at Broomfield Hospital with an inpatient theatre suite (consisting of

25 theatres) and day stay unit (consisting of three theatres). Emergency patients are seen on

Billericay ward, which is also the inpatient ward for Essex ear, nose and throat network. There is a

surgical emergency ward with a GP referral and ambulatory unit process where general surgery

emergencies are assessed and admitted or treated.

In addition, some elective orthopaedics, ophthalmology, and day case surgery is carried out at

Braintree Community Hospital. There are plans to expand the elective orthopaedic work at

Braintree to offer better patient choice and create a centre of excellence. At the time of our

inspection, Braintree Community Hospital offered elective hip and knee replacement surgery to

elective patients only.

Clinics take place at St Peter's Hospital in Maldon and Braintree Community Hospital for several

specialties in addition to those at Broomfield Hospital.

The trust is the centre for ENT and OMFS which work as hub and spoke networks with

neighbouring trusts.


The trust had 35,566 surgical admissions from March 2018 to February 2019. Emergency

admissions accounted for 12,396 (34.9%), 18,318 (51.5%) were day case, and the remaining

4,852 (13.6%) were elective.


Ward/Unit Speciality or description Inpatient beds Theatres admissions and day stay unit

Surgical day stay with inpatient capacity

0

SEW (Surgical Emergency Ward)

Emergency surgical assessment unit

19

Rayne Ward Surgical – Urology and vascular

26

Day stay unit Surgical Day Stay with inpatient capacity

0

Notley Ward Trauma and orthopaedics 28

Lister Ward Orthopaedic rehabilitation (and medical patients)

20

John Ray Ward Elective orthopaedic ward 28


Billericay Ward Emergency and elective specialist surgery

24

Preadmission Service Anaesthetic preassessment Theatres Theatre suite

Day Surgery (Braintree Community Hospital)

Two theatres primarily for ophthalmology and elective orthopaedic

Elective orthopaedic (Braintree Community Hospital)

Elective orthopaedic activity to a maximum of 16 beds

16

During this inspection, we visited surgical wards, main theatres and day stay theatres, the post

anaesthetic care unit and pre-assessment. We reviewed 21 medical records, policies and

pathways and spoke with 28 staff (of varying grades) and five patients and relatives.





Mandatory training

The service provided mandatory training in key skills to all staff however and most staff

had completed it.




Broomfield Hospital


staff in surgery at Broomfield Hospital is shown below:


Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)

Hand hygiene 295 308 95.8% 85% Yes Information governance 295 308 95.8% 95% Yes

Waste management 295 308 95.8% 85% Yes Equality and diversity 292 308 94.8% 85% Yes Medicine management training 282 298 94.6% 85% Yes Health and safety 287 308 93.2% 85% Yes Moving and handling 280 308 90.9% 85% Yes Moving and handling for people handlers

267 299 89.3% 85% Yes

Fire safety 264 308 85.7% 85% Yes Adult immediate life support 171 205 83.4% 85% No Adult basic life support 81 101 80.2% 85% No


In surgery, the trust target was met for nine of the 11 mandatory training modules for which

qualified nursing staff at Broomfield Hospital were eligible.


surgery at Broomfield Hospital is shown below:


Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)

Medicine management training 16 16 100.0% 85% Yes Waste management 190 200 95.0% 85% Yes Information governance 184 200 92.0% 95% No Health and safety 180 200 90.0% 85% Yes Hand hygiene 176 200 88.0% 85% Yes Moving and handling 176 200 88.0% 85% Yes

Fire safety 169 200 84.5% 85% No Equality and diversity 151 200 75.5% 85% No Adult immediate life support 61 91 67.0% 85% No Adult basic life support 73 115 63.5% 85% No Paediatric immediate life support 48 85 56.5% 85% No Paediatric basic life support 37 113 32.7% 85% No

In surgery, the trust target was met for five of the 12 mandatory training modules for which medical

staff at Broomfield Hospital were eligible.

During surgical procedures, children were accompanied and cared for by paediatric trained

members of staff from the children and young people’s service.


Nursing staff received and kept up-to-date with their mandatory training. Data supplied by the trust

following our inspection showed that nursing staff’s overall compliance with mandatory training

was 93% as of 31 October 2019.

Mandatory training was a mixture of face to face and online training. Staff accessed computer

terminals throughout ward and office areas to complete required training. We spoke with nursing

staff from varying grades. Staff told us they could access training however it was sometimes a

challenge to fit online training in the working day.


training. Locally, ward managers oversaw nurse compliance with mandatory training. In a bid to

improve compliance, staff requiring training were reminded on staff notice boards and in person by

ward managers.

Medical staff did not keep up-to-date with their mandatory training. We spoke with service leaders

who described various challenges in maintaining medical staff’s compliance with mandatory

training targets.

Data supplied by the trust following our inspection showed that medical staff training overall

compliance was 84% as of 31 October 2019. This did not meet the trust’s target of 85%.

Senior staff told us there was a lack of communication around mandatory training and competency

requirements from start of employment. At the time of our inspection, induction processes were

being reviewed in the aim of improving compliance with mandatory training.


Issues included but were not limited to; a lack of automated reminders when courses were due for

renewal, staffing and poor communication with new medical staff around the requirements of

mandatory training during the initial induction period. In response to non-compliance, the service

was looking at adopting a training model, used by a local NHS trust to improve compliance. At the

time of our inspection no formal plans had been made.

Audit days (monthly) were used to provide opportunities for mandatory training for staff who were

non-compliant.

The service provided sepsis training for staff within the surgery division. Overall, 95.8% of nursing

staff and 75.4% of medical staff had completed sepsis training.

Safeguarding


agencies to do so. However, whilst not all staff were up-to-date with training on how to

recognise and report abuse, they knew how to apply it.







Broomfield Hospital


nursing staff in surgery at Broomfield Hospital is shown below:

The tables below include prevent training as a safeguarding course. Prevent works to stop individuals from getting involved in or supporting terrorism or extremist activity.


Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)

Prevent - awareness 17 17 100.0% 85% Yes Safeguarding children (level 3) 1 1 100.0% 60% Yes Safeguarding adults (level 1) 294 308 95.5% 95% Yes Safeguarding children (level 1) 288 308 93.5% 95% No

Prevent - basic awareness 282 308 91.6% 85% Yes Safeguarding children (level 2) 280 308 90.9% 95% No Safeguarding adults (level 2) 279 308 90.6% 95% No

In surgery, the trust target was met for four of the seven safeguarding training modules for which



in surgery at Broomfield Hospital is shown below:


Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)



Safeguarding adults (level 1) 157 200 78.5% 95% No Safeguarding adults (level 2) 136 199 68.3% 95% No Safeguarding children (level 1) 135 200 67.5% 95% No


In surgery, the trust target was met for one of the five safeguarding training modules for which

medical staff at Broomfield Hospital were eligible.


Nursing and medical staff received training specific for their role on how to recognise and report

abuse. However, not all staff were up-to-date with training. Nursing staff compliance ranged from

90.6% to 93.5% and was therefore near the trust’s target of 95% compliance. Medical staff did not

reach the target in any four of the safeguarding training courses with compliance ranging between

64% and 78.5%.

After our inspection we requested up to date data showing compliance with safeguarding training.

Overall, 87% of nursing and medical staff had received training. However, the service did not

supply data by staff group. This was below the trust target of 95%.


those with protected characteristics under the Equality Act. All staff we spoke with could describe

potential safeguarding concerns and subsequent reporting and escalation processes. Staff had

access to adult and child safeguarding polices. Both were within their review date and easily

accessible to staff through computer terminals.

Safeguarding information and guidance was available both electronic and in poster/paper format

at regular intervals through departments.

Staff knew how to make a safeguarding referral and who to inform if they had concerns. Staff

knew how to access safeguarding leads to gain advice relating to safeguarding concerns. Out of

hours, the trust’s site team supported staff. The trust’s safeguarding team responded to

safeguarding concerns raised and were accessible to staff.


with other agencies to protect them. Staff were clear of their responsibilities and could describe

trust processes for the reporting of concerns and liaising with other agencies such as social

services.


The service did not always control infection risk well. The service used some systems to

identify and prevent surgical site infections. Staff used equipment and some control

measures to protect patients, themselves and others from infection. They mostly kept

equipment and the premises visibly clean.

Staff cleaned equipment after patient contact but did not always label equipment to show when it

was last cleaned. During our observations of surgical wards, we saw inconsistent use of ‘I am

clean stickers’, which were used to show that staff had cleaned equipment after use. Whilst nearly

all equipment appeared clean, it was not clear if effective cleaning had taken place.


Steps and parallel bars within the therapy room were marked with ‘I am clean’ stickers. However,

equipment was visibly dusty, sticky in places and had hairs on surfaces. We raised our concerns

to the ward manager who advised they would rectify this issue.

Wards had side rooms for the isolation of patients with known or suspected infectious disease.

Clear signage was in place to restrict access to side rooms in the event of caring for a patient with

an infectious disease.

Staff did not always work effectively to prevent, identify and treat surgical site infections. Theatre

and post anaesthetic care unit staff were provided with gowns to cover surgical scrub clothing

when leaving theatre areas. During our inspection we saw that staff did not always use gowns and

that they were not always properly tied, leading to possible ineffective practices in preventing and

controlling the spread of infection. When we returned at our unannounced inspection, we saw on

six occasions that staff did not have gowns tied correctly and in two cases, we saw staff leaving

theatre areas without gowns in place. We escalated our concerns to the matron for the service.

The matron advised that this had previously been identified as a risk and in response to our raising

of concerns, the service circulated information to staff outlining the importance of gowns to prevent

and spread the risk of infection and placed signage in key areas within the department. However,

staff were still not using gowns as required.

Staff within the theatre department were not fully compliant with the surgical site infection (SSI)

bundle, used to prevent SSI’s. The National Institute for Health and Care Excellence, quality

standard QS49, Quality statement three, recommends the measurement and documenting of core

temperature in accordance with NICE’s guideline on ‘hypothermia: prevention and management in

adults having surgery’. This was also not in line with NICE guideline NG125, maintaining patient

homeostasis.

We raised our concerns at the time of our inspection relating to a lack of documented temperature

taking during surgical procedures. The trust reminded all staff of intraoperative warming guidance,

and complied an action plan to address any identified areas of non-compliance.

After our inspection we requested surgical site infection (SSI) data. In colorectal surgery, from

October 2018 to September 2019, inpatient infection rates ranged from 4.2% to 6.3%. This was

below the national average for all months.

In gastric surgery, from October 2018 to September 2019, inpatient infection rates were between

2.9% and 3.8%. Whilst this was above the England average, it is to be noted that this reflects a

small patient group with one inpatient surgical site infection during this period.

The service monitored SSI rates in orthopaedic services, which included total hip replacements

(THR), total knee replacements (TKR) , fractured neck of femur (NOF) and long bone fractures.

Surgical site infection rates for April 2018 to March 2019 can be seen in the table below:

Orthopaedic service Q1 Q2 Q3 Q4

THR 0% 0% 1.2% 1.5%

TKR 1.1% 1.2% 2.7% 2.7%

NOF 2.2% 2.0% 1.7% 2.2%

Long bone fractures 2.2% 0% 0% 1.5%

The SSI rates detailed above related to one or two patients per quarter.

Theatre changing areas (main theatres) were cramped and contained a lack of effective hanging

space and shoe storage. We raised concerns during our inspection that visibly dirty theatre clogs


were in changing areas, mixed with outdoor shoes. Changing rooms also had areas of damaged

flooring. This potentially posed an infection prevention and control risk. Staff told us this point had

been raised but nothing had been done to date to address these concerns. We escalated our

concerns to a matron during our inspection The matron assured us that these concerns would be

addressed.

Pre-admission clinics for planned and elective surgery took place. Patients were screened for

methicillin-resistant staphylococcus aureus (MRSA) at this appointment. MRSA is a specific

bacteria that is resistant to the methicillin group of antibiotics. In the event of a positive result,

patients were offered treatment to further prevent and control the spread of infection.

MRSA screening for elective and non-elective patients was not consistently compliant with the

trust target (95% and above). Data supplied by the service after our inspection demonstrated that

compliance in theatres and anaesthetics from November 2018 to October 2019 varied. The target

was 95% and was not met in six months of this period for non-elective patients and in 10 months

for elective patients. Non-compliance ranged from 85% to 94.4% during this time. For the same

time frame in surgery, the target was not met any month months of this period for non-elective and

elective patients. Results varied from 81% to 93% for this timeframe.

Ward areas were clean and had suitable furnishings which were clean and well-maintained. All

clinical areas (including theatres) were visibility clean and free from dirt. Throughout the course of

our inspection we saw cleaning taking place at regular intervals.

Trolley beds, mattresses and wheelchairs were free from tears to prevent and control the spread

of infection and enable effective cleaning to take place.

However, one blood glucose monitoring box contained clean needles with blood on. We raised our

concerns to the senior nurse in charge who immediately removed this from service and replaced

with clean equipment.


Personal protective equipment (PPE) was available at regular intervals throughout clinical areas.

PPE included, but was not limited to; gloves, masks and aprons. Staff had arms bare below the

elbow to prevent and control the spread of infection.

Hand cleansing gel was available at regular intervals in all areas we visited. Information displaying

the ‘five moments of hand hygiene’ was available for both staff and visitor information. This was in

line with the World Health Organisation (WHO) guidelines on hand hygiene in health care.

However, during our inspection, we saw that not all theatre staff used cleansing hand gel entering

the theatre department. This is not good practice to prevent and control the spread of infection.

The service carried out monthly local audits to assess if effective practices were in place to detect,

prevent and control the spread of infection. Audits covered various areas including, but not limited

to; hand hygiene, decontamination of equipment and urinary catheter care bundle (where

applicable).

Audit data provided after our inspection demonstrated that for October 2019, hand hygiene

compliance was 69% for Heybridge ward, 98% for Rayne ward, 100% for Billericay ward and 73%

for the surgical assessment ward. Staff were individually challenged if noted to be non-compliant

with hand hygiene guidance with local action plans in place to monitor and improve compliance.

Disposable curtains used to separate cubicles and provide privacy were visibly clean, undamaged

and replaced at regular intervals.


Equipment was stored above floor level to enable effective cleaning to take place.

Staff could access an infection control policy to provide guidance on preventing and controlling the

spread of infection. In addition, other guidance was in place for safe handling of devices such as

intravenous cannulas (used to administer medicines and fluids). In addition, an infection

prevention and control link nurse was available for advice and support.

Pre-assessment clinics were carried out for all elective (planned) surgical patients where MRSA

screening took place prior to surgery.

Staff complied with the Control of Substances Hazardous to Health Regulations 2002. Cleaning

fluids were securely stored with risk assessments in place. We reviewed risk assessments and

saw all were within their review date and accessible to staff electronically.


The design, maintenance and use of facilities and premises kept people safe. Staff

managed clinical waste well. Staff were trained to check equipment however, staff did not

always check equipment in line with service policy and procedures.

Surgical areas and wards were located to minimise transfer times and improve patient access.

Patients could reach call bells and staff responded quickly when called. During our inspection, we

saw that call bells were answered in a timely manner. Patients had call bells within reach.

Staff carried out daily safety checks of specialist equipment. Emergency equipment including

resuscitation trolleys were checked on both a daily and weekly basis, in line with trust policy. We

saw that trolleys in ward areas had been checked on a regular basis since August 2019.

Emergency equipment was well maintained, accessible and tidy meaning staff could gain access

to vital equipment in a timely manner. Emergency equipment was tagged, with corresponding

documentation of tags numbers so staff could be assured equipment was complete and not

tampered with.

In the theatre department, staff completed daily checks on ‘technical check sheets’ to ensure

equipment including anaesthetic machines and resuscitation equipment were safe for use. We

reviewed check sheets from 1 to 6 November 2019 and saw a check had not been completed on 5

November 2019. In another theatre we looked at check sheets for anaesthetic machines. This had

not been completed on the day of our inspection. We raised our concerns with staff who advised

equipment had been checked but not documented.

Within recovery areas, staff had access to emergency resuscitation equipment. We reviewed one

trolley and checklists within recovery and equipment had been checked on a daily basis, in line

with trust policy.

Difficult airway trolleys were located within the theatre department and had been checked on a

regular basis to ensure the availability of equipment. Difficult airways equipment is used when

clinicians require specialist equipment to manage a patient’s airway.

Staff disposed of clinical waste safely. Clinical waste was clearly segregated from domestic waste

in colour coded bags. Sharps (needles) were disposed of in appropriate containers which were

within safe fill limits to prevent needlestick injuries to staff and others.

We reviewed a sample of consumable items from all wards we visited. All consumables were

found to be in date and well organised.


Reusable surgical equipment was cleaned and sterilised offsite. We visited the sterile services

department (SSD) and saw equipment was sealed, tidy and well organised, with clear separation

of ‘clean’ and ‘dirty’ areas to prevent cross contamination. Operating equipment was prepared in

advance to ensure availability on the day of surgery.

Surgical equipment was tracked and colour coded, dependent on speciality, This meant in the

event of post-operative complications, equipment could be tracked and examined, should the need

arise.

Trust wide, registers were in place to monitor service requirements of individual pieces of

equipment. We inspected a number of items including defibrillators, blood pressure machines and

electrocardiographs. All demonstrated that service and maintenance had taken place at

recommended intervals.

Fire extinguishers throughout the surgical division were secured to the wall and serviced at

recommended intervals.


Staff did not always complete and update risk assessments for each patient. However, staff

identified and quickly acted upon patients at risk of deterioration.

Pre-assessment clinics were carried out for all elective (planned) surgical patients. Clinics

assessed patient suitability and health prior to surgical procedures taking place.


appropriately. In all records we reviewed, we saw that national early warning scores (NEWS) had

been recorded and acted upon in a timely manner, where applicable.

Staff within interventional radiology (managed by radiology services at the trust) utilised one of the

main theatres. Theatres provided anaesthetic support for patient’s undergoing sedation for

interventional radiology and at the time of our inspection.

Staff knew about and dealt with any specific risk issues. Staff had access to a clinical guideline

named ‘early identification and treatment of sepsis’. The guideline was within review data and

directed staff on actions to take in event of suspected or known sepsis. The guideline contained

sepsis screening and action tools/flowcharts, which we saw were prominently displayed in clinical

areas.

After our inspection we requested up-to-date compliance for sepsis training. The service provided

sepsis training for staff within the surgery division. Overall, 95.8% of nursing staff and 75.4% of

medical staff had completed sepsis training.

It is to be noted that a number of staff groups failed to meet the trust target of 90% including but

not limited to; medical staff (FY2, ST3+ and consultants).

Staff did not always complete risk assessments for each patient on admission / arrival. Staff were

required to complete venous thromboembolism (VTE) risk assessments for all patients. After our

inspection we requested audit data for VTE risk assessment compliance. The national target for

VTE risk assessment completion is 95%. From November 2018 to October 2019, surgery services

did not achieve the 95% target, with compliance ranging from 80.6% to 90.3%. Whilst failing to

meet the target, compliance had risen steadily from March 2019. When reviewing medical

records, we found that four did not contain a venous thromboembolism (VTE) risk assessment

(either paper or electronic). VTE risk assessment compliance was identified as a risk at our last

inspection in October 2018.


VTE risk assessments were documented on a hand held electronic device. As the majority of

patient documentation was paper based, staff described the electronic recording of VTE as

disjointed and therefore difficult to achieve compliance with.

The World Health Organisation (WHO) checklist is a tool used in theatres to improve safety of

surgical procedures by bringing together the whole operating team. The checklist is used at

various stages of surgery, including prior to anaesthesia, prior to incision and before staff leave the

operating room.

Staff at the hospital used the WHO checklist for each patient having surgery. During our

inspection, we saw the ‘time out’ section of checks taking place which is used to check patient

identity, the site of surgery and what procedure is planned to take place. During this check, we

noted that the consultant surgeon was not involved in this process. Therefore, we could not gain

assurances that there was a positive safety culture in relation to the WHO checklist. A senior

member of staff described difficulties in ‘getting the consultants and anaesthetists on board’ with

WHO checklist completion. However, there was a focus within the service to improve compliance

with the WHO checklist which was discussed at regular intervals at meetings.

The Local Safety Standards for Invasive Procedures (LocSSIPs) Group oversaw implementation

of the WHO safer surgery checklists. In May 2019 the group requested more assurance with

compliance with the WHO checklist. As a result, an observational audit of theatres and the

endoscopy suite took place. Results demonstrated that in four out of 40 cases a debrief was not

conducted, in seven cases the debrief was conducted without the full attention of staff.

The theatre team carried out monthly self-assessment audits to improve compliance with the WHO

checklist. From April 2019 to September 2019, compliance was 100% for staff carrying out all

elements of the WHO checklist.

The service had 24-hour access to mental health liaison and specialist mental health support. Staff

had access to the 24 hour mental health liaison team in the event that support was required for a

patient. We saw that contact details and advice was available on the trust’s intranet.

Staff completed, or arranged, psychosocial assessments and risk assessments for patients

thought to be at risk of self-harm or suicide. Staff could contact the mental health team and

inpatient documentation contained risk assessments for patient with suspected or known mental

health illness.

Staff did not always share key information to keep patients safe when handing over their care to

others. On occasions, staff told us that patients arrived from the emergency department without a

handover. This meant that receiving staff were not fully aware of incoming patients acuity upon

arrival. Staff explained that whilst there was no evidence of harm to date, this practice led to a

poor patient experience and possible delays when arriving on the ward.

Shift changes and handovers included all necessary key information to keep patients safe.

Handovers were through and included a wide range of staff and other healthcare professionals.

The standard operating procedure for orthopaedic care at Braintree Community Hospital detailed

clear patient escalation in the event of a deteriorating patient, along with eligibility criteria for the

service (for elective patients only).

Nurse staffing


The service did not have enough nursing and support staff with the right qualifications,

skills, training and experience to keep patients safe from avoidable harm and to provide the

right care and treatment. However, managers regularly reviewed and adjusted staffing

levels and skill mix, and gave bank and agency staff a full induction.

Broomfield Hospital

The table below shows a summary of the nursing staffing metrics in surgery at Broomfield Hospital

compared to the trust’s targets, where applicable:

Surgery annual staffing metrics August 2018 to July 2019 July 2018 to June 2019 August 2018 to July 2019

Staff Group


Annual vacancy

rate

Annual turnover

rate

Annual sickness

rate

Annual bank

hours (% of

available hours)

Annual agency

hours (% of

available hours)

Annual unfilled

hours (% of

available hours)

Target 13% 12% 3.8%


275 25% 4% 4.2% 73,605 (10%)

58,626 (8%)

249,719 (34%)



Nurse staffing rates within surgery at Broomfield Hospital were analysed for the past 12 months


vacancy and bank use.

The service did not have enough nursing and support staff however there was a trust wide

recruitment initiative in progress at the time of our inspection. All staff we spoke with described

challenges around nurse staffing levels. Data provided prior to our inspection showed that there

was a 25% vacancy rate for qualified nurses which therefore exceeded the trust target of 13%.

We reviewed one root cause analysis investigation relating to a hospital acquired pressure ulcer.

The investigation described how a lack of staff had impacted on care provided for a patient, with a

lack of comfort rounding taking place due to reduced staffing levels. All staff we spoke with

described times where staffing was below planned levels and that often, staff were moved to other

wards within the hospital to provide cover.

Senior nursing staff described a passionate drive to recruit, retain and ‘grow’ their own registered

nurses to improve staffing levels. We spoke with staff on one surgical ward who described

supporting staff from healthcare assistant, to health care support worker training to then embark

on registered nurse training.

The service had reducing vacancy rates. The trust had embarked on an overseas recruitment

programme. At the time of our inspection recruitment had improved with more staff awaiting start

dates.

Vacancy rates within theatres remained higher than the 13% trust target at 27.8% for band five

and 19.8% for band six nurses. At the time of our inspection, 10 registered nurses from the


overseas recruitment programme were due to commence work within theatres to help reduce

current vacancy rates.

However, overall nurse vacancy rates within surgery remained higher that the trust target at 20%

as of 31 October 2019.


and healthcare assistants needed for each shift in accordance with national guidance. Theatre

staffing was managed in line with Association for Perioperative Practice (AfPP) and adjusted for

complex cases where enhanced staffing levels were required.

During our inspection we saw that the number of nurses and healthcare assistants matched

planned levels.

Turnover rates

The service had reducing turnover rates.

Monthly turnover rates over the last 12 months for qualified nurses show a downward shift from

January 2019 to June 2019.


Sickness rates

The service had rising level of sickness rates from May 2019 to June 2019.


Monthly sickness rates over the last 12 months for qualified nurses show an upward shift from

January 2019 to June 2019.


Agency staff usage

The service had rising rates of bank and agency nurses. Monthly agency hours over the last 12

months for qualified nurses show a downward trend from September 2018 to January 2019 before

gradually rising in the final six months of the period.

Monthly agency hours over the last 12 months for qualified nurses show a downward trend from

September 2018 to January 2019 before gradually rising in the final six months of the period.

(Source: Routine Provider Information Request (RPIR) - Nursing Bank and Agency tab)

Managers aimed to use bank and agency staff that were familiar with the service. Where possible,

senior staff told us they used regular agency workers to ensure familiarity with ward areas.


Please see the competent staff section of this report for more information on staff induction.

Medical staffing

Broomfield Hospital

The service had not enough medical staff with the right qualifications, skills, training and


treatment. However, managers regularly reviewed and adjusted staffing levels and skill mix

and gave locum staff a full induction.

The table below shows a summary of the medical staffing metrics in surgery at Broomfield


Surgery annual staffing metrics

August 2018 to July 2019 July 2018 to June 2019 August 2018 to July 2019

Staff Group


Annual vacancy

rate

Annual turnover

rate

Annual sickness

rate

Annual bank

hours (%

Annual locum

hours (%

Annual unfilled

hours (%


of available hours)

of available hours)

of available hours)

Target 13% 12% 3.8%


200 16% 3% 0.9% 36,431 (7%)

28,272 (6%)

53 (<1%)


Medical locum tabs)

The service had low turnover rates for medical staff. The trust target was 12% and there was a

turnover rate of 3% for medical staff.

Managers could access locums when they needed additional medical staff.

Medical staffing rates within surgery at Broomfield Hospital were analysed for the past 12 months


turnover, sickness and locum use.

Vacancy rates

The service had below average vacancy rates for medical staff.

Monthly vacancy rates over the last 12 months for medical staff show a downward shift from

February 2019 to July 2019.


Bank staff usage

The service had reducing rates of bank staff usage.


Monthly bank hours over the last 12 months for medical staff show a downward trend from

September 2018 to January 2019.

(Source: Routine Provider Information Request (RPIR) – Medical locum tab)

Staffing skill mix

In May 2019, the proportion of consultant staff, junior (foundation year 1-2) staff and registrars

reported to be working at the trust was similar to the England average. The proportion of middle

career staff working at the trust was marginally higher when compared to the England average.

Staffing skill mix for the whole time equivalent staff working at Mid Essex Hospital Services

NHS Trust

This

Trust

England

average

Consultant 49% 50%


Registrar Group~ 28% 28%

Junior* 10% 11%



The service had a good skill mix of medical staff on each shift and reviewed this regularly.

The service always had a consultant on call during evenings and weekends. Staff described that

they could access consultant when required. Out of hours, cover was provided on an on-call basis.


However, senior medical staff described that whilst consultant staffing was at appropriate levels,

there were gaps in the junior doctor rota. This led to middle grade and consultant staff ‘acting

down’ to fill vacant shifts.

Records

Staff did not always keep detailed records of patients’ care and treatment. Records were

clear, easily available but not always up to date for staff providing care. Paper and

electronic patient details were not always stored securely.

Medical records were predominantly paper based, with staff using electronic tablets for completion

of patient observations (blood pressure, respiratory rate and early warning scores) and venous

thromboembolism risk assessments.

Whilst staff could access them easily, patient notes were not always comprehensively completed.

When not in use, paper based medical records were stored in lockable cabinets, near to the

patient. We reviewed 21 sets of medical records. In three records, fluid balance charts were not

comprehensively completed.


Paper notes accompanied patients at the point of transfer.

Records were not always stored securely. On three occasions we saw computer terminals were

unlocked and medical records left unattended. We raised our concerns to a senior member of staff

who advised they would discuss these concerns with the staff members involved.

Senior staff within the service recognised the need for improvement in patient documentation and

medical records completion. Nursing and medical records were audited every other week

(documentation standards audit and care plan audits). A total of 10 sets of notes a month in each

area were audited using a variety of audit tools.

We identified concerns around the quality of documentation at our previous inspection in October

2018 where we found that records were poor in completion and contained various incomplete risk

assessment including those for malnutrition and pressure sores. A number of action plans and

audits had been implemented and carried out since October 2018. The action plan from July 2019

demonstrated improvement in some areas of assessment documentation including but not limited

to; eating and drinking, falls assessments and safeguarding. However, compliance was still poor in

other areas.

Audit data from November 2019 still showed poor compliance in medical record completion

relating to infection and sepsis, moving and handling and two-hourly care rounding assessment

documentation.

Audit results from July 2019 to October 2019 showed poor compliance with surgical care plan

completion in the following areas: lying and standing blood pressure recording, documentation of

individual needs, multifactorial assessment and medication review requests.

In the documentation standards audit, areas of non-compliance included but were not limited to;

electronic sepsis recoding, documentation within care plan booklets, entries lacked dates and a

lack of entered corresponding care plan.

The quarter two 2019/2020 surgery medical division documentation standards action plan had

been developed in November 2019. Due to it’s infancy, we were unable to see consistent

improvements in documentation.


Staff described the process of discharge letter completion. Doctors completed discharge letters

that were then sent to the patient’s GP by the ward clerk. We reviewed one discharge letter and

saw it was comprehensive and sent to the patient’s GP in a timely manner.

Medicines


medicines. However, controlled drugs checking systems and processes were not

embedded or carried out in line with trust policy.


storing medicines.

We reviewed seven prescription cards and saw that documentation was signed/dated, allergies

were documented, non-administrated medicines had a documented reason as to why this was the

case. Antibiotics had been prescribed as per guidelines (where required), writing was legible.

However, in two records, no documented patient weight was present.

Medicines were securely stored and locked in all areas we inspected. Access to drugs was

restricted to authorised personnel only. We reviewed medicines with theatre and on wards and

saw they were well organised and within their expiry dates.

Controlled drugs (CDs) cupboards were secured to walls, had robust locks in place and were

made of metal with strong hinges in line with The Misuse of Drugs Act 1971. Staff checked

controlled drugs in line with national guidance, ensuring two staff members were present at each

check.

We reviewed two months of controlled drugs checks on a surgical ward and saw medicines had

been checked on a daily basis from 1 October 2019 to 7 November 2019 with the exception of one

day.

However, staff did not always store and manage medicines in line with the provider’s medicines

policy. Ward staff described changes to local controlled drug checking processes that required two

CD checks per day. Staff found checking controlled drugs twice a day led to challenges around

compliance, estimating that each check with two members of staff took approximately 40 minutes.

We saw that twice daily checks had not taken place since 1 October 2019 with the exception of

five days within this period. This was not in line with the services controlled drugs policy

(ratification issue date June 2019) which stated: “a complete stock balance check must be

performed twice daily at the commencement of the shift. These checks may be performed with

staff from separate shifts i.e. night shift to early shift’.

Controlled drugs within the recovery area had been checked on a regular basis. In addition,

fridges within this area had daily checks carried out to maintain and ensure the integrity of

medicines stored within this area.

Medicines fridges on wards were checked on a daily basis in line with trust policy. If temperatures

were noted to be out of range, staff took appropriate action and notified pharmacy to ensure

medicines were safe for use. We saw evidence of escalation where fridges had been out of normal

range.

Intravenous fluid warming cabinets within the theatre department were maintained at

recommended temperatures and checked on a regular basis.

Medicines used within theatre were labelled and stored safely.



about their medicines. We saw medicine reviews taking place during our inspection and patients

told us that they understood why medicines were prescribed and how to take them upon discharge

if applicable.

Staff followed current national practice to check patients had the correct medicines. Each ward

had access to a pharmacist who visited on a regular basis.


received their medicines safely.

Staff within theatres described occasions where some medicines were not available. In response

to concerns, they were exploring the possibility of having a dedicated pharmacy technician to help

with this issue. Main theatres had a named pharmacist to provide support where required.

Incidents



whole team and the wider service.

When things went wrong, staff apologised and gave patients honest information and suitable

support. Managers ensured that actions from patient safety alerts were implemented and

monitored.

Never Events

Broomfield Hospital




From August 2018 to August 2019, the trust reported two incidents that were classified as never

events in surgery. Both occurred at Broomfield Hospital.

One never event occurred in February 2019 and involved a wrong site block and the other

occurred in April 2019 due to a misplaced naso or orogastric tube.



Broomfield Hospital

In accordance with the Serious Incident Framework 2015, the trust reported 26 serious incidents

(SIs) in surgery which met the reporting criteria set by NHS England from August 2018 to August

2019. All of the incidents reported within surgery occurred at Broomfield Hospital and represented

20.5% of all serious incidents reported by the trust as a whole.


Incident type Number of incidents Percentage of total Surgical/invasive procedure incident meeting SI criteria

9 34.6%

Pressure ulcer meeting SI criteria 4 15.4% Slips/trips/falls meeting SI criteria 3 11.5%


VTE meeting SI criteria 3 11.5% HCAI/Infection control incident meeting SI criteria 2 7.7% Abuse/alleged abuse of adult patient by staff 1 3.8%

Substance misuse whilst inpatient meeting SI criteria

1 3.8%

Pending review (a category must be selected before incident is closed)

1 3.8%

Treatment delay meeting SI criteria 1 3.8% Diagnostic incident including delay meeting SI criteria (including failure to act on test results)

1 3.8%

Total 26 100.0%


Staff knew what incidents to report and how to report them. All staff we spoke with could give

examples of potential incidents and describe the electronic incident reporting system in use. Staff

described a culture of feeling able to raise concerns when things went wrong and give examples of

learning from incidents where practice had changed.

Staff raised concerns and reported incidents and near misses in line with trust policy. We reviewed

a number of electronic incident reports and saw they had been reported and acted upon in a timely

manner.

Staff reported serious incidents clearly and in line with trust policy.

The service had identified non-compliance with venous thromboembolism (VTE) risk assessment

completion. From August 2018 to August 2019, the service had three serious incidents relating to

VTE’s. In response to concerns, there was a drive on VTE risk assessment awareness and regular

audits taking place. In addition, a video around VTE was produced by intensive care unit staff

outlining medication safety in response to previous serious incidents.

The service had two never events (from August 2018 to August 2019). Never events are serious

patient safety incidents that should not happen if healthcare providers follow national guidance on

how to prevent them. Each never event type has the potential to cause serious patient harm or

death but neither need have happened for an incident to be a never event. One never event

occurred in February 2019 and involved a wrong site block and the other occurred in April 2019

due to a misplaced naso or orogastric tube. Staff confirmed they were aware of never events and

could describe processes in place to prevent re-occurrence.

Theatre staff had introduced the ‘10,000 feet initiative’. This is based upon a safety initiative from

the airline industry where the aim was to reduce distractions and noise for pilots (used by another

healthcare provider within England). Surgeons called ’10,000 feet’ if they felt the environment was

noisy or distracting in the aim of reducing serious incidents within surgery.


families a full explanation if and when things went wrong. The duty of candour is a regulatory duty

that relates to openness and transparency and requires providers of health and social care

services to notify patients (or other relevant persons) of ‘certain notifiable safety incidents’ and

provide reasonable support to that person. Staff could describe the meaning of the duty of candour

and gave examples of when this had been used.

Managers debriefed and supported staff after any serious incident. Incident investigation

outcomes were shared with staff through a variety of methods. Staff received regular emails


highlighted previous incidents, staff rest-room areas displayed incident outcomes and learning. In

addition, the ward ‘safety huddle book’ enabled staff to learn more about recent incidents within

the service.

Daily safety huddles both on wards and within theatres enabled staff to share recent incident

information with staff. Staff described safety huddles and useful to keep up to date with information

and how incidents could be prevented in the future.

Monthly audit meetings provided staff with the opportunity to talk through learning from incidents.

Emails were sent to all staff detailing incident information and also displayed with various areas

throughout departments.


investigations. After our inspection, we requested three root cause analysis (RCA) investigations.

An RCA is a structured investigation to identify the cause of an incident and actions required to

prevent recurrence. A review of RCA’s showed detailed investigations had taken place, with clear

action plans. One RCA we reviewed showed evidence of cross specialist sharing of learning

between the hospital’s emergency department and surgery service.


Incident investigation feedback was incorporated in to daily safety huddles meetings and displayed

within staff rest areas.

Staff met to discuss the feedback and look at improvements to patient care. Senior staff

recognised the importance of pressure ulcer prevention. In response to a previous rise in pressure

ulcers incident reporting, the SSKIN bundle (surface, skin inspection, keep patient moving,

incontinence/moisture and nutrition/hydration) checks had been brought in to daily safety huddles

of one ward.

Managers shared learning about never events with their staff and across the trust. Incidents were

monitored locally though ward managers and also scrutinised at matron and senior management

level to enable sharing with other divisions and local trusts. This was an improvement since our

last inspection.

Monthly surgical mortality and morbidity meeting reviews fed in to service improvement. Changes

to practice included new pathway implementation, amended documentation with evidence of never

event discussion relating to incidents at other healthcare organisations to share learning.

Safety thermometer

The safety thermometer is used to record the prevalence of patient harms and to provide



their elimination.

Data collection takes place one day each month – a suggested date for data collection is given but


date.

Data from the patient safety thermometer showed that the trust reported 48 new pressure ulcers,

five falls with harm and 12 new catheter acquired urinary tract infections from August 2018 to

August 2019 for surgery.


Prevalence rate (number of patients per 100 surveyed) of pressure ulcers,

falls and catheter acquired urinary tract infections at Mid Essex Hospital

Services NHS Trust

1

Total

Pressure

ulcers

(48)

2

Total Falls

(5)

3

Total

CUTIs

(12)

1 Pressure ulcers levels 2, 3 and 4 2 Falls with harm levels 3 to 6 3 Catheter acquired urinary tract infection level 3 only


Safety thermometer data was displayed on wards for staff and patients to see. At the entrance to

surgical wards, display posters informed staff and patients about statistics outlining harm for

previous months (pressure ulcers and falls). This meant that patients, relatives and visitors were

informed about ward performance and statistics.

Staff used the safety thermometer data to further improve services. A trial applying sacral

dressings was in progress on one of the wards we visited. Data showed encouraging results with a

reduction in pressure ulcers. Due to the success, the service was in the process of sharing this

learning with other wards within the surgical division.




practice. Managers checked to make sure staff followed guidance however this was not


always the case with staff completing venous thromboembolism risk assessments. Staff

protected the rights of patients subject to the Mental Health Act 1983.


and national guidance. The service assessed for venous thromboembolism (VTE) in line with the

National Institute for Health and Care Excellence (NICE) guidelines (NG 89, Venous

thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or

pulmonary embolism).

We reviewed the trust’s guideline on the prevention and treatment of VTE which referenced

national guidance and provided clear guidance on VTE treatment and prophylaxis, broken down

by type of surgery and patient (including bariatric surgery). For more information on VTE

assessments, please see the assessing and responding to patient risk section of this report.

Staff had access to a clinical guideline named ‘early identification and treatment of sepsis’. This

provided staff with clear guidance on how to identify and treat sepsis, and contained reference to

national guidance.

Patient documentation booklets and care records contained clear guidance and tools for staff on

the recognition and escalation of patients with known or suspected sepsis. In all records we

reviewed, sepsis documentation had been completed and escalated to senior clinicians where

required.

At handover meetings, staff routinely referred to the psychological and emotional needs of

patients, their relatives and carers. We saw staff thoroughly discussed the needs of patients and

their relatives/carers with other healthcare professionals including physiotherapists, occupational

therapists and social services if required.

The service’s safer surgery pathway (including patient site marking and safe transfer) guideline

was based on national guidance and within review date. The pre-operative fasting policy for adults

and children guideline was within review date, referenced guidelines from the European Society of

Anaesthesiology regarding peri-operative fasting in adults and children.

The peri-procedural anticoagulation in adult patients taking warfarin (blood thinner) and direct oral

anticoagulants guideline referenced national guidance and had been recently ratified in October

2019.

Staff had electronic access to pathways, policies and guidelines through the trust’s intranet.

Computer terminals were available at regular intervals to enable staff to access documentation in

a timely manner. However, some staff told us the system was difficult to navigate leading to

challenges in locating specific documentation.




adjustments for patients’ religious, cultural and other needs.

Staff followed national guidelines to make sure patients fasting before surgery were not without

food for long periods. Staff followed the services pre-operative fasting policy which had been

reviewed in January 2019. The policy contained clear guidance on fasting guidelines, dependent

on patient age and referenced the Royal College of Anaesthetist guidelines. Fasting is required

prior to surgery to prevent aspiration of stomach contents in to the lungs.


Patient mealtimes were protected to ensure patients had quiet time to eat and drink without

interruption.


hydration needs. Dieticians were available to assess patients upon receipt of referral. At all times

during our inspection, we saw that patients had access to fresh drinking water (where clinically

safe to do so).

Staff regularly offered patients both hot and cold drinks. All patients we spoke with told us they had

received enough food and drink during their admission.

Staff did not always fully and accurately complete patients’ fluid charts where needed. In 21

records that we reviewed, five did not have an accurately completed fluid balance chart. We raised

our concerns with the trust during our inspection. In response, senior staff told us the results might

be due to staff sometimes used fluid balance charts for patients who did not require close

monitoring of their fluid balance Senior staff sent a briefing to staff to remind them when charts

should be completed in the aim of improving compliance.

Staff used a nationally recognised screening tool to monitor patients at risk of malnutrition. Staff

assessed patients to monitor for the risk of malnutrition using the Malnutrition Universal Screening

Tool (MUST). Records demonstrated MUST had been completed in all records we reviewed.

Specialist support from staff such as dieticians was available for patients who needed it. Staff

described the dietitian team as responsive and easy to access.

Patients waiting to have surgery were not left nil by mouth for long periods. Staff encouraged to

take clear fluids by mouth as near to surgery as possible to avoid prolonged periods without fluid

and subsequent dehydration. A theatre ‘floor co-ordinator’ contacted wards to advise of theatre

delays, where required.

Pain relief





needs and best practice. Staff used pain scoring tools to assess for levels of pain. The early

warning score in use was also used to assess levels of pain. In addition, pictorial pain scoring was

offered to patients with additional needs such as dementia.

Patients received pain relief soon after requesting it. We saw that pain levels were assessed on a

regular basis, with timely prescribing and administration of pain relief, where required.

Staff prescribed, administered and recorded pain relief accurately. All records we reviewed

showed evidence of accurate prescribing, administration and recording of pain relief.

The trust’s pain team was available Monday to Friday, 9am to 4pm and Saturday 9am-12pm to

provide guidance and advice to staff on adequately managing pain levels for patients. Out of these

hours, support was available from the on call anaesthetic team. Staff described the pain team as

responsive and accessible.


Patient outcomes

Staff monitored the effectiveness of care and treatment. However, we could not always see

that findings were used to make improvements in a timely manner.

Managers used information from the audits to improve care and treatment. Managers and staff

carried out a comprehensive programme of repeated audits to check improvement over time.

Audits covered a number of areas including but not limited to; infection prevention and control,

pressure ulcers and falls.

Managers shared and made sure staff understood information from the audits. Information from

audits was shared through ward meetings, information boards and daily huddles on the ward.

Relative risk of readmission

The service had a higher than expected risk of readmission for elective care than the England

average.

Outcomes for patients were mixed, with some national audits not meeting the national standards.

Please see data below for more information.

Elective Admissions - Broomfield Hospital

From February 2018 to January 2019, patients at Broomfield Hospital had a higher than expected

risk of readmission for elective admissions when compared to the England average.

• Plastic surgery patients at Broomfield Hospital had a higher than expected risk of readmission

for elective admissions when compared to the England average.

• Urology patients at Broomfield Hospital had a higher than expected risk of readmission for

elective admissions when compared to the England average.

• Upper gastrointestinal surgery patients at Broomfield Hospital had a higher than expected risk

of readmission for elective admissions when compared to the England average.




based on count of activity

Non-Elective Admissions - Broomfield Hospital

The service had a lower than expected risk of readmission for non-elective care than the England

average.

From February 2018 to January 2019, patients at Broomfield Hospital had a lower expected risk of

readmission for non-elective admissions when compared to the England average.


• General surgery patients at Broomfield Hospital had a similar to expected risk of readmission

for non-elective admissions when compared to the England average.

• Trauma and orthopaedic patients at Broomfield Hospital had a higher than expected risk of

readmission for non-elective admissions when compared to the England average.

• Urology patients at Broomfield Hospital had a lower than expected risk of readmission for non-

elective admissions when compared to the England average.




based on count of activity

(Source: Hospital Episode Statistics - HES - Readmissions (01/02/2018 - 31/01/2019))

National Hip Fracture Database

Broomfield Hospital

The table below summarises Broomfield Hospital’s performance in the 2018 National Hip Fracture

Database. For five measures, the audit reports performance in quartiles. In this context, ‘similar’

means that the trust’s performance fell within the middle 50% of results nationally.

Metrics (Audit indicators) Hospital

performance



Case ascertainment (Proportion of eligible cases included in the audit)

99.1% Similar Did not meet

Crude proportion of patients having surgery on the day or day after admission (It is important to avoid any unnecessary delays for people who are assessed as fit for surgery as delays in surgery are associated with negative outcomes for mortality and return to mobility)


Crude peri-operative medical assessment rate (NICE guidance specifically recommends the involvement and assessment by a Care of the Elderly doctor around the time of the operation to ensure the best outcome)


Crude proportion of patients documented as not developing a pressure ulcer



(Careful assessment, documentation and preventative measures should be taken to reduce the risk of hospital-acquired pressure damage (grade 2 or above) during a patient’s admission); this measures an organisation’s ability to report ‘documented as no pressure ulcer’ for a patient Crude overall hospital length of stay (A longer overall length of stay may indicate that patients are not discharged or transferred sufficiently quickly; a too short length of stay may be indicative of a premature discharge and a risk of readmission)

15.0 days Better No current standard

Risk-adjusted 30-day mortality rate (Adjusted scores take into account the differences in the case-mix of patients treated)

7.5% Within

expected range No current standard

(Source: National Hip Fracture Database)

Managers and staff used the results to improve patients' outcomes. After our inspection we

requested the service’s action plan for the National Hip Fracture Database. The action plan

outlined areas for improvement including reducing the time to theatre and improvements with pre

and post-operative mental tests and delirium scores. However, the action plan had been

implemented after our inspection and therefore there was little opportunity to see progress with

actions.

Bowel Cancer Audit


National Bowel Cancer Audit.


Trust performance




53.4% Fair Good is over

80%

Risk-adjusted post-operative length of stay >5 days after major resection (A prolonged length of stay can pose risks to patients)

50.0% Better than

national aggregate

No current standard

Risk-adjusted 90-day post-operative mortality rate (Proportion of patients who died within 90 days of surgery; post-operative mortality for bowel cancer surgery varies according to whether surgery occurs as an emergency or as an elective procedure)

0.0% Within


Risk-adjusted 2-year post-operative mortality rate (Variation in two-year mortality may reflect, at least in part, differences in surgical care, patient characteristics and provision of chemotherapy and radiotherapy)

21.4% Within


Risk-adjusted 30-day unplanned readmission rate

8.0% Within



(A potential risk for early/inappropriate discharge is the need for unplanned readmission) Risk-adjusted 18-month temporary stoma rate in rectal cancer patients undergoing major resection (After the diseased section of the bowel/rectum has been removed, the bowel/rectum may be reconnected. In some cases it will not and a temporary stoma would be created. For some procedures this can be reversed at a later date)

43.2% Within


(Source: National Bowel Cancer Audit)

After our inspection we requested the service’s action plan for the National Bowel Cancer Audit.

The action plan was published in January 2019 however, it had not been reviewed in a timely

manner. The most recent review took place in November 2019, which was above the

recommended maximum time frame of six months for review. Whilst there were clear actions and

recommendations, we were unable to see evidence of any action taken from January 2019 to the

date of inspection. Due to recent review, we could not gain assurances that improvements were

being made.

National Vascular Registry


National Vascular Registry.


Trust performance



Abdominal Aortic Aneurysm Surgery (Surgical procedure performed on an enlarged major blood vessel in the abdomen) Case ascertainment (Proportion of eligible cases included in the audit)

91.0% Not applicable Met

Risk-adjusted post-operative in-hospital mortality rate (Proportion of patients who die in hospital after having had an operation)

1.0% Within the


Carotid endarterectomy (Surgical procedure performed to reduce the risk of stroke; by correcting a narrowing in the main artery in the neck that supplies blood to the brain) Case ascertainment (Proportion of eligible cases included in the audit)

100.0% Not applicable Met

Crude median time from symptom to surgery (Average amount of time patients wait to have surgery after the onset of their symptoms)

14 days Not applicable Met

Risk adjusted 30-day mortality and stroke rate (Proportion of patients who die or have a stroke within 30 days of their operation)

1.7% Within the


(Source: National Vascular Registry)


National Oesophago-gastric Cancer Audit

(Audit of the overall quality of care provided for patients with cancer of the oesophagus [the food

pipe] and stomach)


National Oesophago-gastric Cancer Audit.


Trust performance



Trust-level metrics (Measures of hospital performance in the treatment of oesophago-gastric (food pipe and stomach) cancer)


61 to 70% Similar No current standard

Age and sex adjusted proportion of patients diagnosed after an emergency admission (Being diagnosed with cancer in an emergency department is not a good sign. It is used as a proxy for late stage cancer and therefore poor rates of survival. The audit recommends that overall rates over 15% could warrant investigation)

3.8% Better No current standard

Risk adjusted 90-day post-operative mortality rate (Proportion of patients who die within 90 days of their operation)

6.5% Within


Cancer Alliance level metrics (Measures of performance of the wider group of organisations involved in the delivery of care for patients with oesophago-gastric (food pipe and stomach) cancer; can be a marker of the effectiveness of care at network level; better co-operation between hospitals within a network would be expected to produce better results. Contextual measure only. Crude proportion of patients treated with curative intent in the Cancer Alliance (Proportion of patients receiving treatment intended to cure their cancer)


(Source: National Oesophago-Gastric Cancer Audit)

National Emergency Laparotomy Audit

Broomfield Hospital

The table below summarises Broomfield Hospital’s performance in the 2018 National Emergency

Laparotomy Audit. The audit reports on the extent to which key performance measures were met

and grades performance as red (less than 50% of patients achieving the standard), amber

(between 50% and 80% of patients achieving the standard) and green (more than 80% of patients

achieved the standard.



Audit’s Rating



81% Amber Did not meet

Crude proportion of cases with pre-operative documentation of risk of death



(Proportion of patients having their risk of death assessed and recorded in their notes before undergoing an operation) Crude proportion of cases with access to theatres within clinically appropriate time frames (Proportion of patients who were operated on within recommended times)


Crude proportion of high-risk cases (greater than or equal to 5% predicted mortality) with consultant surgeon and anaesthetist present in theatre (Proportion of patients with a high risk of death (5% or more) who have a Consultant Surgeon and Anaesthetist present at the time of their operation)


Crude proportion of highest-risk cases (greater than 10% predicted mortality) admitted to critical care post-operatively (Proportion of patients with a high risk of death (10% or more) who are admitted to a Critical/Intensive Care ward after their operation)

93% Green Met

Risk-adjusted 30-day mortality rate (Proportion of patients who die within 30 days of admission, adjusted for the case-mix of patients seen by the provider)

9% Within

expected range

No current standard

(Source: National Emergency Laparotomy Audit)

After our inspection we requested the service’s action plan for the National Emergency

Laparotomy Audit. The action plan assessment was undertaken January 2019 however, it had not

been reviewed since this time. The action planned lacked a documented review date, with some

actions due completion in April 2019. We could not gain assurances that improvement and

changes from audit findings were taking place in a timely manner.

National Ophthalmology Database Audit

(Audit of patients undergoing cataract surgery)


National Ophthalmology Database Audit.


Trust performance



Trust-level metrics (Measures of hospital performance in the treatment of cataracts Case ascertainment (Proportion of eligible cases included in the audit)

97.1% N/A No current standard

Risk-adjusted posterior capsule rupture rate (Posterior capsule rupture (PCR) is the index of complication of cataract surgery. PCR is the only potentially modifiable predictor of visual harm

2.2% Worse than expected

No current standard


from surgery and is widely accepted by surgeons as a marker of surgical skill. Risk adjusted visual acuity loss (The most important outcome following cataract surgery is the clarity of vision)

No data available

N/A No current standard

(Source: National Ophthalmology Database Audit)

After our inspection we requested the service’s action plan for the National Ophthalmology

Database Audit. The action plan was in working draft format and therefore we were unable to see

evidence of progress to targets which included, but were not limited to; comparison of results

against other surgery providers and ensuring accurate data collection.

National Joint Registry

(Audit of hip, knee, ankle, elbow and shoulder joint replacements)

Broomfield Hospital

The table below summarises Broomfield Hospital’s performance in the 2018 National Joint

Registry.



Comparison to other

hospitals


Tru

st-

lev

el

Case ascertainment (hips, knees, ankles and elbows) (Proportion of eligible cases within the trust that were submitted to the audit)


Proportion of patients consented to have personal details included (hips, knees, ankles and elbows) (Patient details help ‘track and trace’ prosthetics that are implanted. It is regarded as best practice to gain consent from a patient to facilitate entering their patient details on to the register)

99.7% Better Did not meet

Ho

sp

ital

lev

el:

Hip

s

Risk-adjusted 5-year revision ratio (for hips excluding tumours and neck of femur fracture) (Proportion of patients who need their hip replacement ‘re-doing’)

1.0 Within

expected range Met

Risk adjusted 90-day post-operative mortality ratio (for hips excluding tumours and neck of femur fracture) (Proportion of patients who die within 90 days of their operation)

1.0 Within

expected range Met

Ho

sp

ital

lev

el:

K

ne

es

Risk-adjusted 5-year revision ratio (for knees excluding tumours) (Proportion of patients who need their knee replacement ‘re-doing’)

1.2 Within

expected range Did not meet


Risk adjusted 90-day post-operative mortality ratio (for knees excluding tumours) (Proportion of patients who die within 90 days of their operation)

1.7 Within

expected range Did not meet

(Source: National Joint Registry)

National Prostate Cancer Audit

Broomfield Hospital

The table below summarises Broomfield Hospital’s performance in the 2018 National Prostate

Cancer Audit. Please note, the trust was not eligible the final three metrics. These metrics relate to

specific procedures and therefore it was likely that the trust did not have any patients who

underwent those specific procedures.



Comparison to other trusts


Men with complete information to determine disease status (This is a classification that describes how advanced the cancer is and includes the size of the tumour, the involvement of lymph nodes and whether the cancer has spread to different part of the body)

91.9% N/A Did not meet

Percentage of patients who had an emergency readmission within 90 days of radical prostatectomy (A radical prostatectomy involves the surgical removal of the whole prostate and the cancer cells within it; emergency readmission may reflect that patients experienced a complication related to the surgery after discharge from hospital)

No data available N/A No current standard

Percentage of patients experiencing a severe urinary complication requiring intervention following radical prostatectomy (Complications following surgery may reflect the quality of surgical care)


Percentage of patients experiencing a severe gastrointestinal complication requiring an intervention following external beam radiotherapy (External beam radiotherapy uses high-energy beams to destroy cancer cells)


(Source: National Prostate Cancer Audit)

Patient Reported Outcome Measures

In the Patient Reported Outcomes Measures (PROMS) survey, patients are asked whether they

feel better or worse after receiving the following operations:


• Groin hernias

• Varicose veins

• Hip replacements

• Knee replacements

Proportions of patients who reported an improvement after each procedure can be seen on the

right of the graph, whereas proportions of patients reporting that they feel worse can be viewed on

the left. These changes are measured in a number of different ways, descriptions of some of the

indicators presented are below.

The visual analogue scale (EQ VAS) asks patients to mark their health status on the day of the

interview on a vertical scale. The bottom rate (0) corresponds to "the worst health you can

imagine", and the highest rate (100) corresponds to "the best health you can imagine".

The EQ-5D-5L questionnaire has two parts. Five domain questions ask about specific issues;

namely mobility, self-care, usual activities, pain or discomfort, anxiety or depression. The EQ-5D-

5L uses five levels of responsiveness to measure problems. The range is; no problem to

disabling/extreme.

The Oxford Hip Score (OHS) is a patient self-completion report on outcomes of hip operations

containing 12 questions about activities of daily living. A simple scoring and summing system

provides an overall scale for assessing outcome of hip interventions.

In 2016/17 performance on groin hernias was better than the England average for both metrics

reported in the PROMs survey.

For varicose veins, performance was better than the England average for scores relating to the

EQ-5D index. In relation to EQ-VAS scores, the percentage of patients who reported feeling worse

following their procedure was lower than the England average and the percentage of patients who

reported an improvement was similar to the England average.


For hip replacements, performance was slightly better than the England average for the EQ-5D

Index indicator and similar to the England average for the Oxford Hip Score indicator. In relation to

the EQ VAS indicator, the proportion of patients reporting an improvement following procedure

was lower than the England average.

For knee replacements performance was about the same as the England average for all three

metrics.


Competent staff

The service did not always make sure staff were competent for their roles. Managers did

not always appraise staff’s work performance or hold supervision meetings with them to

provide support and development in a timely manner.

Appraisal rates

Broomfield Hospital

As of August 2019, 82.0% of required staff in surgery at Broomfield Hospital received an appraisal,

which was below the trust target of 90%.


Staff group

As of August 2019 Staff who

received an appraisal

Eligible staff

Completion rate

Trust target

Met (Yes/No)

Allied health professionals 26 28 92.9% 90% Yes Medical and dental 156 172 90.7% 90% Yes Additional clinical services 142 164 86.6% 90% No Administrative and clerical 46 56 82.1% 90% No Nursing and midwifery registered 206 275 74.9% 90% No Estates and ancillary 5 7 71.4% 90% No Additional professional, scientific and technical

34 48 70.8% 90% No

Total 615 750 82.0% 90% No

Allied health professionals and medical and dental staff met the 90% trust target. Compliance was

above 70% for all staff groups in surgery at Broomfield Hospital, however, care should be taken

when interpreting the rates as this data only represents a partial year.


Staff were mostly experienced, qualified and had the right skills and knowledge to meet the needs

of patients. However, some staff described challenges around being moved to other wards to

support staffing requirements across the trust. Concerns included a lack of knowledge in specialist

areas they might find themselves working, for example, staff gave examples of surgical staff

working on respiratory wards when this was not their specialist area. After our inspection, the trust

advised that full daily staffing reviews of skill mix, levels and number of substantive staff on duty

were undertaken by the senior nursing team.

Managers gave all new staff a full induction tailored to their role before they started work. All new

registered nurses (including overseas nurses from recent recruitment programmes) were provided


with an induction period including both corporate and local induction. Staff were required to

complete competency booklets and were supported by senior staff to do so.

Agency staff were required to complete a local induction and checklist prior to working in any area.

This demonstrated what competencies they held, for example, intravenous cannulation and other

procedures that may be required in the healthcare setting.

Newly registered nurses in the theatre department were given support from a mentor upon

commencement of role.


their work. We spoke with staff who had been encouraged to develop from healthcare assistant, to

healthcare support worker and then on to registered nurse, telling us they felt very supported

during this process by senior staff within the service.

The clinical educators supported the learning and development needs of staff.


not attend. Information from team meetings were displayed in staff rest room areas and circulated

by email to ensure staff had access to information.


develop their skills and knowledge. Staff of various grades all described a positive learning

environment within their place of work, they felt supported to further develop skills and knowledge.

Manager made sure staff received any specialist training for their role. For example, staff

completed additional intravenous medication competencies to ensure appropriate skills within

various areas of the surgery department.


develop their skills and knowledge. Staff described appraisal processes as meaningful and gave

examples of where they had been supported to attend additional courses to develop them within

their role.

After our inspection we requested up-to-date data for appraisals for nursing and midwifery staff.

Data showed that no staff groups met the trust target of 90% for appraisal completion.

Staff group As of 31 October 2019

Completion rate

Trust target Met (Yes/No)

Allied health professionals 84% 90% No Medical and dental 88% 90% No Additional clinical services 84% 90% No Administrative and clerical 71% 90% No Nursing and midwifery registered 82% 90% No Estates and ancillary 88% 90% No Additional professional, scientific and technical

79% 90% No

Managers made sure staff received any specialist training for their role.






care. Multidisciplinary team (MDT) meetings took place on a regular basis and included a wide

range of healthcare professionals. Staff knew who was responsible for each patient’s care with a

named consultant and nurse in place.


patients. Staff described positive working relationship with other clinicians including doctors,

anaesthetists, consultants and physiotherapists/occupational therapists. During our inspection we

saw a range of healthcare professional including physiotherapist and occupational therapists

discussing patient care.

There was a good relationship between ward staff and theatre staff, including the day surgery unit.

Staff could access up to date patient information through medical records booklets and care plans.

Staff had access to a range of clinical nurse specialist including stoma care, diabetes and learning

disability and they shared information at MDT meetings to improve patient care.

Staff shared information amongst various departments. For example from theatres to wards. Ward

based staff could describe recent never events and changes in practice.

Externally, work was in progress with forging strong working relationships as part of the Mid and

South Essex success Regime, with a planned merger taking place in April 2020. Staff described

ear, nose and throat services working as part of an effective network and that foundations were

being laid prior to the merger in April 2020.

Staff referred patients for mental health assessments when they showed signs of mental ill health

or depression.

Seven-day services


Access to emergency surgical services was available 24 hours a day, seven days a week. Medical

staff were available on a rota system when outside of normal working hours. An on call consultant

was available for response to the hospital within 30 minutes out of hours.

Registrars led daily ward rounds on all wards, including weekends. Patients were reviewed by

consultants depending on the care pathway. Staff told us that consultants were readily available to

discuss patients requiring senior input, for example emergency trauma patients. In addition, ward

rounds were attended by senior nursing staff.


diagnostic tests, 24 hours a day, seven days a week. Diagnostic imaging services (including x-ray,

magnetic resonance imaging and computed tomography) were available 24 hours a day, seven

days a week. This was in line with standard five (priority standard) of the NHS seven day services.

Pharmaceutical, anaesthetic and pathology services were accessible 24 hours a day, seven days

a week to ensure access to service in a timely manner to aid clinical decision making (on an on

call basis when out of hours).

Dietician support was available Monday to Friday, 9am to 5pm. The pain management team was

available six days a week, with access to an on call anaesthetic outside of normal working hours.


The surgical emergency ward was open for surgical GP referrals and ambulatory patients Monday

to Friday.

The day surgery unit (DSU) was open Monday to Friday, 7am to 9.30pm. At our last inspection

(October 2018), staff reported the re-opening of this unit outside of normal hours as an escalation

area. At this inspection, staff told this practice had ceased, with DSU escalation/contingency areas

only opening on senior executive approval.

Health promotion


Staff assessed patients eligibility for elective surgery at pre-assessment clinics. This gave staff the

opportunity to offer information to patients on healthy living prior to surgical procedures.

The service had relevant information promoting healthy lifestyles and support on wards/units.

Advice on healthy living, nutrition, hydration and smoking cessation was available for patients.


to live a healthier lifestyle. Medical records contained documented discussion around smoking and

alcohol consumption with onward referral to specialist nurses if required.

Elective surgical orthopaedic patients at Braintree Community Hospital received information

booklets relating to their planned operation (hip and knee replacement). Information books were

thorough and informative with a wide range of pre and post-surgical information and rehabilitation

advice.

Further information on health promotion was available on the trust’s website and included smoking

cessation advice.





They used agreed personalised measures that limit patients' liberty.



stated that Deprivation of Liberty Safeguarding (DoLS) training is included in the MCA training

module.

Broomfield Hospital


nursing and medical staff in surgery at Broomfield Hospital is shown below:

Staffing group As of August 2019

Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)

Nursing and midwifery registered 252 304 82.9% 95% No Medical and dental 157 199 78.9% 95% No


In surgery, the 95% trust target was not met for the MCA/DoLS module by qualified nurses and

medical and dental staff as of August 2019.


Clinical (medical and nursing) staff did not always receive or keep up to date with training in the

Mental Capacity Act and Deprivation of Liberty Safeguards. After our inspection we requested up-

to-date data for MCA and DoLS training. Data showed 83% of nursing and medical staff had

completed this training at required intervals. This was below the service’s target of 95%.



and 2004 and they knew who to contact for advice. A policy named consent to examination or

treatment was available for staff to access electronically. The policy had recently been reviewed in

August 2019. The policy provided guidance for staff on determining if a patient had capacity, the

seeking of consent and processes for recoding written consent.


guidance. Staff clearly recorded consent in the patients’ records. We reviewed 21 patient records.

In all cases we saw consent had been documented.


about their care. The trust wide safeguarding team reviewed all MCA and DoLs documentation to

ensure correct processes were being followed. Staff had access to clinical nurse specialists for

learning disability and dementia in the event that further advice and support was required.

Staff made sure patients consented to treatment based on all the information available. We

observed staff explaining treatment and procedures in detail with patients during our inspection.

Managers monitored the use of Deprivation of Liberty Safeguards and made sure staff knew how

to complete them. Staff describe the meaning of deprivation of liberty and managers maintained

oversight of this.


Act and Deprivation of Liberty Safeguards. The trust’s liberty safeguard policy and procedure was

available for staff to access electronically. The policy was within review date. It provided guidance

for staff on requirements for the MCA and DoLS, how to apply for a deprivation of liberty

authorisation and the roles and responsibilities of staff.


Compassionate care




Broomfield Hospital

The Friends and Family Test response rate for surgery at Mid Essex Hospital Services NHS Trust

was 22.9% which was worse than the England average of 24.0% from July 2018 to June 2019.


A breakdown of FFT performance by ward for surgical wards at Broomfield Hospital is shown

below. The percentage of respondents that said they would recommend the ward to family or

friends was 83% or higher for all medical wards for these 12 months overall.

1. The total responses exclude all responses in months where there were less than five responses at a particular ward (shown as gaps in the data above), as well as wards where there were less than 100 responses in total over the 12-month period.

2. Sorted by total response. 3. The formatting above is conditional formatting which colours cells on a grading from highest to lowest, to aid in

seeing quickly where scores are high or low. Colours do not imply the passing or failing of any national standard.

(Source: NHS England Friends and Family Test)

Patients said staff treated them well and with kindness. We spoke with six patients during our

inspection. All patients gave positive feedback about the care, treatment and support they had

received from staff. Staff were described as ‘lovely, kind, caring and very helpful’. One patient

said: ‘staff are as kind as my own family, they actually call me by my name which means a lot’.


patients and those close to them in a respectful and considerate way. During our inspection, we

saw curtains were drawn to respect privacy. Staff introduced themselves to patients by name,

were respectful and treated patients with dignity. All patient we spoke with described feeling

knowledgeable about their treatment and future care plans.

Staff followed policy to keep patient care and treatment confidential. Information boards contained

restricted information about patients to maintain confidentiality.




how they may relate to care needs.

Emotional support


They understood patients’ personal, cultural and religious needs.

The trust’s chaplaincy team provided access to a team of chaplains from different denominations.

The chaplaincy team was available 24 hours a day, seven days a week to help support patients,

their relatives and carers.



it. Patients had access to a number of clinical nurse specialist to provide both physical and

emotional support. One patient told us they had felt supported by the stoma care team and that

they were offered psychological support at regular intervals.

Whilst staff did not receive formal training in the chaperone role, staff could support patients where

requested.


maintain their privacy and dignity.


on their wellbeing and on those close to them.



and make decisions about their care and treatment. Staff made sure patients and those

close to them understood their care and treatment.

We spoke with six patients who all described feeling informed about their care and that they had

received enough information about what to expect.

The service had developed comprehensive information books for patients undergoing hip or knee

replacement. The books provided a wide range of information including pre-surgery, post-surgery

and rehabilitation advice.

Staff talked with patients, families and carers in a way they could understand, using

communication aids where necessary. Staff used a range of tools to help communication with

patients who had additional needs. Tools included picture books and pictorial pain scoring.


supported them to do this. Staff welcomed feedback and information in ward areas encouraged

patients, relatives and carers to provide feedback about the care received.

Staff supported patients to make advanced decisions about their care.

Staff supported patients to make informed decisions about their care. All patients we spoke with

described feeling well informed about their care and future treatment plans.

Patients gave positive feedback about the service. All patients we spoke with gave positive

feedback about the care and treatment they were receiving.





to plan care.


population. At the time of our inspection, plans were in place to merge with two other local NHS


trusts to form one single organisation by April 2020. Senior staff had recognised the need to

ensure accessible services for the local community including 24 hour emergency care and

maternity services. Emergency theatre access was available 24 hours a day, seven days a week.

Services for orthopaedic care had been extended to Braintree Community Hospital for elective

patients. This enabled local patients to access the service in a timelier manner. Locally, new hip

and knee replacements pathways had been developed for elective, low risk patients attending

Braintree Community hospital for joint replacement which was in draft at the time of our inspection.


report a potential breach. In the 12 months prior to our inspection, surgery services reported 30

mixed sex breaches. All breaches occurred during April 2019 to June 2019 in the day surgery unit.

Trust staff reported all occasions of mixed sex breaches using internal incident reporting systems

and from October 2019 the day surgery unit was opened under executive approval only to cope

with an increase in demand, if required.

Facilities and premises were appropriate for the services being delivered. Facilities were well

maintained, clean and staff had access to equipment to provide care. All areas were accessible for

those with additional needs such as wheelchair access.

Staff could access emergency mental health support 24 hours a day, 7 days a week for patients

with mental health problems, learning disabilities and dementia. Staff could describe how to

access emergency mental health support during normal working hours and out of hours.


intervention. A range of clinical nurse specialists and ward based champions were available to

provide support and guidance for patients with complex needs, including but not limited to;

dementia and learning disability.


service offered a day surgery unit, so patients could receive surgery and be discharged on the

same day. All patients we spoke with were positive about this service.

The service’s surgical emergency ward (SEW) provided a direct access point for surgical

assessment, allowing patients to be redirected to the most appropriate clinical area/pathway.






received the necessary care to meet all their needs. Ward based staff had become ‘champions’ to

support other staff and patients with additional or complex needs including but not limited to;

learning disability and dementia.

Pre-assessment clinics for surgical patients allowed staff to thoroughly assess a patients suitability

prior to admission and identified any particular individual needs. The pre-assessment clinics

provided an opportunity to identify additional various needs including dietary requirements, social

history/background and any post-operative support a patient may require.

Wards were designed to meet the needs of patients living with dementia. Ward areas were clearly

signed and during our inspection, we saw that call bells were within the patients’ reach.



documents. ‘This is me’ documentation was used by staff to learn about any specific or complex

needs a patient may have, Staff reported this documentation as very useful, helping to improve the

care they gave.


community. Leaflets were available in braille and a number of languages other than English upon

request.


signers when needed. Translation services were in place to support patients whose first language

was not English. Staff could describe how to access translation services.


Individual dietary requirements could be discussed at pre-assessment or in the event of an

emergency admission, staff could offer a range of food and drink to meet cultural and religious

needs. Menu choices offered a range of foods.


treatment. Staff used pictorial signs and other communication aids to assist patient with additional

needs.

Trust-wide there were a number of clinical nurse specialist to support patient with additional needs

such as dementia, stoma care, tissue viability and learning disability. In addition, ward based

champions were placed to offer guidance to both patients and staff where required.

Access and flow

We could not gain assurances that people could access the service when they needed it

and received the right care promptly. Waiting times from referral to treatment and

arrangements to admit, treat and discharge patients were not formally monitored at the

time of our inspection.

Average length of stay

Broomfield Hospital - elective patients

From March 2018 to February 2019 the average length of stay for patients having elective surgery

at Broomfield Hospital was 3.6 days. The average for England was 3.8 days.

• The average length of stay for patients having elective plastic surgery at Broomfield Hospital

was 4.1 days. The average for England was 3.8 days.

• The average length of stay for patients having elective trauma and orthopaedic surgery at

Broomfield Hospital was 4.3 days. The average for England was 3.7 days.

• The average length of stay for patients having elective urology surgery at Broomfield Hospital

was 2.1 days. The average for England was 2.5 days.


Elective Average Length of Stay - Broomfield Hospital


Broomfield Hospital - non-elective patients

The average length of stay for patients having non-elective surgery at Broomfield Hospital was 4.0


• The average length of stay for patients having non-elective general surgery at Broomfield

Hospital was 3.3 days. The average for England was 3.6 days.

• The average length of stay for patients having non-elective plastic surgery at Broomfield

Hospital was 1.7 days. The average for England was 1.5 days.

• The average length of stay for patients having non-elective trauma and orthopaedics

surgery at Broomfield Hospital was 9.4 days. The average for England was 8.4 days.

Non-Elective Average Length of Stay - Broomfield Hospital




Cancelled operations

A last-minute cancellation is a cancellation for non-clinical reasons on the day the patient was due

to arrive, after they have arrived in hospital or on the day of their operation. If a patient has not


been treated within 28 days of a last-minute cancellation, then this is recorded as a breach of the

standard and the patient should be offered treatment at the time and hospital of their choice.

Over the two years, the percentage of cancelled operations at the trust fluctuated month on month

with the worst performance reported in Q2 2017/18 and Q1 2018/19 with 20% of cancelled

operations not treated within 28 days in each period. There has been a decrease in the proportion

of cancelled operations not treated within 28 days at the trust from Q3 2018/19 to Q1 2019/20. In

Q2 2019/20, this trust cancelled 182 surgeries, of which 7% were not treated within 28 days.

Percentage of patients whose operation was cancelled and were not treated within 28 days

- Mid Essex Hospital Services NHS Trust

Over the two years, the percentage of cancelled operations at the trust was consistently above the

England average. Cancelled operations as a percentage of elective admissions only includes short

notice cancellations.

Cancelled Operations as a percentage of elective admissions - Mid Essex Hospital Services

NHS Trust


Patient moving wards per admission

The trust has stated that the systems they have in place are unable to differentiate between

clinical and non-clinical reasons for patients moving wards and therefore this data is not recorded.


(Source: Routine Provider Information Request (RPIR) – Ward moves tab)

Patient moving wards at night

From August 2018 to July 2019, there were 673 patients moving wards at night within surgery. Of

these, 672 occurred at Broomfield Hospital. The wards with the highest number of patient ward

moves at night were the surgical emergency ward with 285 ward moves, Notley ward with 113

ward moves and Billericay ward with 80 ward moves.

(Source: Routine Provider Information Request (RPIR) – Moves at night tab)
















Managers monitored waiting times and made sure patients could access emergency services

when needed and received treatment within agreed timeframes and national targets. Theatre lists

were managed in advance using an electronic tool to assess utilisation. Previously, staff described

that lists were frequently overbooked, leading to late finishing for staff, In response to this, staff

challenge consultant surgeons in advance, with evidence to show the impact of over booking lists

to prevent over booking and subsequent lists over running. Staff reported a significant

improvement in late finishes over recent months.

After our inspection we requested theatre utilisation data. Senior staff monitored data to try and

ensure that theatres were utilised in an efficient way. Data showed from April 2019 to September

2019 theatres were utilised 72% to 78% of the time. However, future alignment and improved

utilisation was a focus upon merging with other NSH trusts in April 2020.

On a daily basis at 2.30pm, the next day’s lists were reviewed, enabling staff to pull forward

planned work or accommodate emergency surgery if cancellations occurred.

However, staff with theatres expressed concerns about the frequent overrunning of elective

surgery lists. They described overruns being problematic as they often led to a delay in the theatre

lists for emergency patients.

Staff also described challenges around capacity as Lister Ward (previously surgical) had been

relocated to medical care therefore placing pressure on current bed capacity.

Managers and staff worked to make sure patients did not stay longer than they needed to.

Discharge planning was discussed at regular intervals, with forward planning and estimation of


when patients may be fit for discharge. However, out of 21 records we reviewed, four records did

not contain a completed discharge checklist.

Whilst most patients were discharged from the ward, the service had access to a discharge lounge

if required. Staff described difficulties with timely discharge when waiting for confirmation of social

and reablement care in the community. At the time of our inspection, one patient on the ward had

been waiting seven days for a social care package to be put in place.

Managers worked to keep the number of cancelled operations to a minimum. We spoke with

theatre services managers during our inspection. In response to cancelled operations, theatre lists

were reviewed in advance, and a work stream was in place to decrease cancelled operations. The

work stream had demonstrated a month on month reduction in cancellations. Staff had recognised

a proportion of cancellations were at short notice due to coughs and colds. In response to this,

staff called patients one to two days prior to surgery to reduce the risk of short notice cancellation

due to coughs and colds. Therefore, vacant slots could be allocated elsewhere, improving theatre

productivity.

When patients had their operations cancelled at the last minute, managers made sure they were

rearranged as soon as possible and within national targets and guidance. Senior nursing staff

within the surgery division spoke with patients who had operations cancelled at short notice. All

patients were rebooked at the earliest opportunity, some being offered a new date on the day of

cancellation. The service had a work stream in place which was demonstrating month on month

reduction in cancellations.

National targets state that patients should begin their first treatment for cancer within 62 days,

following an urgent GP referral for suspected cancer. After our inspection we requested 62 day

standard data which can be seen in the table below:

Oct 18

Nov 18

Dec 18

Jan 19

Feb 19

Mar 19

Apr 19

May 19

Jun 19

Jul 19

Aug 19

Sep 19

Performance 69.5%

64.4%

69.8% 55.2% 67.2%

66.4%

71.8%

67.9% 59.8% 59.1% 59.9%

60.2%

Patients within 62 days

91 65 75 66.5 55.5 73 94 84.5 65.5 69.5 72.5 62

Patients above 62 days

40 36 32.5 54 32.5 37 37 40 44 48 48.5 41

Total Patients

131 101 107.5 120.5 99 110 131 124.5 109.5 117.5 121 103

As data shows, the service did not see 95% of patients within the recommended national 62 day

cancer treatment timeframe.

The service moved patients only when there was a clear medical reason or in their best interest.

There had been no occasions in the last 12 months where intensive care patients had been cared

for within recovery areas to create capacity for patients in intensive care in the last 12 months.

Staff could not always avoid moving patients between wards at night. A proportion of patient were

admitted to the service from the emergency department, for example, fracture neck of femur (hip).

As a result, the pathways in place sometimes meant that patients were required to move due to

capacity. Locally, senior managers were aware of keeping night moves to a minimum, where

possible.


Staff planned patients’ discharge carefully, particularly for those with complex mental health and

social care needs. Staff regularly reviewed patients awaiting discharge with involvement of other

healthcare professional such as physiotherapists, occupational therapists and social services.

Staff supported patients when they were referred or transferred between services.

Managers made sure they had arrangements for surgical staff to review any surgical patients on

non-surgical wards. Surgical outlier patients (those not placed on surgical wards) were regularly

reviewed both locally and at trust-wide bed meetings to ensure that patients were identified and

reviewed on a regular basis. Manager worked to minimise the number of surgical patients on non-

surgical wards, where possible.

Senior staff within the service described challenges around patient access to services including

endoscopy. In response to this, a capacity and demand model had recently been completed,

which led to consideration of weekend opening. At the time of our inspection, this was in the

process of discussion.

During our inspection we saw that the theatre recovery area was staffed overnight between the

days of Monday to Wednesday. Staff expressed concerns that patients were regularly exposed to

prolonged stays within this area if beds were not available within the hospital. During our

inspection, we saw that one patient had been within the recovery area for 20 hours.






Broomfield Hospital

From August 2018 to July 2019, the trust received 137 complaints in relation to surgery at

Broomfield Hospital (23.1% of the total complaints received by the trust). The trust took an

average of 37.2 days to investigate and close complaints. This was not in line with their complaints

policy, which states complaints should be completed within 25 working days


Type of complaint Number of complaints Percentage of total Clinical treatment - surgical group 104 75.9% Communications 8 5.8%

Appointments including delays and cancellations

8 5.8%

Clinical treatment - general medicine group 5 3.6% Values and behaviours (staff) 4 2.9% Clinical treatment - obstetrics and gynaecology 2 1.5% Clinical treatment - anaesthetics 2 1.5% Facilities services (including; access for people with disability, cleanliness, food, parking, maintenance and portering)

1 0.7%

Admissions, discharge and transfer arrangements excluding delays due to absence of care package

1 0.7%

Clinical treatment - accident and emergency 1 0.7%


Clinical treatment - clinical oncology 1 0.7% Total 137 100.0%


Patients, relatives and carers knew how to complain or raise concerns. All patients we spoke with

could describe how they would make a complaint, either verbally to staff or through the patient

advice and liaison team, or by letter.

The service clearly displayed information about how to raise a concern in patient areas. Complaint

information was displayed at regular areas throughout the wards, signposting patients and

relatives on how to make a complaint or feedback about the service.

Managers investigated complaints and identified themes. However, complaints were not always

handled in line with the trust’s complaints policy, taking an average of 37.2 days rather than the

stipulated 25 days.


the investigation into their complaint. We reviewed three recent complaint responses from patients

or their relatives. Complaint responses provided feedback as how learning had been shared with

staff in response to received complaints.


service. Ward managers described how they handled complaints, investigated and shared

complaint investigations outcomes and learning with staff. We saw that complaints were discussed

at daily huddles and displayed in staff restroom areas.


Broomfield Hospital

From August 2018 to July 2019 there were 149 compliments received for surgery at Broomfield

Hospital (13.3% of all compliments received trust wide). The highest number of compliments were

received by orthopaedics (18.1%), followed by Rayne ward (16.8%) and ophthalmology (11.4%).

A breakdown of compliments by department at Broomfield Hospital is shown below:

Department Number of compliments Percentage of total Orthopaedics 27 18.1% Rayne ward 25 16.8% Ophthalmology 17 11.4% General surgery 15 10.1%

Urology 13 8.7% Heybridge ward 9 6.0% Day stay unit/theatre admissions unit 9 6.0% Notley ward 7 4.7% Billericay ward 6 4.0% Trauma and assessment unit 5 3.4%

Ear, nose and throat oral surgery 4 2.7% Surgical emergency ward 4 2.7% Lister ward 3 2.0% John Ray ward 3 2.0% Theatres 2 1.3% Total 149 100.0%





consultants.


and carer experience group and also with individuals and their managers during appraisal. The

trust uses its Datix system to analyse themes from compliments.



Leadership

Leaders had the skills and abilities to run the service. They understood and managed the

priorities and issues the service faced. They were visible and approachable in the service

for patients and staff. They supported staff to develop their skills and take on more senior

roles.

Surgery was located in the surgical, anaesthetics and theatres division which encompassed:

general surgery, specialist surgery (ophthalmology, oral maxillofacial surgery (OMFS), ear nose

and throat (ENT) and audiology, musculoskeletal (MSK - trauma and orthopaedics and

rheumatology), anaesthetics, theatres and critical care and surgical specialities with endoscopy

(upper and lower gastrointestinal, colorectal, breast, vascular and urology.

The divisional director, associate director of operation and two associate directors of nursing

oversaw the division and in turn reported to the executive team.

Locally, both theatres and surgical wards were led by matrons who were supported by ward

managers, who in turn supported ward and theatre based staff.

The divisional leads told us they felt well supported by the executive team. However, some staff

within the surgical division reported a lack of visibility and support from the executive team and

that concerns were not always listened too or acted upon. Concerns centred around a feeling that

the executive team were focused on the upcoming merger, rather than current issues within the

department. Staff expressed concerns that ‘goodwill’ was running out, and a focus was put on

financial targets rather that patients and staff. Other staff described a ‘gap’ in access to the

executive team.

Vision and strategy





At the time of our inspection, Mid Essex Hospital Service was planning to become one new single

NHS Organisation in conjunction with two other local NHS trusts, by an expected date of 1 April

2020. The vision included running all three hospitals under one leadership team.


Staff we spoke with were aware of the strategy and recognised the challenges that this strategy

posed and staff within the service felt passionate about providing the best care possible. Staff

described future plans for more cohesive working with other local NHS trust staff.

Part of the merger included Mid Essex hospital becoming the major elective surgical site for the

three hospitals.

The trust’s vision was: ‘to be a healthcare organisation that puts patient care first and whose

reputation for excellence and innovation inspires our patients, staff and the population we serve’.

The service’s values underpinned the vision and in 2015 the following values statement was

agreed; ‘We are a kind, professional, positive team’.

During our inspection we saw that staff demonstrated the service’s values through their course of

work. Patient feedback also described staff as adhering to the vision and values statement.

The service had a cancer improvement plan in place and was working in collaboration with other

stakeholders and the East of England Cancer Alliance.

Culture

Staff mostly felt respected, supported and valued. However, the service promoted equality

and diversity in daily work and provided opportunities for career development. The service

had an open culture where patients and their families could raise concerns without fear.

The majority of staff described an open culture, feeling they could raise concerns without a fear of

reprisal. However, there were some staff who did not feel supported by the senior leadership

team.

There was a strong focus on recruiting, retaining and developing staff currently in employment. At

ward level, senior nursing staff were passionate about create a nurturing environment to support

and develop staff knowledge and expertise.

In the theatre department, a focus had been placed on improving the culture which historically had

been poor due to the attitude of some clinicians. Senior nursing staff described an ‘open door’

policy to improve their visibility to staff within the service. All nursing staff we spoke with described

feeling well supported by senior leaders, describing them as ‘supportive and helpful’.

As identified at our previous inspection in September 2018, concerns were highlighted around

medical staff displaying behaviours that prohibited a positive safety culture. Whilst overall culture

had improved, some staff’s compliance with venous thromboembolism risk assessments and

thorough completion of the World Health Organisation (WHO) checklist still showed room for

improvement.

Senior staff had identified ‘group quality priorities 2019/2020’, aiming for zero tolerance of never

events and increased focus to sharing learning at cross site level, in particular from previous never

events.

In April 2019, the trust introduced a new external guardian service, providing staff with a

confidential and independent opportunity to raise concerns therefore ensuring anonymity. The

external service reported back to the trust’s organisational development committee with

information for staff being shared on the trust’s intranet, on corporate induction days and through

leaflets and staff events.


Governance

We could not gain assurance that leaders always operated effective governance processes

throughout the service. Staff at all levels were clear about their roles and accountabilities

and had regular opportunities to meet, discuss and learn from the performance of the

service, however, performance did not always show steady and sustainable signs of

improvement.

Clinical governance meetings took place on a monthly basis for anaesthetics and theatres,

musculoskeletal surgery, specialist surgery and general surgery. We reviewed meeting minutes for

October 2019 and saw meetings were generally well attended. Meeting minutes discussed a

number of topics including but not limited to; workforce, mandatory training and incidents.

For the month of October 2019, meeting minutes highlighted that there were 241 incidents classed

as requiring investigation or closure. We could not gain assurances that incidents were

investigated in a timely manner.

General surgical audit meetings took place on a monthly basis and offered local medical students

the opportunity to attend.

However, a number of areas of concern remained from our previous inspection in October 2018.

Issues included; poor medical records documentation and poor infection prevention and control

processes. We could not gain assurances that there were effective governance processes in place

to embed and sustain improvement in performance.


Leaders and teams used systems to manage performance effectively. However, not all risks

were identified and escalated with identified actions to reduce their impact.

The surgical division held and maintained an electronic risk register. Top risks included but were

not limited to; nurse staffing, junior doctor staffing, late notice cancellations of surgery and the

inability to accommodate elective and non-elective surgical patient in an appropriate environment.

Risks were RAG (red, amber, green) rated to indicate the level risks posed. Each risk had a

named lead, detailed actions taken to mitigate risk and when further review was due.

However, areas of poor compliance with medical record completion was not identified as a risk on

the risk register. This had been identified at our previous inspection in October 2018. In addition,

infection prevention and control concerns within the theatre department were not identified as a

risk.

Cramped condition within theatre changing areas were not reflected on the service’s risk register.

The services top five theatre risks were displayed in staff areas:

• Overbooked theatre lists

• Day surgery Unit – use as a contingency area

• A lack of patient pre-assessment

• Availability of pharmacy medicines

• Ageing instruments (a repair and replacement programme was in progress at the time of

our inspection).


Compliance with completion of venous thromboembolism (VTE) risk assessments had been

identified by senior staff as a risk to the service. In response to this, a ‘focus month’ took place in

June 2019 in the aim of improving awareness with staff. Learning was shared through a variety of

methods including but not limited to; trust safety alerts, governance meetings and patient safety

meetings. Whilst VTE risk assessment compliance was not meeting the 95% target, it is to be

noted that data showed an improvement in performance from March 2019, however, this was not

reflected on the service’s risk register.















with NHS Improvement/England and commissioners. Electronic scorecards (broken down to

surgery and theatre/anaesthetic areas) enabled senior staff to oversee and monitor key safety

information including but not limited to; serious incidents, falls resulting in injury and pressure

ulcers. Senior staff attended monthly meetings to discuss dashboard data.

The service carried out regular audits to monitor performance, including but not limited to;

controlled drugs storage, transient workers, drug trolley and VTE risk assessments.

At our previous inspection in October 2018, incomplete records, poor compliance with venous

thromboembolism risk assessment completion, infection prevention control processes and

mandatory training compliance were previously identified as a risk. Whilst mandatory training

compliance had improved, issues still remained around IPC processes, medical records

documentation and VTE assessment completion. Therefore we could not gain assurances that

effective governance frameworks and oversight of risk were in place to enable sustained changes

and improvements.


The service did not always collect reliable data and analyse it. Staff could not always find

the data they needed, in easily accessible formats, to understand performance, make

decisions and improvements. Information systems were not always integrated but were

secure. Data or notifications were not always consistently submitted to external

organisations as required.







However, the electronic system for patient records did not communicate with the system used to

track and maintain patient flow, therefore leading to difficulties. In response to this the trust had

implemented an interim director for improvement, who commenced in post in October 2019.

In addition, senior staff told us that records relating to mandatory training compliance were not

always accurate. For example, medical staffing records contained staff that had left the service,

leading to possible inaccurate data.

Engagement

Leaders and staff actively and openly engaged with patients and staff. They collaborated

with partner organisations to help improve services for patients.

Senior staff welcomed feedback from staff and described ‘open door’ policies. Staff within the

theatre department had adopted the ‘Greatex’ system, used so staff could nominate colleagues for

outstanding work or going above and beyond. This had been well received and welcomed by staff.

The service facilitated patient and carer experience groups, enabling feedback about the service.

Listening events provided patients and their relatives/carers with an opportunity to feedback about

their experience.

An Oscar nomination scheme was in use for staff to nominate colleagues for outstanding work or

going above and beyond.


All staff were committed to continually learning and improving services. Leaders


Staff from Notley ward were passionate about reducing the number of hospital acquired sacral

pressure ulcers. Previous data showed Notley ward as having a high prevalence of pressure

ulcers in the last two years. In response to findings the ‘react to red’ project was trialled from July

2019 to August 2019 which focussed on the prevention of sacral pressure ulcers using

preventative sacrum dressings for patients with fractured neck of femur (hip). Results were

positive, with no patients in the trial acquiring a sacral pressure ulcer.

The service offered a one-stop clinic for lower limb care and treatment as this had been identified

as being underutilised.

The service had expanded the number of robotic procedures on offer which included; upper

gastrointestinal, colorectal, urology and head and neck surgery.


Maternity


Mid Essex Hospital Services NHS Trust provides a range of hospital and community-based

maternity services across three sites; Broomfield Hospital in Chelmsford, St Peter’s Hospital in

Maldon and St Michael’s Hospital (also known as William Julien Courtauld Hospital) in Braintree.

The trust has 62 maternity beds.

Broomfield Hospital provides consultant and midwife led care for high and low risk women.

Inpatient maternity services include a consultant led delivery suite, midwife led birthing suite and

postnatal ward. Delivery suite has 10 ensuite delivery rooms, one bereavement suite and two

dedicated obstetric theatres. The birthing suite has four delivery rooms, two of which have static

birthing pools. The postnatal ward has 20 beds. There is also a 14-bedded antenatal day

assessment unit open 24 hours a day, seven days a week. Outpatient maternity services are

provided on the hospital site and in conjunction with community services.

St Peter’s Hospital and St Michael’s Hospital both have birthing centres which provide midwife led

care to women with uncomplicated pregnancies and labours. The birthing centres also act as hubs

for community and acute outreach provision, including consultant led clinics.

There are three community midwifery teams based at each hospital site. They provide antenatal

and postnatal care from GP surgeries, children’s centres and birthing centres, as well as home

visits. A home birth service is also available.

From August 2018 to July 2019 there were 4,300 deliveries at the trust. The number of deliveries

per location is show below:

• 3,192 (74.2%) - Broomfield Hospital consultant led unit

• 682 (15.9%) - Broomfield Hospital midwife led birthing suite

• 107 (2.5%) - Home births

• 138 (3.2%) - St Peter’s midwife led birthing centre

• 181 (4.2%) - St Michael’s midwife led birthing centre

(Source: Routine Provider Information Request (RPIR) – Maternity overview)

From January to December 2018 there were 3,941 deliveries at the trust.

A comparison from the number of deliveries at the trust and the national totals during this period is

shown below.


Number of deliveries at Mid Essex Hospital Services NHS Trust – Comparison with other

trusts in England.

(Source: Hospital Episode Statistics (HES))

A profile of all deliveries and gestation periods from January to December 2018 can be seen in the

tables below. Both the profile of deliveries in terms of single and multiple births and profile of

mother’s age was similar at the trust when compared with the England average.

Notes: A single birth includes any delivery where there is no indication of a multiple birth. This table does not

include deliveries where delivery method is 'other' or 'unrecorded'.


Notes: This table does not include deliveries where delivery method is 'other', 'Missing' or 'unrecorded'.

We inspected inpatient, outpatient and community maternity services provided at Broomfield

Hospital on 5 to 7 November 2019. We did not inspect the maternity services located at St Peter’s

Hospital and St Michael’s Hospital. We visited:

• Antenatal clinic (A401)

• Delivery suite (A402); including obstetric theatres and recovery area, and the midwifery led

birthing unit

• Antenatal day assessment unit (A404)

• Postnatal ward (A405)

• Early pregnancy assessment unit

At the last inspection in June 2016, we rated the maternity and gynaecology service good for all

five key questions (safe, effective, caring, responsive and well-led). Since then the inspection

methodology has changed. We no longer inspect maternity jointly with gynaecology, so we cannot

compare our new ratings directly with previous ratings. This is the first inspection of maternity as a

single core service.

Our inspection was announced (staff knew we were coming) because of the number of core

services we inspected. We also returned for an unannounced inspection (staff did not know we

were coming) to enable us to observe routine activity. Before the inspection visit, we reviewed

information that we held about the service and information requested from the trust, including

performance data, policies and meeting minutes.

During our inspection visit, the inspection team:

• Spoke with 10 women who were using the service and one partner

• Spoke with 54 staff members; including midwives, doctors, managers, specialist midwives and

maternity care assistants

• Observed two handover meetings

• Observed the environment and care provided to women and their babies

• Reviewed 21 maternity care records and 22 prescription charts.






Mandatory training

The service did not always make sure staff completed mandatory training in key skills.

Medical staff completion rates for some training courses did not meet the trust target.

Furthermore, staff were not individually competency assessed for cardiotocography

interpretation. The service was acting to address this. However, midwifery staff received

and kept up to date with their mandatory training.




Broomfield Hospital – midwifery staff level

Maternity staff received and kept up to date with their mandatory training.

A breakdown of compliance for mandatory training courses as of August 2019 for qualified

midwifery staff in maternity at Broomfield Hospital is shown below:

Training module name

As of August 2019

Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)

Paediatric basic life support 1 1 100.0% 85% Yes Medicine management training 121 123 98.4% 85% Yes Health and safety 135 139 97.1% 85% Yes Adult basic life support 147 152 96.7% 85% Yes

Information governance 133 139 95.7% 95% Yes Waste management 131 139 94.2% 85% Yes Moving and handling for people handlers

128 136 94.1% 85% Yes

Moving and handling 130 139 93.5% 85% Yes Equality and diversity 125 139 89.9% 85% Yes Fire safety 125 139 89.9% 85% Yes Hand hygiene 118 139 84.9% 85% Yes

In maternity, the trust target was met for all 11 of the mandatory training modules for which

qualified midwifery staff at Broomfield Hospital were eligible.


Broomfield Hospital – medical staff level

Medical staff did not always keep up to date with their mandatory training.


maternity at Broomfield Hospital is shown below:

Training module name

As of August 2019

Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)

Health and safety 21 21 100.0% 85% Yes Information governance 21 21 100.0% 95% Yes Medicine management training 2 2 100.0% 85% Yes Waste management 21 21 100.0% 85% Yes Moving and handling 20 21 95.2% 85% Yes Adult basic life support 6 7 85.7% 85% Yes Fire safety 18 21 85.7% 85% Yes

Hand hygiene 18 21 85.7% 85% Yes Equality and diversity 16 21 76.2% 85% No Adult immediate life support 14 21 66.7% 85% No

In maternity, the trust target was met for eight of the 10 mandatory training modules for which

medical staff at Broomfield Hospital were eligible. Following our inspection, the trust provided

updated mandatory training data. As of November 2019, completion rates for the two modules not

met remained below the trust target; 70% for equality and diversity and 75% for adult immediate

life support (Source: Additional Evidence Request, DR104).


The mandatory training was comprehensive and met the needs of women, babies and staff. In

addition to the trust mandatory training modules, staff received maternity specific training. The

content was in line with national recommendations and included annual multidisciplinary obstetric

emergency training, sepsis, newborn life support, human factors and situational awareness,

antenatal screening and cardiotocography (CTG) interpretation. Cardiotocography is used in

pregnancy to monitor fetal heartbeat and uterine contractions. Some training topics changed

annually in response to national initiatives, local changes in practice and/or incidents. A ‘PRactical

Obstetric Multi-Professional Training’ (PROMPT) approach was used to deliver obstetric

emergency training. Research shows that PROMPT has been associated with improved clinical

outcomes and reduced patient safety incidents (The PROMPT Maternity Foundation and Royal

College of Obstetricians and Gynaecologists). Maternity staff participated in a range of obstetric

emergency scenarios, which were both hospital and community based. The service only held

PROMPT training at the hospital. There was no emergency skills training specifically for

community midwives which was set in a home environment. This meant they did not have the

opportunity to practise managing an emergency during a homebirth. The service also held regular

live, impromptu emergency skills drills to ensure staff knew what to do in the event of an obstetric

emergency. These had been staged in all maternity inpatient areas and both standalone birthing

units.

Maternity and medical staff mostly kept up to date with their maternity specific training. As of

November 2019:

• 93% of midwives and maternity care assistants had completed the maternity mandatory

training programme;


• 95.4% of midwives and 100% of medical staff had completed PROMPT;

• 97.1% of midwives and 78.9% of medical staff had completed annual CTG training;

• 90% of midwives and medical staff had completed newborn life support training

(Source: Additional Evidence Request, DR72 to DR75).

Senior staff told us the four doctors who were not up to date with CTG training had completed it,

but they had not yet seen evidence to confirm this when we requested this information. However,

we found staff were not individually competency assessed for CTG interpretation. The service

assessed CTG competency through a group interactive session. This was not in line with national

recommendations (NHS England, Saving Babies’ Lives Version Two: A care bundle for reducing

perinatal mortality (March 2019)). We raised this with managers who took immediate action to

address this concern. When we returned for the unannounced inspection, managers told us they

had introduced an individual CTG competency assessment which eligible staff completed when

they attended their maternity specific training. Managers told us they hoped to introduce a full-day

dedicated to CTG training and a compulsory on-line competency assessment for eligible staff.

Clinical staff completed training on recognising and responding to women with mental health

needs, learning disabilities and autism. Topics covered included maternal mental health disorders,

risk assessment and referral pathways.


training. Staff could monitor their own training needs through the trust’s electronic system, which

sent an email alert when due. The practice development midwife had oversight of training needs

and completion rates, which they monitored monthly. They were supported by two clinical

facilitators. Staff who needed to update their training were booked on the next available course.

Safeguarding

Staff understood how to protect women and babies from abuse and worked well with other

agencies to do so. However, medical staff completion rates for safeguarding adults training

courses did not meet the trust target. Furthermore, not all staff were aware of the abduction

policy. This meant there was a risk that some staff would not know what to do if a baby was

abducted from the maternity unit.

Staff received safeguarding training specific for their role on how to recognise and report abuse.

Safeguarding training was delivered in line with national recommendations and included scenario-

based discussion and learning from incidents and serious case reviews. The training programme

included professional responsibilities, categories of abuse, safeguarding processes, female genital

mutilation (FGM), child sexual exploitation (CSE), domestic violence and preventing radicalisation.

Staff said they learned from safeguarding training and put what they learned into practice.

However, completion rates for some safeguarding training modules was below the trust target. All

registered professionals working in direct contact with children, young people and families were

required to complete safeguarding children training at level three. This was in line with national

recommendations (RCPCH, Safeguarding Children and Young People; Roles and Competencies

for Healthcare Staff. Intercollegiate Document (January 2019)).


Midwifery staff kept up to date with their safeguarding training however, not all medical staff did.

The trust set a target of 95% for the completion of safeguarding modules.


The tables below include Prevent training as a safeguarding course. Prevent works to stop



Broomfield Hospital – midwifery staff level


midwifery staff in maternity at Broomfield Hospital is shown below:


Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)

Safeguarding adults (level 1) 136 139 97.8% 95% Yes Safeguarding adults (level 2) 136 139 97.8% 95% Yes Safeguarding children (level 1) 134 139 96.4% 95% Yes Prevent - basic awareness 133 139 95.7% 85% Yes

Safeguarding children (level 2) 133 139 95.7% 95% Yes Prevent - awareness 99 111 89.2% 85% Yes Safeguarding children (level 3) 113 139 81.3% 95% No

In maternity, the trust target was met for six of the seven safeguarding training modules for which

qualified midwifery staff in maternity at Broomfield Hospital were eligible.

Broomfield Hospital – medical staff level


in maternity at Broomfield Hospital is shown below:


Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)

Prevent - basic awareness 19 21 90.5% 85% Yes Prevent - awareness 16 21 76.2% 85% No Safeguarding adults (level 1) 16 21 76.2% 95% No Safeguarding adults (level 2) 16 21 76.2% 95% No

Safeguarding children (level 1) 16 21 76.2% 95% No Safeguarding children (level 2) 16 21 76.2% 95% No Safeguarding children (level 3) 1 21 4.8% 95% No

In maternity, the trust target was met for one of the seven safeguarding training modules for which

medical staff in maternity at Broomfield Hospital were eligible.


Following our inspection, the trust provided updated safeguarding training data. As of November

2019, medical staff completion rates for safeguarding adults levels 1 and 2 had declined

(worsened); 75% for safeguarding adults level 1 and 70% for safeguarding adults level 2 (Source:

Additional Evidence Request, DR77). However, the midwifery and medical staff completion rates

for safeguarding children level 3 had improved to 98% (Source: Additional Evidence Request,

DR76).

The service had clear systems, processes and practices to safeguard women and children from

avoidable harm, abuse and neglect that reflected legislation and local requirements. Safeguarding

policies and pathways were in date and were accessible to staff through the trust’s intranet.

Safeguarding information was displayed publicly in all areas of the service. Posters were also


displayed on the back of toilet doors advising people how to access support if they were

experiencing domestic violence and/or abuse.

Staff could give examples of how to protect women from harassment and discrimination, including

those with protected characteristics under the Equality Act. Staff screened all women for

safeguarding risks. The risk assessment covered all types of abuse such as physical, emotional,

financial and sexual. Women and/or babies found to be at risk of abuse were referred

appropriately for additional care and support as needed.

Staff knew how to identify adults, children and babies at risk of, or suffering, significant harm and

worked with other agencies to protect them. Staff told us they worked collaboratively with health

visitors, GPs, the police, the perinatal mental health team and social workers to protect vulnerable

women and children. We reviewed 21 sets of maternity care records which showed women were

routinely asked about domestic abuse. This was in line with national recommendations (National

Institute for Health and Care Excellence (NICE), domestic violence and abuse: multi-agency

working [PH50] (February 2014). Staff understood their mandatory duty to report all cases of

female genital mutilation (FGM) in girls under the age of 18 and those at risk of FGM being

performed. The Female Genital Mutilation Information Sharing (FGM-IS) system was used by staff

to alert healthcare professionals to girls under the age of 18 who were at risk of FGM. The FGM-IS

is a national electronic system which supports the early intervention and ongoing safeguarding of

girls under the age of 18, who have a family history of FGM.


spoke with were confident to make safeguarding referrals and were able to provide examples of

how they had responded to safeguarding concerns. The trust’s electronic patient record (EPR)

system enabled staff to create an alert for women with safeguarding concerns, and those subject

to a child protection or child in need plan. This meant staff could easily identify when any woman

with known safeguarding concerns attended the service. Individual safeguarding records were

electronic and stored on the EPR system, such as referrals, child protection conference meeting

minutes and management plans. This meant staff had immediate access to up to date

safeguarding information. The trust had a lead midwife for safeguarding who was available to

provide support, supervision, training and updates for staff. Staff could contact the lead midwife for

safeguarding, or other members of the trust’s safeguarding team, if they needed advice and

support with any safeguarding concerns. The lead midwife for safeguarding also visited the wards

daily, Monday to Friday, to support women and staff with any safeguarding concerns.

There were arrangements for safeguarding supervision and peer review. Community midwives

participated in quarterly safeguarding supervision, where they reflected on safeguarding cases to

enhance their knowledge and skills and promote positive outcomes for women and their children.

This was in line with national recommendations (HM Government, Working Together to Safeguard

Children: A guide to interagency working to safeguard and promote the welfare of children (July

2018).

Staff followed safe procedures for children visiting the ward. Women’s and their partners children

only could visit the maternity unit.

The service had an abduction policy, but four out of six staff we spoke with were not aware of it.

Nor had staff undertaken baby abduction drills. This meant there was a risk that some staff may

not know what to do if a baby was abducted from the maternity unit. However, in line with the

trust’s policy, most staff could describe what actions they would take if they suspected a baby had

been abducted. Furthermore, there were measures and controls in place to minimise the risk of a

baby being abducted. Access to and exit from the inpatient wards was by means of swipe card


access or an intercom buzzer system. There was also closed-circuit camera television video

(CCTV) at ward entrance and exit points. This meant staff could monitor who was entering and

leaving the wards. Babies had identification labels applied to each ankle after birth to ensure

correct identification of the infant, in case mother and baby were separated at any time. The labels

were checked on transfer to the postnatal ward and then daily by staff as part of the routine

postnatal check. Staff told us if they found a baby with both labels missing they would check the

identity of all babies on the ward to ensure each baby was with their mother. When we returned for

our unannounced inspection, managers told us they had a mock baby abduction exercise planned

for December 2019.



protect women, babies, themselves and others from infection. However, staff did not

always label equipment to show when they last cleaned it.

Most ward areas were clean and had suitable furnishings which were clean and well-maintained.

However, we found areas in the midwife led birthing suite which were dusty, including a cot and

trolleys where equipment was stored. When we returned for our unannounced inspection, we

found all areas in the midwife led unit were clean.

Cleaning records were up to date and demonstrated that all areas were cleaned regularly. The

service had housekeeping staff who were responsible for cleaning patient and public areas, in

accordance with daily and weekly checklists. Infection prevention and control (IPC) audits were

undertaken and the results were used to improve IPC practice where needed. The trust’s IPC

team audited the antenatal day assessment unit in October 2019 and the delivery suite and

postnatal ward in November 2019. We requested the audit compliance results but were not

provided with these. However, the action plans showed four areas of non-compliance for delivery

suite, six for the postnatal ward and eight for the antenatal day assessment unit. We saw all

actions had been completed (Source: Additional Evidence Request, DR60). Side rooms were

available on the antenatal and postnatal wards, which could be used to admit women with a

known or suspected infection. Staff could describe what they would do if a woman required

isolation due to infection.

Staff told us they cleaned equipment after patient contact. However, they did not always label

equipment to show when it was last cleaned. We saw equipment that was not in use on the

antenatal day assessment unit and midwife led birthing suite was not labelled to show when it had

been cleaned. However, equipment on the postnatal ward and delivery suite was labelled. All the

equipment we saw appeared visibly clean and well-maintained.


There was access to hand washing facilities, hand sanitising gel and PPE, such as gloves and

aprons, in all areas. Community staff carried a supply of IPC equipment for use when they visited

women at home, such as hand sanitising gel, gloves and cleaning wipes. We saw staff washed

their hands before and following patient contact. This was in accordance with national guidance

(National Institute for Health and Care Excellence (NICE), Infection prevention and control: QS61,

Quality statement 3 (April 2014)). Women we spoke with confirmed staff washed their hands.

Hand hygiene audits were completed monthly and the results were used to improve hand hygiene

practice where needed. Audit results for the service showed hand hygiene compliance was

consistently 100% (Source: Additional Evidence Request, DR61). We observed staff adhered to


the trust’s ‘arms bare below the elbows’ policy to enable effective hand washing and reduce the

risk of spreading infections.

Managers monitored postnatal readmission rates for infection. From November 2018 to October

2019, 23 women were readmitted within 42 days of delivery because of suspected or known

infection. In relation to the total number of deliveries for this period, this equated to a postnatal

readmission rate of 0.5% for maternal infection (Source: Additional Evidence Rest, DR220).

Women were screened for MRSA during pregnancy if they had an induction of labour, planned or

emergency caesarean section or any risk factors for MRSA. Women were offered treatment before

they had their baby if they screened positive. This was to reduce the risk of developing an infection

in a wound, such as caesarean section scar. From November 2018 to October 2019 compliance

with MRSA screening for women with planned procedures was 96.5% on average. This was in line

with the trust target of 95%. However, compliance for women who underwent emergency

caesarean section was 85.1% on average. Managers had acted to improve compliance. For

example, MRSA swabs and pathology request forms were added to emergency caesarean section

packs (Source: Additional Evidence Request, DR96a and DR96b).



Staff managed clinical waste well.

During our announced inspection, we found not all equipment had been safety tested to ensure it

was fit for purpose and safe for patient use. We looked at 33 items of equipment, of which 20 had

either expired safety test dates or had no label to show the item had been safety tested. However,

12 of these items had expired four days before our inspection. We raised this as a concern and

managers told us medical engineers were in the process of safety testing the equipment. When

we returned for our unannounced inspection, we looked at 50 items of equipment all of which had

up to date safety test dates.

Staff carried out daily safety checks of specialist equipment. Staff checked adult and neonatal

emergency equipment daily. We reviewed eight checklists which were mostly completed.

The service had enough suitable equipment to help them to safely care for women and babies.

This included cardiotocograph (CTG) machines (used to monitor fetal heartbeat and uterine

contractions), resuscitaires (used to support newborn babies who may need resuscitation after

delivery) and ultrasound machines. A fetal blood gas analyser was available on delivery suite. This

was in line with national recommendations (Royal College of Obstetricians and Gynaecologists

(RCOG), Safer Childbirth: Minimum Standards for the Organisation and Delivery of Care in Labour

(2007)). Community midwives had the equipment they needed, such as baby scales, carbon

monoxide monitors and Doppler fetal monitors. However, they did not have transcutaneous

bilirubinometers (a non-invasive device used to measure the serum bilirubin level of babies with

suspected jaundice). Staff told us if they suspected jaundice they would refer the baby to the

hospital for testing and paediatric review. We checked a range of consumable items for expiration

dates and all were in-date, such as syringes, needles, dressings and delivery packs. Store rooms

were tidy and well-organised.

Women could reach call bells and staff responded quickly when called. We observed call bells

were answered in a timely manner during the inspection. Women we spoke with told us staff

responded to them quickly when called.


The design of the environment followed national guidance. The service had two dedicated

obstetric theatres and recovery area. All maternity departments and wards were situated on the

fourth floor, alongside the neonatal unit. This enabled timely transfer when needed. All the delivery

rooms on the delivery suite and midwifery led birthing suite had ensuite facilities. This was in line

with national guidance (Department of Health (DH), Children, young people and maternity

services. Health Building Note 09-02: Maternity care facilities (2013)). Laboratory facilities with

blood and blood products was available on site. We observed fire exits were kept clear and free

from obstruction.

The service had suitable facilities to meet the needs of women. There were two static birthing

pools in the midwife led birthing suite for women who wanted to labour and/or birth in water.

Staff disposed of clinical waste safely. Waste management was handled appropriately with

separate colour coded arrangements for general waste and clinical waste. Sharps, such as

needles, were disposed of in sharps containers which were dated and labelled with the hospital’s

details for traceability purposes. This was in line with national guidance (Health and Safety

Executive Health and Safety (Sharp Instruments in Healthcare) Regulations 2013: Guidance for

employers and employees (March 2013)). Arrangements for the control of substances hazardous

to health (COSHH) were adhered to. Cleaning equipment was stored securely in locked

cupboards. This meant unauthorised persons could not access hazardous cleaning materials.


Staff completed and updated risk assessments for each woman and baby and took action

to remove or minimise risks. Staff identified and quickly acted upon women and babies at

risk of deterioration.

There was a designated four-bedded triage unit in the antenatal day assessment unit. This

provided 24-hour assessment, review and care planning for pregnant women from 17 weeks

gestation. Women could telephone for advice if they had any concerns or health issues such as

reduced fetal movements or suspected labour. Staff documented all telephone calls and a full

history was taken using the situation, background, assessment, recommendation (SBAR)

communication tool. If a woman called three times in 24-hours they were invited to the unit for

assessment, as staff recognised that frequent calls could be because of domestic violence or

mental health concerns. Birthing equipment was available in the triage unit if a woman presented

in advanced labour and could not be transferred to delivery suite. Staff told us they did not use a

system to determine the time in which a woman should be seen by a midwife and/or doctor based

on the symptoms they had, such as a traffic light RAG (red, amber, green) rating. Staff told us they

used their clinical judgement and prioritised women as needed. For example, they would aim to

see women who reported no fetal movements as soon as they arrived and aimed to see all women

within 30 minutes of arrival. This was in line with national guidance (National Institute for Health

and Care Excellence (NICE), Safe midwifery staffing for maternity settings overview (September

2019).

Staff used a nationally recognised tool to identify deteriorating women and escalated them

appropriately. The service used a modified early obstetric warning score (MEOWS) tool. This was

designed to aid early recognition of acutely unwell women by monitoring physical parameters such

as breathing rate, heart rate, temperature and blood pressure. We reviewed 19 MEOWS charts

and found they were completed and scored. We also saw women were referred promptly to the

medical team for review when indicated by their MEOWS score. Managers audited the completion


of MEOWS charts quarterly and acted to improve completion when needed. From April to June

2019, 65% of MEOWS charts audited were fully and correctly completed. To improve completion,

managers shared the results with staff and gave improvement practice points. The most recent

audit from July to September 2019 showed compliance had improved to 90% (Source: Additional

Evidence Request, DR94a and DR94b).

Staff used a nationally recognised tool to identify women at risk of developing a pressure ulcer.

Staff assessed women routinely in accordance with trust policy, such as on admission during

pregnancy and labour, if they had a body mass index of 40 or above and if an epidural was sited.

Specialist equipment was used for women who were identified as high risk, such as air

mattresses.

Staff used a buddy system to review cardiotocography (CTG) interpretation. This was in line with

national recommendations (NHS England, Saving Babies’ Lives Version Two: A care bundle for

reducing perinatal mortality (March 2019)). The service used the ‘fresh eyes’ approach. This

meant a second midwife was required to review the CTG recording hourly during labour, to ensure

it had been interpreted correctly and escalated when needed. The maternity records we reviewed

showed CTG peer reviews were performed hourly and were escalated appropriately.

Staff completed risk assessments for each woman at their initial booking appointment and updated

them throughout pregnancy, labour and the postnatal period as needed. We reviewed 21

maternity care records which confirmed this. These included social, medical, obstetric and mental

health risk assessments. The outcome of these risk assessments was used to plan future care

provision. Women who were high-risk and unsuitable for midwife led care were referred to an

obstetrician for review and management.

Staff knew about and dealt with any specific risk issues such as gestational diabetes, blood clots

and smoking. Women who were at high risk of gestational diabetes were offered diagnostic

testing. Staff completed venous thromboembolism (VTE) risk assessments (used to determine a

patient’s risk of developing a blood clot) at booking, antenatal admissions and postnatally. This

was in line with national recommendations (RCOG, Reducing the Risk of Venous

Thromboembolism during Pregnancy and the Puerperium: Green-top Guideline No. 37a (April

2015). From May to October 2019, 100% of VTE assessments audited were complete, correctly

assessed and the appropriate action pathway had been followed (Source: Additional Evidence

Request, DR95).

Staff offered women carbon monoxide screening at booking and mostly recorded the outcome. We

reviewed 21 records, four of which had no carbon monoxide level recorded. We were unable to

determine whether these women had declined the test. Staff risk assessed women for fetal growth

restriction and used customised fetal growth charts to help identify babies who were not growing

as expected. Women who were identified at risk were referred for serial growth scans during

pregnancy. In quarter 1 (April to June 2019) and quarter 2 (July to September 2019), 100% and

98% of pregnancies were appropriately screened and monitored according to risk. For the same

period, 92% and 98% of all fundal height measurements were plotted on individualised GROW

charts (Source: Additional Evidence Request, DR97). However, managers recognised the current

scanning capacity would not enable them to meet national recommendations. They had added this

to the service’s risk register and developed an action plan to increase scanning capacity, which

included the recruitment of additional sonographers.

There was a pathway for the management of sepsis. Staff we spoke with could describe what

actions they would take if a woman was admitted with suspected or known sepsis including

prompt administration of fluids and antibiotics.


Swabs used for vaginal birth and perineal suturing were counted for completeness by two

members of staff. This was in line with national recommendations (NSPA, Reducing the risk of

retained swabs after vaginal birth and perineal suturing: 1229 (May 2010). We reviewed 16

records and saw two members of staff had verified the swab count.

The service had 24-hour access to mental health liaison and specialist mental health support (if

staff were concerned about a woman’s mental health. Staff could contact the crisis team for urgent

mental health support when needed. Staff told us they responded promptly.

Staff completed, or arranged, psychosocial assessments and risk assessments for women thought

to be at risk of self-harm or suicide. Staff routinely asked women about their mental health when

they had their booking appointment, throughout pregnancy and postnatally. Women at risk were

referred to the specialist perinatal mental health midwife and local perinatal mental health team for

review, support and treatment.

Staff shared key information to keep women safe when handing over their care to others. The

service used the SBAR communication tool when handing over care. SBAR is a structured method

for communicating critical information that requires immediate attention and action. From June to

November 2019, records audited showed staff completed SBAR handovers. The delivery suite

‘patient safety at a glance’ (PSAG) whiteboard was configured with SBAR. It included key

information about each woman’s history, observations, risks and management plan which health

professionals could see at a glance.

Shift changes and handovers included all necessary key information to keep women safe.

Midwifery handovers took place at the start of each shift, with a further three medical handovers a

day. We observed two handovers which were structured and detailed. Staff handed over all

necessary information about each woman such as history, risks, observations, medicines

prescribed and management care plans.

The World Health Organisation (WHO) surgical safety checklist ‘Five Steps to Safer Surgery’ was

used in maternity theatres. However, compliance was variable. In August 2019, an observational

audit showed compliance was 75% for the safety briefing, 87% for sign in, 89% for time out, 74%

for sign out, 81% for swab count and 58% for debrief. The observers reported staff completed the

WHO checklist well for women who had a planned caesarean section but there was poor

compliance with emergency cases, particularly in terms of debrief. We saw an action plan had

been developed to improve compliance. The service planned to re-audit completion of surgical

safety checklists in January 2020 (Source: Additional Evidence Request, DR93). We reviewed six

WHO checklists and found they were fully completed.

Midwifery staffing

The service had enough maternity staff with the right qualifications, skills, training and

experience to keep women and babies safe from avoidable harm and to provide the right

care and treatment. Managers regularly reviewed staffing levels and skill mix, and gave

bank and agency staff a full induction.

The service had enough maternity staff of all grades to keep women and babies safe. All maternity

staff we spoke with told us staffing levels had improved since the new head of midwifery had

joined the service in September 2019. This was because the establishment (planned staffing

levels) had increased, most vacancies had been recruited to and flexible working had been

introduced. Staff mostly felt there was enough maternity staff to meet the demands of the service.


From November 2018 to November 2019, 99% of women received one-to-one care in established

labour (Source: Additional Evidence Request, DR65).

The number of midwives and health care assistants on shift on each ward did not always match

the planned numbers. However, an escalation plan was in place to address staffing shortages.

This included the redeployment of midwives from other areas and/or specialist roles to support the

unit when needed. From August 2018 to July 2019, the trust reported 22% of available hours were

not filled by staff. This is shown in the table below. The safer staffing nursing report for May 2019,

which was the most recent safer staffing report available on the trust’s website, reported 90% of

day and 89.8% of night hours on delivery suite, 89.4% of day and 87.2% of night hours on the

midwife led unit and 96.9% of day and 98.87% of night hours on the postnatal ward were filled by

registered midwives. We saw staffing levels were displayed publicly in all clinical areas for

midwives and maternity care assistants. On the days of our inspection, including our unannounced

visit, we found planned staffing levels were mostly met.

Broomfield Hospital

The table below shows a summary of the nursing staffing metrics in maternity at Broomfield


Maternity annual staffing metrics August 2018 to July 2019 July 2018 to June 2019 August 2018 to July 2019

Staff group


Annual vacancy

rate

Annual turnover

rate

Annual sickness

rate

Annual bank

hours (% of

available hours)

Annual agency

hours (% of

available hours)

Annual unfilled

hours (% of

available hours)

Target 13% 12% 3.8%


110 14% 7% 4.4% 29,606 (15%)

2,907 (1%)

43,202 (22%)


Nursing Bank Agency tabs)

Nurse staffing rates within maternity at Broomfield Hospital were analysed for the past 12 months


sickness and bank use.

Vacancy rates

From August 2018 to July 2019, the annual average vacancy rate for midwives was 14%. This

was slightly higher (worse) than the trust target of 13%. However, the service had reducing

vacancy rates, which is shown in the graph below.


Monthly vacancy rates over the last 12 months for qualified nurses, health visitors and midwives at

Broomfield Hospital showed a downwards shift from February 2019 to July 2019. This indicated an

improvement in vacancy rates. The service had employed 13 full-time equivalent (FTE) band 5

midwives in September 2019. We were told the service had 7.5 full-time equivalent (FTE) midwife

band 6 vacancies and five FTE maternity care assistant vacancies when we inspected.


Turnover rates

The service had low turnover rates. The turnover rate was below the trust target of 12%.

Monthly turnover rates over the last 12 months for qualified nurses, health visitors and midwives at

Broomfield Hospital showed a shift from January 2019 to June 2019, with an increase from April

2019. However, the turnover rate remained below the trust target.


Agency staff usage

Managers limited their use of bank and agency staff and requested staff familiar with the service.

From August 2018 to July 2019, the service reported 15% of shifts were covered by bank staff and

1% by agency staff. All staff we spoke with told us the use of bank and agency midwives had

reduced. This was partly because the new head of midwifery had introduced flexible working hours

and allowed staff to work reduced hours if they wished. Prior to this, we were told permanent staff

had to work a minimum of 30 hours per week. Those who wanted to work less had to do so

through the bank. Agency staff were not used in the community.


Most bank staff had been employed or were still employed as substantive (permanent) staff within


the trust. Bank staff were required to complete the same trust and service specific mandatory

training as permanent staff. Agency staff had an induction before they commenced duties. This

was undertaken by a senior midwife.

Monthly agency hours over the last 12 months for qualified nurses, health visitors and midwives at

Broomfield Hospital showed a shift from February 2019 to July 2019.


Midwife to birth ratio

From January to December 2018 the trust had a ratio of one midwife to every 29.4 births. This was

similar to the England average of one midwife to every 24.6 births. However, the maternity

dashboard showed this had increased (worsened) from April to October 2019, with an average of

one midwife to every 33.4 births. This corresponded with a general increase in deliveries during

this period.

(Source: Electronic Staff Records – EST Data Warehouse)

Managers accurately calculated and reviewed the number and grade of midwives and maternity

care workers needed for each shift, in accordance with national guidance. A midwifery staffing

establishment review was undertaken and presented to the board in June 2019. The trust used the

Birthrate Plus midwifery workforce tool to calculate the midwifery staff needed based on activity,

case mix and demographics. Birthrate Plus is recommended by the Department of Health,

endorsed by the Royal College of Midwives and is incorporated within the national maternity safety

strategy (NHS Resolution, Maternity incentive scheme - year two (2018)). The establishment

review showed the service had a shortfall of 3.47 full-time equivalent (FTE) midwives for clinical

care and 6.20 FTE non-clinical midwives. Managers told us they had recruited several specialist

midwives to lead on improvement and safety initiatives, in accordance with national

recommendations. These included a fetal surveillance lead midwife, quality improvement lead

midwife and a Better Births lead midwife. At the time of our inspection, the service was also

recruiting for an additional perinatal mental health and bereavement midwife to help meet the

increasing demands for these services.

Staffing incidents were reported through the trust’s electronic reporting system. From 20

November 2018 to 19 November 2019, the service reported 45 incidents related to staffing. Most

of these were categorised as unit closure of one of the standalone birthing units (53.3%) or failure

and/or delay in access and admission (22.2%). Managers acted to minimise the risk from staffing

shortages to women and/or babies, such as the redeployment of staff.


The ward manager could adjust staffing levels daily according to the needs of women. Staffing

levels, skill mix and patient acuity were monitored and reported regularly throughout the day. A

senior midwife was the designated daily ‘bleep holder’ from 8am to 4pm. Their role was to monitor

and manage any staffing issues. Staff could contact them for assistance with any staffing issues

when needed. Out of these hours, the delivery suite coordinator and manager on-call were

available. Staffing levels were also reviewed at the daily safety huddle and handovers. An acuity

tool was used to monitor staffing levels and patient acuity four-hourly. The tool flagged whether a

shift was safe or unsafe by a traffic light system. Green indicated staffing numbers were safe,

amber indicated staffing numbers were safe but required escalation to maintain safety and red

indicated staffing numbers were unsafe and required escalation. We reviewed the acuity tool for

October 2019 and found 10 occasions when staffing levels were red rated (5.4%). This meant

most shifts in October 2019 were rated safe for staffing (94.6%).

Student midwives were supernumerary and not included in the midwife-staffing establishment.

Every student was assigned a midwife to work with on shift.

Medical staffing

While planned medical staffing levels were met, the service did not always have enough

medical staff with the right qualifications, skills, training and experience to keep women

and babies safe from avoidable harm and to provide the right care and treatment.

The service did not always have enough medical staff to keep women and babies safe. Most staff

we spoke with felt there was not always enough medical staff to meet the needs of women and/or

babies in a timely manner. They also told us medical staffing levels had not increased despite an

increase in activity. The service provided 68 hours of consultant obstetric on-site cover per week

(Source: Mid and South Essex University Hospitals Group, Maternity Staffing Strategy (October

2019)). When not on site, a consultant was on-call from home. However, the consultant on-call

was also responsible for covering any emergencies in the gynaecology service. This meant there

was a risk they may not always be available to attend maternity emergencies in a timely manner.

A middle grade/registrar doctor and junior doctor supported the on-call consultant and were on-site

24 hours a day, seven days a week. Managers had recognised medical staffing was a risk and

funding had been allocated to mitigate this risk by providing a second registrar at nights and

weekends to manage activity. Staff told us this worked well. However, from Monday to Thursday

the service had one doctor at middle grade/registrar level who covered both the maternity and

gynaecology service. Staff told us this meant women were not always reviewed in a timely

manner, particularly those awaiting review on the antenatal day assessment unit.

Obstetric anaesthetic cover was available 24 hours a day, seven days a week. Emergency work

on delivery suite was covered by a staff grade/specialist anaesthetist. A consultant anaesthetist

was also available from 8am to 6pm to cover the elective caesarean section list. There was a

designated lead anaesthetist for obstetrics. This was in line with national recommendations (Royal

College of Anaesthetists (RCoA), Guidelines for the Provision of Anaesthesia Services for an

Obstetric Population 2019 (January 2019)).

There were three consultant-led ward rounds per day, where activity was discussed, and women

were reviewed. Women were prioritised according to their risk.

The medical staff matched the planned number on all shifts in each department. As the table

below shows, from August 2018 to July 2019 on average, there were no vacancies for medical

staff and all available hours were filled.


Broomfield Hospital

The table below shows a summary of the medical staffing metrics in maternity at Broomfield

Hospital compared to the trust’s targets, where applicable.

The trust has reported that there are no medical staff working exclusively in maternity at St Peter’s

Hospital and St Michael’s Hospital.

Maternity annual staffing metrics August 2018 to July 2019 July 2018 to June 2019 August 2018 to July 2019

Staff group


Annual vacancy

rate

Annual turnover

rate

Annual sickness

rate

Annual bank

hours (% of

available hours)

Annual locum

hours (% of

available hours)

Annual unfilled

hours (% of

available hours)

Target 13% 12% 3.8%


28 0% 8% 0.3% 1,918 (3%)

2,619 (5%)

0 (0%)


Medical locum tabs)

Medical staffing rates within maternity were analysed for the past 12 months and no indications of

improvement, deterioration or change were identified in monthly rates for turnover, sickness, bank

use and locum use.

Vacancy rates

The service had low vacancy rates for medical staff. As of June 2019, the service reported a

medical vacancy rate of 2% which was below (better than) the trust target of 13%.

Monthly vacancy rates over the last 12 months for medical staff show a downward trend from

November 2018 to April 2019 and medical staff in maternity at the trust were over established in

February, March and April 2019.



Sickness rates for medical staff were low. From July 2018 to June 2019, the sickness rate for

medical staff was 0.3%. This was below (better than) the trust target of 3.8%.

The service had low turnover rates for medical staff. From July 2018 to June 2019, the turnover

rate for medical staff was 8%. This was below (better than) the trust target of 12%.

The service had low rates of bank and locum staff used. From August 2018 to July 2019, 3% of

shifts were filled by bank medical staff and 5% by locum medical staff. Managers could access

locums when they needed additional staff. There were no medical shifts unfilled by substantive

and temporary staff.

Managers made sure locums had a full induction to the service before they started work. Locum

doctors received an induction before they commenced duties. Managers we spoke with told us

locums who were familiar with the service were used where possible.

Staffing skill mix

The service had a good skill mix of medical staff on each shift and reviewed this regularly. The

service always had a consultant, middle grade/registrar level doctor, junior doctor and anaesthetist

on-call 24 hours a day, seven days a week. Staff told us they could contact the on-call obstetric

team whenever they needed them.

In April 2019, the proportion of consultant staff and registrars reported to be working at the trust

was lower than the England average. The proportion of junior (foundation year 1-2) and middle

career staff was higher.

Staffing skill mix for the 27.2 whole time equivalent staff working in maternity at Mid Essex

Hospital Services NHS Trust.

This

Trust

England

average

Consultant 36% 42%



Junior* 11% 6%




Records

Staff kept detailed records of women’s care and treatment. Records were clear, up-to-date

and mostly available to all staff providing care.

Women’s notes were comprehensive, and staff could mostly access them easily. The service

mainly used paper-based records, with some information held on the trust’s electronic patient

record system. Community staff told us there could be a delay in booking information being

available to hospital staff. This was because most community midwives did not have laptops and

had to return to the hospital to update the electronic patient record system. To address this, four

community hubs were opening in January 2020 (Source: Additional Evidence Request, DR83).

These would be equipped with computer terminals so that community staff could record women’s

information on the electronic patient record system in a timely manner. Furthermore, all women

had their handheld pregnancy records which included all their booking information. Staff told us it

was uncommon for women’s records to be unavailable for clinics.

Records were contemporaneous, legible, dated and signed. We reviewed 21 sets of maternity

records and found these were mostly completed in line with professional standards (NMC, The

Code: Professional standards of practice and behaviour for nurses, midwives and nursing

associates (October 2018). Handheld records contained a complete record of antenatal test

results. This was in line with national guidance (NICE, Antenatal care: QS22, Quality statement 3

(April 2016). Regular maternal and fetal assessment was evident, such as blood pressure, urine

analysis, symphysis-fundal height measurement and fetal movements. Relevant past and current

medical, obstetric, social and mental health information was documented. Risk assessments were

completed with details of further action taken when indicated. It was evident from the records if

women had additional needs, such as language and literacy, sight and hearing. Staff had access

to up to date management plans for women with safeguarding and mental health concerns. These

were stored on the electronic patient record system. All authorised staff could access, and update

safeguarding management plans as needed.

Managers audited records to ensure staff completed them in line with national standards and trust

policy. Audits carried out from June to November 2019 showed staff were mostly compliant with

record keeping standards. There were two occasions when staff had not documented the time the

entry was made. A letter detailing where improvement was needed was sent to these staff

members (Source: Additional Evidence Request, DR92).

When women were transferred from the community to the hospital, to different wards and/or

discharged home, there were no delays in staff accessing their records. Women carried their own

handheld pregnancy records which they were advised to bring to each antenatal appointment and

when they attended the hospital. Discharge summaries were sent to community midwives, health

visitors and GPs to help ensure continuity of care in the community. The summary included

information about the woman’s pregnancy, birth and postnatal care, medicines prescribed, and

ongoing risks and/or follow-up care needed. Women were given the personal child health record

(also known as the ‘red book’). Staff completed the required sections and told women what the

record was for and how to use it. The red book is a national standard health and development

record which is used to monitor growth and development of the child, up to the first four years of

life.

Records were stored securely. Women’s maternity records were stored in lockable trolleys on the

delivery suite and postnatal ward. We observed these were locked when not in use. The maternity

records of women on the antenatal day assessment unit were stored behind the midwives’ station.


These were not secured. However, we observed the station was not left unattended by staff.

Electronic records were password protected. We saw computer terminals were locked when not in

use.

Medicines

Prescription charts were not always completed with women’s weight and allergy status.

Furthermore, storage temperatures were not always checked daily and temperature

checklists were not always completed fully. However, staff followed systems and

processes when safely administering and recording medicines.

We found prescription charts were not always fully completed. We reviewed 22 charts and found

three did not have the woman’s allergy status documented. This is essential to avoid serious

medication errors from being made. Furthermore, women’s weight was not documented in seven

charts. This is important because the correct dose of some medicines is determined by patient

weight, such as anti-clotting medicine. Women at risk of developing a blood clot were routinely

prescribed anti-clotting medicine to reduce this risk; the correct dose of which was determined by

the woman’s weight. However, staff told us they used the woman’s booking weight to determine

the correct dose which was in line with national guidance (RCOG, Reducing the Risk of Venous

Thromboembolism during Pregnancy and the Puerperium: Green-top Guideline No. 37a (April

2015). All the prescription charts were signed, legible and medicines were given as prescribed.

Antibiotics were prescribed and reviewed in line with trust policy.

Staff did not always store and manage all medicines and prescribing documents in line with the

trust’s policy. Ambient and fridge temperatures were not always checked daily to ensure

medicines stored were effective and safe for patient use. We reviewed 18 checklists completed

from 1 September to 5 November 2019 for delivery suite, the antenatal day assessment unit

(ADAU) and postnatal ward and found 65 occasions when the fridge and/or ambient temperature

had not been checked daily. Furthermore, according to the ambient checklists for the ADAU, the

temperature had exceeded 25°C for seven consecutive days. However, staff had not recorded

what escalation and corrective action they had taken. This was not in line with the trust’s policy

(Source: Additional Evidence Request, DR101). Managers told us this had been escalated to

pharmacy staff, who had checked and confirmed the medicines stored were safe and effective at

up to 30°C. We raised these concerns with senior staff and when we revisited the service on our

unannounced inspection we found all checklists had since been completed with details of

escalation and action taken when indicated.

Medicines were stored securely in all clinical areas we visited. Controlled drugs (medicines subject

to additional security measures) were stored correctly in locked cupboards and stock was checked

by two qualified members of staff twice a day. The keys for medicine cupboards and fridges were

stored in a safe which only qualified members of staff had access to. This prevented unauthorised

personnel from accessing medicines. We found medicine storage areas were well organised and

tidy, with effective processes in place to ensure stock was regularly rotated. All medicines we

checked were within their use by date, including intravenous fluids (fluid given through a vein).

Staff reviewed women’s medicines regularly and provided specific advice to women and carers

about their medicines. Staff showed women or their carer how to administer anti-clotting medicine

when this was prescribed for them to take at home. Women we spoke with confirmed this. Staff

provided advice to women about medicine options for pain relief during labour, which included the


risks and benefits of each option. Staff could contact pharmacy staff for advice about women’s

medicines when needed.

Staff followed current national practice to check women had the correct medicines. Midwives

undertook additional drug administration training if they were involved in medication incidents and

had not followed current national practice. We saw staff checked women’s identification to ensure

they had the correct medicines before they gave them. Staff checked women had the correct

medicines to take home before they discharged them.

The service had systems to ensure staff knew about safety alerts and incidents, so women

received their medicines safely. Staff knew how to report medicine errors and incidents and we

saw these were investigated and learning was shared with staff. From August 2018 to August

2019 the service reported 40 medication incidents through the National Reporting and Learning

System. This equated to 2.6% of total incidents reported by the service. All incidents were graded

as having caused no harm. Common themes included missed and/or delayed administration and

wrong dose, wrong frequency and/or wrong route. We saw learning from medicine incidents were

shared with staff.

Decision making processes were in place to ensure women’s behaviour was not controlled by

excessive and inappropriate use of medicines. Women with known drug and alcohol misuse were

referred to the local specialist treatment and recovery service for assessment. This included

whether stabilising drug use or detoxification programme was appropriate before delivery.

Incidents

The service managed patient safety incidents well. Staff recognised incidents and near

misses and reported them appropriately. Managers investigated incidents and shared

lessons learned with the whole team and the wider service. When things went wrong, staff

apologised and gave women honest information and suitable support. Managers ensured

that actions from patient safety alerts were implemented and monitored.

All staff knew what incidents to report and how to report them. The trust used an electronic

reporting system which all grades of staff had access to. Staff we spoke with said they were

encouraged to report incidents and felt confident to do so. They described a “good reporting

culture” within the service and trust.

Staff reported all incidents that they should report. The service had up to date guidance on what

should be reported as an incident which staff could access easily. We saw staff reported a wide

range of incidents including near misses. From August 2018 to August 2019, staff reported 1,518

maternity incidents through the National Reporting and Learning System (NRLS). Incidents were

graded as having caused no harm, low harm or severe harm. Most incidents were graded as

having caused no harm (95.3%). The most common themes for incidents reported were related to

treatment and/or procedure, access, admission, transfer, discharge (including missing patient)

(20.3%) and other (13.6%) (Source: RPM Analysis, NRLS Notifications and StEIS incidents

Detail).

Never events

The service had no never events on any maternity wards and departments.






event in maternity.

(Source: Strategic Executive Information System (StEIS))

Managers shared learning with their staff about never events that happened elsewhere. Staff we

spoke with confirmed this. Staff told us they received trustwide safety alerts which included

learning from never events and serious incidents that had happened in the three hospitals within

the trust.


Staff reported serious incidents clearly and in line with trust policy. All potential serious incidents

were reviewed by the trust’s serious incident panel which met three times a week. If an incident

was declared as a serious incident the panel appointed an appropriate senior member of staff to

lead the investigation and conduct a root cause analysis (RCA). Incidents which met the reporting

criteria were referred to the Healthcare Safety Investigation Branch (HSIB) for independent

investigation. The HSIB’s maternity investigation programme is part of a national action plan to

make maternity care safer. They investigate incidents that meet the Each Baby Counts criteria and

maternal deaths of women while pregnant or within 42 days of the end of pregnancy.

Broomfield Hospital

In accordance with the Serious Incident Framework 2015, the trust reported nine serious incidents

(SIs) in maternity which met the reporting criteria set by NHS England from August 2018 to August

2019. All of the incidents were reported at Broomfield Hospital.

A breakdown of the incident types reported is in the table below:

Incident type Number of incidents Percentage of total Maternity/Obstetric incident meeting SI criteria: baby only (this include foetus, neonate and infant)

5 55.6%

Surgical/invasive procedure incident meeting SI criteria

1 11.1%

Abuse/alleged abuse of adult patient by staff 1 11.1% Pending review (a category must be selected before incident is closed)

1 11.1%

VTE meeting SI criteria 1 11.1% Total 9 100.0%


Managers investigated incidents thoroughly. Women and their families were involved in these

investigations. Managers reviewed all incidents reported at the daily safety huddle, Monday to

Friday. Where necessary, investigations were initiated to identify any learning and actions needed

to address incidents and minimise recurrence. We reviewed the investigation reports for three

serious incidents and found comprehensive investigations were carried out. The reports included

details of the investigating officer/team including their qualifications and experience, involvement


and support of the woman and relatives, lessons learned and recommendations. Each report had

an action plan to minimise recurrence (Source: Additional Evidence Request, DR67).

Managers debriefed and supported staff after any serious incident. The serious incident reports we

reviewed included details of the involvement and support provided for staff. Professional midwifery

advocates offered restorative clinical supervision sessions to midwives involved in an

investigation. One of the reports we reviewed showed staff were given group psychological

support after a distressing event. One-to-one psychological support was offered to those who

needed it. Staff we spoke with told us they received support from their managers and peers if they

were involved in a serious incident. Staff were provided with additional training if identified as a

learning action.

Staff understood the duty of candour. They were open and transparent and gave women and

families a full explanation when things went wrong. The trust had an up to date duty of candour

policy which staff could access through the trust’s intranet. The duty of candour is a regulatory

duty that relates to openness and transparency and requires providers of health and social care

services to notify patients (or other relevant persons) of certain notifiable safety incidents and

provide reasonable support to that person, under Regulation 20 of the Health and Social Care Act

2008 (Regulated Activities) Regulations 2014. A notifiable safety incident includes any incident

that could result in, or appears to have resulted in, the death of the person using the service or

severe, moderate or prolonged psychological harm. Staff we spoke with were aware of the

importance of being open and honest with women and families when something went wrong, and

of the need to offer an appropriate remedy or support to put matters right and explain the effects of

what had happened. We saw the duty of candour regulation was followed in the incident reports

we reviewed. Women and families were involved in the investigation process and informed of the

outcome. The investigation report was shared with the woman, her family and/or representative(s)

on completion (Source: Additional Evidence Request, DR67).


Staff could indicate if they wanted feedback from incidents they had reported through the

electronic reporting system. Feedback from incidents was shared with staff in a variety of ways

such as safety huddles and handovers, hot topics, email, newsletters and staff noticeboards. We

read two copies of the women’s and children’s divisional quarterly newsletter which included

learning from maternity, gynaecology and paediatric related incidents. Staff told us they felt well

informed about incidents.

Staff met to discuss the feedback and look at improvements to women’s and babies care.

Incidents were a standing agenda item at monthly team and governance meetings. We reviewed

three sets of mortality and morbidity meeting minutes which showed incident themes and areas for

improvement were discussed. Individual cases of maternal and perinatal morbidity and mortality

were also presented, including learning and recommendations. The meetings were well attended

by members of the multidisciplinary team (Source: Additional Evidence Request, DR68). All cases

of perinatal mortality were reviewed with the aid of a national perinatal mortality tool. This was in

line with national recommendations (MBRRACE-UK, Perinatal Mortality Review Tool (February

2018).

There was evidence that changes had been made as a result of feedback. For example, in July

2019 the service commenced a 12-month quality improvement project to reduce the rate of

postpartum haemorrhage (PPH) (excessive blood loss following delivery) of 1,500mls or more by

50% by May 2020. This was in response to an increase in incidents of this. From March to June

2019, the average rate of births at the trust with PPH greater than/or equal to 1,500mls was 5.3%


This was higher than the national rate of 2.7%. Actions taken to reduce the PPH rate included

completion of PPH risk assessment on admission to delivery suite, second midwife to be present

at delivery and the administration of medicine for management of the third stage (delivery of the

placenta and membranes) with delivery of the anterior shoulder (the shoulder of the baby that

faces the pubic symphysis of the mother during delivery) (Source: Additional Evidence Request,

DR98a).

Safety thermometer

The service used monitoring results well to improve safety. While safety thermometer data

was not shared with staff, women and visitors, other safety information was displayed

publicly.

Safety thermometer data was not displayed on wards for staff and women to see. While managers

collected data for the maternity safety thermometer, the results were not displayed. However,

other safety information was displayed publicly. For example, we saw television screens in each

department with learning from incidents and audit results displayed on a loop.

Managers submitted data monthly to the national maternity safety thermometer. The safety

thermometer was designed to support improvements in patient care and experience. Harms

associated with maternity were recorded such as perineal trauma, infection and babies with an

Apgar score less than seven at five minutes.

The safety thermometer data showed the service did not achieve over 95% harm free care for the

last 12 months. From August 2018 to July 2019, the trust’s average combined harm free score

was 49.9%. This was significantly lower (worse) than the England average of 75.1%. Managers

told us this was because some of the figures submitted had been wrongly recorded by staff. This

had significantly skewed some of the data submitted.

Staff used the safety thermometer data to further improve services. For example, from August

2018 to July 2019, the percentage proportion of women that had a PPH greater than 1,000mls

was 22.5%. This was significantly higher (worse) than the England average of 10.1%. In response,

the service had commenced a 12-month quality improvement project to reduce the rate of PPH.



The service provided care and treatment based on national guidance and best practice.

Managers checked to make sure staff followed guidance. Staff protected the rights of

women subject to the Mental Health Act 1983.

Staff followed up to date policies to plan and deliver high quality care according to best practice

and national guidance. Antenatal records showed women received care in accordance with

national guidance and standards. For example, all pregnant women were offered fetal anomaly

screening (NICE, Antenatal care: QS22, Quality statement 10 (April 2016)). Staff offered pregnant

women testing for gestational diabetes if they were identified at risk of it at booking (NICE,

Antenatal care: QS22, Quality statement 6 (April 2016)). Staff offered women who had had one or

more previous caesarean sections the opportunity to discuss birth options in their current

pregnancy (NICE, Caesarean section: QS32, Quality statement 1 (June 2013)).


Managers checked to make sure staff followed guidance and used the results to improve.

Compliance with the Saving Babies’ Lives care bundle was monitored and reported quarterly. An

audit of compliance in quarter 2 (July to September 2019) showed most recommendations were

being met. For example, women were offered carbon monoxide screening at booking and the

outcome was recorded when accepted. Information and advice leaflet on reduced fetal movement

was given to and discussed with all pregnant women by 24 weeks of pregnancy. Symphysis-

fundal height measurement was routinely monitored from 24 weeks of pregnancy. Where

compliance was not 100%, we saw action was taken to improve. For example, staff who had not

completed cardiotocography (CTG) training and assessment were asked to evidence this within

the month (Source: Additional Evidence Request, DR97).

Managers made sure guidelines reflected current evidence-based guidance and quality standards.

Guidelines were reviewed every three years or when national guidance was published. Staff were

informed of updated guidelines through email. Managers were working collaboratively to develop

network guidelines to standardise care across the local maternity system. The guidelines we

reviewed were in line with and referenced current national guidance. All maternity guidelines were

within review date. We saw staff could access guidelines easily through the trust’s intranet. Trust

policies were assessed to ensure guidance did not discriminate because of race, ethnic origin,

nationality, gender, culture, religion or belief, sexual orientation and/or age.

Staff protected the rights of women subject to the Mental Health Act and followed the Code of

Practice. Staff knew how to access support and advice to best meet the needs of women with

mental health concerns. Staff assessed all women for risk of mental health issues at booking and

monitored psychological wellbeing throughout the perinatal period. Women identified at risk were

referred to the specialist perinatal mental health midwife. Mental health assessment, care and

treatment was also available from the local perinatal mental health service. Women with current or

history of moderate and/or severe psychiatric disorder had a pre-birth planning meeting at 32

weeks gestation. This involved the prospective parents and all involved health care professionals.

A care pathway for the management of psychiatric emergencies was in place.

At handover meetings, staff routinely referred to the psychological and emotional needs of women,

their relatives and carers. We saw staff discussed all aspects of women’s care including

psychological and emotional needs at handover meetings.


Staff gave women and babies enough food and drink to meet their needs and improve their

health. They used special feeding and hydration techniques when necessary.

Staff made sure women and babies had enough to eat and/or drink, including those with specialist

nutrition and hydration needs. Women were encouraged to eat and drink as normal in the early

stages of labour to maintain hydration and energy. Staff checked women’s hydration regularly

during labour and treated dehydration with oral or intravenous fluids when needed. Staff supported

women with feeding their baby and respected women’s choice of feeding method. Staff educated

and helped women who wanted to breastfeed. This was confirmed from women we spoke with

and feedback we read. For example, one woman wrote, “[staff member] went out of her way to

help me breastfeed throughout the night and nothing was too much trouble”. From January to

October 2019, 77.2% of women on average initiated breastfeeding at birth. For the same period,

85.3% of women were breastfeeding 10 days after birth. Both breastfeeding rates were higher

(better) than the trust’s target. Community midwives and maternity care assistants provided


feeding support to women at home. Staff followed up to date guidance and infant feeding

pathways. Babies were routinely weighed and monitored for jaundice to ensure their nutritional

and hydration needs were being met.

The service did not provide infant formula to women who chose not to breastfeed. Women were

told to bring formula and feeding equipment with them, such as bottles and teats. Infant formula

was provided for babies when clinically indicated, such as concerns with weight and blood sugar

levels, following paediatric review. Staff monitored babies at risk of hypoglycaemia (low blood

sugar) after delivery to ensure blood sugar levels were within the normal range.

There was a milk kitchen on the postnatal ward where women could store expressed breast milk

or formula. Checklists showed the fridge temperature was checked daily to ensure milk was stored

within the recommended range. The fridge was locked which meant milk could not be taken or

tampered with. Stored milk was labelled with the date, time and mother’s name.

Staff fully and accurately completed women’s fluid and baby feeding charts where needed.

Maternity care records we reviewed confirmed this. We saw staff put infant feeding plans in place

and escalated babies for medical review when indicated.

Specialist support from staff such as dietitians, ear, nose and throat (ENT) specialists, cleft lip and

palate specialists and infant feeding specialists was available for women and babies who needed

it. For example, dietetic support was provided for women with pre-existing or gestational diabetes

and women who had a body mass index (BMI) of 40 or higher.

Staff used a nationally recognised screening tool to assess babies with tongue tie who would

benefit from frenulotomy (a procedure that separates tongue tie). Babies with suspected tongue tie

and breastfeeding difficulties were referred to the midwife led frenulotomy clinic for assessment

and division, if appropriate.

Women admitted for planned caesarean section were not left nil by mouth for long periods. Staff

gave women intravenous fluid during and after the procedure to ensure they kept hydrated. After

caesarean section, women could eat and drink as soon as they wished if they were recovering

well with no complications.

Pain relief

Staff assessed and monitored women regularly to see if they were in pain and gave pain



Staff assessed women’s pain using a recognised tool and gave pain relief in line with individual

needs and best practice. We saw women’s pain levels were regularly assessed using a numerical

pain scale. Staff could access pain assessment tools for women with communication difficulties

when needed.

Women received pain relief soon after requesting it. Women we spoke with told us they were

asked if they needed pain relief regularly and were given it promptly. Managers did not monitor

epidural waiting times. This meant we could not determine if women were ready to receive an

epidural within 30 minutes from request, in line with national recommendations (OAA/AAGBI,

Guidelines for Obstetric Anaesthetic Services (2013)). Managers told us women were rarely

delayed in having an epidural because a dedicated obstetric anaesthetist was available 24 hours a


day, seven days a week. In the event the anaesthetist was busy in theatre, for example, a second

on-call anaesthetist was called. Staff offered women alternative analgesia while they waited.

Staff prescribed, administered and recorded all pain relief accurately. Pain relief could be

prescribed as suppositories or injection if women were unable to tolerate oral medication. We saw

post-operative women were prescribed and given regular pain relief to keep them comfortable.

Women were routinely given local anaesthetic before perineal suturing and were offered non-

steroidal anti-inflammatory drug (NSAID) suppository medicine following suturing, unless

contraindicated. Women who had undergone caesarean section were given pain relief for use at

home when they were discharged.

Midwives provided pregnant women with evidence-based information about the availability and

provision of different types of analgesia. Pharmacological (medicine based) methods of pain relief

were readily available, including ‘gas and air’, opioids (such as pethidine and morphine) and

patient controlled epidural anaesthesia. Non-pharmacological methods of pain relief were also

available, such as transcutaneous electrical nerve stimulation (TENS), hydrotherapy (water) and

aromatherapy. Pain relief options for women who wanted a homebirth were gas and air, TENS or

hydrotherapy. The birthing units offered TENS, hydrotherapy, gas and air, oral morphine and

pethidine. Women who needed stronger pain relief in labour were transferred to delivery suite for

epidural.

Outcomes


improvements and achieved good outcomes for women and babies. The service had been

accredited under the UNICEF UK Baby Friendly Initiative.

The service participated in all relevant national clinical audits. The service performed well in

clinical outcome audits and managers used the results to improve services further. For example,

the service participated in the Avoiding term admissions into neonatal units (Atain) programme.

This was designed to reduce avoidable causes of harm that could lead to infants born at term

(from 37 weeks gestation) being admitted to a neonatal unit. In partnership with neonatal care

staff, the service had introduced initiatives to reduce the number of unexpected term admissions.

This included workstreams for hypoglycaemia, respiratory distress, jaundice, hypothermia and

birth asphyxia (Source: Additional Evidence Request, DR85). From January to October 2019, the

percentage of unexpected term admissions was 2% on average. This was in line with the trust

target.

The tables below summarise the trust’s performance in two national maternity and neonatal audits.

In the latest national audit of perinatal mortality, the trust’s perinatal mortality rate was more than

5% and up to 15% lower (better) than the national average. The trust performed within the

expected range in the National Neonatal Audit Programme for measures related to maternity care.

National Neonatal Audit Programme

Broomfield Hospital

The table below summarises Broomfield Hospital’s performance in the 2018 National Neonatal

Audit Programme against measures related to maternity care.




Comparison to other hospitals

Meets national standard?

Are all mothers who deliver babies from 24 to 34 weeks gestation inclusive given any dose of antenatal steroids? (Antenatal steroids reliably reduce the chance of babies developing respiratory distress syndrome and other complications of prematurity)

87.8% Within expected

range Met

Are mothers who deliver babies below 30 weeks gestation given magnesium sulphate in the 24 hours prior to delivery? (Administering intravenous magnesium to women who are at risk of delivering a preterm baby reduces the chance that the baby will later develop cerebral palsy)

59.5% Within expected

range No current standard

(Source: National Neonatal Audit Programme)

National Maternity and Perinatal Audit Programme

Mid Essex Hospital Services NHS Trust were ineligible for the 2017 National Maternity and

Perinatal Audit Programme as the trust submitted incomplete data and the audit was unable to

perform analysis on the data that was submitted.

(Source: National Maternity and Perinatal Audit Programme)

MBRRACE-UK Perinatal Mortality Surveillance Report


MBRRACE-UK Perinatal Mortality Surveillance Report for births in 2016. MBRRACE-UK

undertakes a programme of work involving the surveillance of maternal deaths, late fetal losses,

stillbirths and infant deaths, to provide evidence to improve the care provided to women, babies

and families.


Trust performance

Comparison to other trusts with similar

service provision

Meets national standard?

Stabilised and risk-adjusted perinatal mortality rate (The death of a baby in the time period before, during or shortly after birth is a devastating outcome for families. There is evidence that the UK’s death rate varies across regions, even after taking into account differences in poverty, ethnicity and the age of the mother.)

5.21

Up to 10% higher than the average

for the comparator

group

No current standard

(Source: MBRRACE-UK)


The latest Perinatal Mortality Surveillance Report published in October 2019 for births in 2017

showed an improvement in trust performance. The stabilised and risk-adjusted perinatal mortality

rate had reduced to 4.78. This was more than 5% and up to 15% lower (better) than the national

average.

Managers maintained a clinical performance and governance dashboard (maternity dashboard)

which monitored outcomes in relation to maternal and neonatal morbidity and mortality indicators.

These included but were not limited to third and fourth-degree tears, massive obstetric

haemorrhage (excessive blood loss of two litres or more), maternal deaths and stillbirths.

Performance was tracked monthly against locally agreed thresholds. A traffic light system was

used to rate performance against the agreed thresholds. A red flag indicated areas that required

investigation to ensure safety and quality was maintained. From January to October 2019 the

service mostly met the agreed threshold each month for all maternal and neonatal morbidity and

mortality indicators (Source: Additional Evidence Request, DR86).

Outcomes in relation to delivery method were in line with the England average. Managers

monitored delivery method outcomes through the maternity dashboard. From January to October

2019 the vaginal (non-interventional) delivery rate was mostly red flag rated. On average, the

percentage of women who achieved a vaginal delivery was 59.3%. This was lower than the trust

target of 65% or more. However, this was similar to the England average. The elective (planned)

caesarean section rate was also mostly red or amber flag rated. On average, the percentage of

women who had a planned caesarean section was 14.1%. This was higher than the trust target of

less than 11.9%. However, the emergency caesarean section rate was mostly green flag rated,

with an average monthly rate of 15.7%. This was in line with the trust target of less than 15.5%. At

the time of inspection, managers were auditing all caesarean sections that occurred in November

2019 to identify if all sections were indicated and whether improvements could be made to reduce

the section rate.

Standardised Caesarean section rates and modes of delivery

The tables below summarise the percentage of deliveries at the trust by delivery method

compared with the England average. The trust’s vaginal (non-interventional) delivery rate was

slightly higher than the England average, while caesarean section rates were in line with the

England average.

From January 2018 to December 2018 the total number of caesarean sections was similar to

expected. The standardised caesarean section rates for elective sections and emergency sections

were also similar to expected.


Notes: Standardisation is carried out to adjust for the age profile of women delivering at the trust and for the proportion of privately funded deliveries. Delivery methods are derived from the primary procedure code within a delivery episode. This table includes all deliveries, including where the delivery method is 'other' or 'unrecorded'.

In relation to other modes of delivery from January 2018 to December 2018 the table below shows

the proportions of deliveries recorded by method in comparison to the England average. The

caesarean section rate at the trust was similar to the England average, the instrumental delivery

rate was slightly lower than the England average and the non-interventional delivery rate was

slightly higher.

Notes: This table does not include deliveries where delivery method is 'other' or 'unrecorded'. 1Includes elective and emergency caesareans 2Includes forceps and ventouse (vacuum) deliveries 3Includes breech and vaginal (non-assisted) deliveries

(Source: Hospital Episode Statistics (HES))

Maternity active outlier alerts

As of 2 September 2019, the trust had no active maternity outliers. An outlier is an indication of

care or outcomes that are statistically higher or lower than would be expected. They can provide a

useful indicator of concerns regarding the care people receive. Maternity outliers include elective

and emergency caesarean section rates, and neonatal and maternal readmission rates.

(Source: Hospital Evidence Statistics (HES)

Managers carried out a comprehensive audit programme. The service had an annual audit

programme to review the effectiveness of care and treatment. The programme included national

and local audits, such as the National Pregnancy in Diabetes Audit and audit of maternal anaemia

(Source: Additional Evidence Request, DR91). Ad hoc audits were also undertaken in response to

incidents and clinical performance data when indicated. We saw each audit had been assigned a

lead and target date for completion.


Managers used information from audits to improve care and treatment. Improvement was checked

and monitored. For example, an audit of obstetric anal sphincter (OASIS) (third and fourth-degree

perineal tears) was done following the introduction of Episcissors (surgical scissors used for

episiotomy designed to cut at a 60° angle). Results of the audit showed the use of Episcissors had

made a significant improvement in the OASIS rate. From January to October 2019, the percentage

of women who sustained a third or fourth-degree tear was 1.6% on average. This was in line with

the trust target of 2% or less. However, the audit did show some midwives did not feel confident to

perform episiotomy and/or use the Episcissors. In response to this, the specialist midwife for

perineal health had commenced additional teaching sessions for staff.

Managers shared and made sure staff understood information from the audits. Staff we spoke with

confirmed this. We saw the results of the latest modified early obstetric warning score (MEOWS)

documentation audit were displayed on television screens in each department for staff, women

and visitors to see. Minutes of meetings we reviewed showed audits were a standing agenda item

at divisional governance and board meetings.

The service was accredited by the UNICEF Baby Friendly Initiative. They had achieved level two

accreditation. This level is awarded to services that have educated staff to implement Baby

Friendly standards.

Competent staff

The service made sure staff were competent for their roles. Managers appraised staff’s

work performance and held supervisions meetings with them to provide support and

development. However, some staff did not find the appraisal process useful.


women. Midwives were supported to attend a three-day maternity specific training programme

annually. The programme included but was not limited to cardiotocography (CTG) interpretation,

antenatal, newborn screening and assessment of fetal growth including the use of Gestational

Related Optimal Weight (GROW), bereavement and multidisciplinary emergency training.

Maternity care assistants completed a two-day training programme. As of November 2019, 93% of

maternity staff had attended maternity specific training (Source: Additional Evidence Request,

DR75). Bereavement and multidisciplinary emergency training were a standard part of the

maternity specific training programme. Staff told us the training was comprehensive and relevant

to their roles. However, we found staff were not individually competency assessed for CTG

interpretation. This has been reported under the mandatory training sub-heading within the safe

domain of this report. As of 20 November 2019, 89.7% of eligible staff had completed a practical

fetal growth competency assessment and 70.1% had completed an on-line Growth Assessment

Protocol (GAP) competency assessment. Midwives could independently perform venepuncture

(taking blood samples), cannulation (inserting a tube into a vein) and perineal suturing when they

had completed training and demonstrated competency.

Managers gave all new staff a full induction tailored to their role before they started work. All staff

attended the trust’s induction programme which included mandatory training. Newly qualified

midwives completed a comprehensive preceptorship programme to support their development

from band 5 to band 6. The programme included three weeks of role specific training, regular

progress reviews, reflections on practice and competency assessments. Preceptorship midwives

were rotated to work in all areas of the maternity service during the 12-month programme and


were allocated a buddy to support them. Staff told us they felt well supported during their

preceptorship.

Professional midwifery advocates (PMAs) supported midwifery staff to develop through regular,

constructive clinical supervision of their work. The service had nine PMAs who provided group

restorative clinical supervision sessions. Staff could also contact a PMA for advice and support

when needed, such as if they had been involved in an incident. Community midwives had regular

safeguarding supervision with the lead midwife for safeguarding.

Managers supported medical staff to develop through regular, constructive clinical supervision of

their work. Trainee and junior doctors we spoke with told us they felt well supported from senior

medical staff and could approach them for advice at any time. Junior doctors attended protected

weekly teaching sessions and participated in clinical audits. Results of the 2019 General Council

Medical (GMC) national training survey showed doctors in training rated the training they received

‘within expectations’ for 15 of 18 indicators, including clinical supervision, induction and

educational supervision. The service was rated well above the national average (but less confident

of statistical significance) for supportive environment but was rated well below the national

average (but less confident of statistical significance) for teamwork and handover.

There were enough clinical educators to support staff learning and development. The service had

a lead practice development midwife and two clinical facilitators. Their main role was to support

staff to complete mandatory training and develop training packages in line with national

recommendations and local need. They were also available to support preceptorship midwives on

shift. For example, we were told when a preceptorship midwife was allocated to operating theatre

for the first time, a clinical facilitator would go with them for support. The service had 10 staff

members who were trained to deliver the Practical Obstetric Multi-Professional Training

(PROMPT) approach to obstetric emergency training. The PROMPT team consisted of consultant

obstetricians, anaesthetists and midwives. However, some staff told us consultants did not always

fully participate in PROMPT training.


not attend. Staff we spoke with confirmed this.

Managers identified any training needs their staff had and gave them the opportunity to develop

their skills and knowledge. Poor or variable performance was identified through the appraisal

process, complaints, incidents and feedback. Managers worked with the practice development

team and/or PMAs to ensure staff received additional support and training when needed.


develop their skills and knowledge. Most staff told us they were encouraged and supported to

develop their knowledge, skills and practice. Some additional training courses were available such

as the newborn and infant physical examination (NIPE), midwifery high dependency care,

mentorship and masters in midwifery care. However, some staff told us opportunities were limited

due to a lack of funding.

Managers made sure staff received any specialist training for their role. For example, staff had

received training in a new method used to induce labour which the service was trialling.

Appraisal rates

Broomfield Hospital

Managers supported staff to develop through yearly, constructive appraisal of their work. However,

feedback from staff regarding the appraisal process was mixed. Of the six staff we spoke to about


the appraisal process, three told us they found it beneficial while the other three felt it was a ‘tick

box exercise’.

As of August 2019, 86.6% of required staff in maternity at Broomfield Hospital received an

appraisal, which was lower than the trust target of 90%. We found appraisal completion rates had

improved on inspection. As of November 2019, 94% of midwives, medical staff and maternity care

assistants had received an annual appraisal (Source: Additional Evidence Request, DR79).

A breakdown by staff group can be found in the table below:

Staff group



Eligible staff

Completion rate

Trust target

Met (Yes/No)

Healthcare scientists 1 1 100.0% 90% Yes Additional clinical services 26 27 96.3% 90% Yes Nursing and midwifery registered 94 106 88.7% 90% No Administrative and clerical 19 24 79.2% 90% No Medical and dental 15 21 71.4% 90% No Total 155 179 86.6% 90% No



Doctors, midwives and other healthcare professionals worked together as a team to benefit

women and babies. They supported each other to provide good care.

Staff held regular and effective multidisciplinary meetings to discuss women and babies and

improve their care. All necessary staff were involved in assessing, planning and delivering

women’s care and treatment. We observed a multidisciplinary handover and ward round, which

was attended by the obstetric medical team, delivery suite coordinator, anaesthetists and

midwifery staff. Women with known risks were reviewed with care and treatment planned.


women and babies. Staff worked together with other specialties to benefit women and babies. This

included endocrinology for women with diabetes, paediatrics, haematology, psychiatry,

anaesthetics and physiotherapy. Women with a high body mass index (40 or above) were

reviewed by a consultant anaesthetist around 32 weeks gestation to discuss management plans

for labour and delivery. Physiotherapy staff attended the postnatal ward daily, Monday to Friday, to

provide care and treatment to women who would benefit from their input, such as women who had

a caesarean section or had sustained a third or fourth-degree tear. A multidisciplinary team cared

for women with multiple pregnancies, which included a multiple pregnancy specialist midwife and

fetal medicine specialist obstetrician. Women and babies who needed higher levels of care were

referred to neighbouring trusts with tertiary fetal medicine centres as needed. Obstetric and

midwifery staff were involved in the management and care of pregnant or postnatal women who

were admitted to non-maternity wards for medical reasons. A member of the safeguarding team

visited the wards daily, Monday to Friday, to support the care of women with safeguarding

concerns. The team worked closely with other professionals and agencies, such as health visitors

and social workers.


Staff referred women for mental health assessments when they showed signs of mental ill health,

such as depression. A specialist perinatal mental health midwife was available to support women

at risk of, or with mental ill health. They worked closely with the local perinatal mental health team.

Seven-day services

Most key services were available seven days a week to support timely care.

Consultants led daily ward rounds on all wards, including weekends. Women were reviewed by

consultants depending on their care pathway. All women admitted to the service who were high

risk were reviewed by a consultant. Anaesthetic cover was available for emergencies 24 hours a

day, seven days a week. This was in line with national recommendations (RCoA, Guidelines for

the Provision of Anaesthesia Services for an Obstetric Population 2019 (January 2019)). There

was 24-hour access to dedicated obstetric theatres and theatre staff.


diagnostic tests, 24 hours a day, seven days a week. This included but was not limited to x-ray,

ultrasound, computerised tomography (CT), magnetic resonance imaging (MRI) and pathology

when needed. The trust’s trigger response team (TaRT) was available to enhance the care of

acutely ill women in hospital.

Key services were available to women 24 hours a day, seven days a week. For example, women

(or their partners/relatives) could call the telephone triage service for advice or attend the unit if

they had any concerns or health issues. Community midwives offered seven-day services for

home births. There were on-call arrangements to facilitate the home birth service and provide any

other advice or care to women at home as needed.

Health promotion

Staff gave women practical support and advice to lead healthier lives.

The service had relevant information promoting healthy lifestyles and support on every ward and

department. Breastfeeding information was displayed including guidance on the health benefits,

positioning and attachment. Staff educated women about safe sleeping to reduce the risk of cot

death before they were discharged. The service had a range of information leaflets promoting

healthy lifestyles such as postnatal exercises, exercise in pregnancy and weight control in

pregnancy. The service provided parentcraft classes for women and their partners. These were

designed to help prepare prospective parents for labour and birth, infant feeding and adaption to

parenthood. Specialist classes were available for parents expecting twins, triplets or more babies.

Staff assessed each woman’s health when admitted and provided support for any individual needs

to live a healthier lifestyle. Community midwives offered all women carbon monoxide testing at

booking to identify smokers or those exposed to carbon monoxide through other sources. Women

who smoked were referred to smoking cessation services. Women with gestational diabetes were

empowered and supported to manage their own health, care and wellbeing. For example, women

received dietary advice and were given equipment to enable them to monitor their blood sugar

levels. A specialist midwife provided dietary and lifestyle advice to women with a body mass index

greater than 40 (morbidly obese).

The service supported national priorities to improve the population’s health. Women were advised

to have influenza (flu) and pertussis (whooping cough) vaccinations in line with national


recommendations (NICE, Antenatal care for uncomplicated pregnancies: CG62, (February 2019)).

Maternity records we reviewed confirmed this.


Staff supported women to make informed decisions about their care and treatment. They

followed national guidance to gain women’s consent. They knew how to support women


However, not all staff were up to date with Mental Capacity Act and Deprivation of Liberty

Safeguards training.



and 2004 and they knew who to contact for advice. Staff could explain their roles and

responsibilities if a woman lacked capacity to make their own decisions or was experiencing

mental ill health.

Staff knew how to access policy and get accurate advice on the Mental Capacity Act and

Deprivation of Liberty Safeguards. Staff understood Gillick competence and Fraser Guidelines and

supported young women who wished to make decisions about their treatment. Up to date policies

were available on the trust’s intranet regarding consent, Deprivation of Liberty Safeguards and the

Mental Capacity Act (MCA) 2005, including the treatment of young people and children in

accordance with Gillick Competence and Fraser Guidelines. Gillick Competence is a term used in

medical law to decide whether a child (under 16 years of age) can consent to his or her own

medical treatment, without the need for parental consent. Fraser Guidelines are used specifically

to decide if a young person can consent to contraceptive or sexual health advice and treatment.

Staff demonstrated how to access policies through the trust’s intranet. Staff could contact

specialist midwives, nurses and other professionals who had expertise with supporting women in

vulnerable circumstances for advice when needed, such as teenagers and women experiencing

mental ill health.

Staff gained consent from women for their care and treatment in line with legislation and guidance.

We saw staff gained verbal and/or written consent from women prior to undertaking any

procedures or treatment. Women told us staff explained care and treatment and sought their

consent. One woman told us, “consent is always gained before treatment”. This was in line with

national legislation (Health and Social Care Act 2008 (Regulated Activities) Regulations 2014:

Regulation 11 Need for consent (November 2014) and national guidance (Department of Health,

Reference guide to consent for examination or treatment (July 2009)).

Staff clearly recorded consent in women’s records. Staff documented consent for care and

treatment given, such as vaginal examinations. Medical staff obtained written consent from women

prior to surgery, such as caesarean section. The maternity care records we reviewed confirmed

this.

Staff made sure women consented to treatment based on all the information available. We

observed staff clearly explained the benefits and risks of induction of labour to a woman and her

partner. This enabled them to make an informed decision about their care.



Not all clinical staff had completed training on the Mental Capacity Act and Deprivation of Liberty

Safeguards.


stated that Deprivation of Liberty Safeguarding (DoLS) training was included in the MCA training

module.

Broomfield Hospital


nursing and medical staff in maternity at Broomfield Hospital is shown below:


Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)

Medical and dental 18 21 85.7% 95% No Nursing and midwifery registered 15 22 68.2% 95% No

In maternity, the target was not met for MCA/DoLS training module by medical staff or qualified

midwives at Broomfield Hospital.


As of November 2019, completion rates remained below the trust target. The service reported

80% of medical and midwifery staff had completed MCA/DoLS training.


Compassionate care

Staff treated women with compassion and kindness, respected their privacy and dignity,


Staff were discreet and responsive when caring for women. Staff took time to interact with women

and those close to them in a respectful and considerate way. Staff introduced themselves to

women and their birthing partners and made them aware of their roles and responsibilities. We

observed staff were polite, friendly and warm with women and their families.

Women said staff treated them well and with kindness. Women and partners we spoke with were

positive about the care they had received. One woman told us, “The midwives are incredible,

100% excellent”. Several other women described the staff as, really kind, friendly and supportive

and told us they felt, safe, secure and cared for. We also read many compliments and thank you

cards from women regarding their care. One woman wrote, “Every single midwife treated me with

kindness, compassion and respect”.

Staff followed policy to keep women’s care and treatment confidential. Women’s preferences for

sharing information with their partner and family members was established and respected. We

saw staff discussed women’s care and treatment in non-public areas to minimise the risk of

confidential information being overheard. Women’s privacy and dignity was respected. Staff closed

curtains and doors to protect women’s privacy and knocked on doors before they entered rooms.

Birthing rooms had “in use” signs by the door to alert staff when they were occupied and prevent

anyone from entering without consent.


Staff understood and respected the individual needs of each woman and showed understanding

and a non-judgmental attitude when caring for or discussing women with mental health needs. We

observed staff discussed women in vulnerable circumstances at handovers with compassion,

respect and sensitivity. Women with mental health concerns could be referred to the perinatal

mental health team for additional support, care and advice. Staff responded in a compassionate,

timely and appropriate way when women were in pain or were anxious and distressed. For

example, we saw staff took time to listen to women who were worried about their baby’s

movements and invited them to attend the unit for timely review.

Staff understood and respected the personal, cultural, social and religious needs of women and

how they may relate to care needs. Women we spoke with, maternity care records we reviewed

and observations we made confirmed this.


Friends and family test performance (antenatal), Mid Essex Hospital Services NHS Trust

From July 2018 to June 2019 the trust did not receive any responses to the maternity Friends and

Family Test (antenatal).

Friends and family test performance (birth), Mid Essex Hospital Services NHS Trust

From July 2018 to June 2019 the trust’s maternity Friends and Family Test (birth) performance (%

recommended) fluctuated around the England average. The trust’s performance was 90% or

greater in all months. Performance was lowest in October 2018 (91%) and February 2019 (90%).

Friends and family test performance (postnatal ward), Mid Essex Hospital Services NHS

Trust

From July 2018 to June 2019 the trust’s maternity Friends and Family Test (postnatal ward)

performance (% recommended) fluctuated around the England average. The trust’s performance

was 90% or greater in all months.


Friends and family test performance (postnatal community), Mid Essex Hospital Services

NHS Trust

From July 2018 to June 2019 the trust’s maternity Friends and Family Test (postnatal community)

fluctuated around the England average. The trust’s performance was 94% or greater in all months.

(Source: Friends and Family Test – NHS England)

CQC Survey of women’s experiences of maternity services 2018

The trust performed similarly to other trusts for 17 out of 19 questions in the CQC maternity survey

2018. The trust performed worse than other trusts for the two remaining survey questions. Both

questions were related to staff during labour and birth.

Area Question Score (0-10)

RAG

Labour and birth

At the very start of your labour, did you feel that you were given appropriate advice and support when you contacted a midwife or the hospital?

8.1 About the

same

During your labour, were you able to move around and choose the position that made you most comfortable?

7.4 About the

same

Did you have skin to skin contact (baby naked, directly on your chest or tummy) with your baby shortly after the birth?

9.1 About the

same

If your partner or someone else close to you was involved in your care during labour and birth, were they able to be involved as much as they wanted?

9.4 About the

same

Staff during labour and birth

Did the staff treating and examining you introduce themselves?

9.3 About the

same

Were you and/or your partner or a companion left alone by midwives or doctors at a time when it worried you?

6.6 Worse

If you raised a concern during labour and birth, did you feel that it was taken seriously?

7.0 Worse

If attention was needed during labour and birth, did a staff member help you within a reasonable amount of time

8.8 About the

same

Thinking about your care during labour and birth, were you spoken to in a way you could understand?

9.5 About the

same

Thinking about your care during labour and birth, were you involved enough in decisions about your care?

8.3 About the

same

Thinking about your care during labour and birth, were you treated with respect and dignity?

9.1 About the

same

Did you have confidence and trust in the staff caring for you during your labour and birth?

8.6 About the

same


Care in hospital after the birth

Looking back, do you feel that the length of your stay in hospital after the birth was appropriate?

7.2 About the

same

Looking back, was there a delay in being discharged from hospital?

5.3 About the

same

Thinking about response time, if attention was needed after the birth, did a member of staff help within a reasonable amount of time?

7.2 About the

same

Thinking about the care you received in hospital after the birth of your baby, were you given the information or explanations you needed?

7.5 About the

same

Thinking about the care you received in hospital after the birth of your baby, were you treated with kindness and understanding?

8.2 About the

same

Thinking about your stay in hospital, was your partner who was involved in your care able to stay with you as much as you wanted?

5.6 About the

same

Thinking about your stay in hospital, how clean was the hospital room or ward you were in?

9.2 About the

same

(Source: CQC Survey of Women’s Experiences of Maternity Services 2018)

Emotional support

Staff provided emotional support to women, partners and families to minimise their

distress. They understood women’s personal, cultural and religious needs. Staff were

committed to doing all they could to support the emotional needs of bereaved women, their

partners and families.

Staff gave women and those close to them help, emotional support and advice when they needed

it. Staff recognised when women needed time to talk to them and they went out of their way to

provide this. We saw staff provided open and honest answers to questions and gave as much

reassurance as possible. Women we spoke with said staff were supportive and they knew who to

contact for advice if they had any concerns.

Staff supported women who became distressed in an open environment and helped them maintain

their privacy and dignity. Women who were separated from their baby were given a side room to

minimise any distress caused by being with other mothers and their babies. Staff met women with

a known pregnancy loss at the entrance to delivery suite and escorted them to their birthing room.


conversations. The service had a specialist bereavement midwife who provided training for staff.

Staff were committed to doing all they could to support the emotional and individual needs of

women, partners and families whose baby had died. The specialist bereavement midwife

supported parents from their initial loss, throughout their time in hospital and their return home. We

saw many compliments from bereaved parents about the care and support they had received. One

mother wrote, “Your support pre and post our bereavement has gone above and beyond what we

could ever have imagined”. Another wrote, “The midwives who cared for me and my baby were

great and did an amazing job. [Staff] made an unbearable night more bearable, thank you”.

Another wrote, “Lovely staff, could not have asked for better…incredible and thoughtful in every

way”.



on their wellbeing and on those close to them. Staff routinely assessed women’s mental health

and emotional wellbeing throughout the antenatal and postnatal period. They recognised when

women would benefit from additional care and support and referred to specialist services when

needed, such as the perinatal mental health team. A debriefing service was also available. This

provided women and their partners with the opportunity to discuss any unresolved concerns or

issues they had regarding their pregnancy or birth experience. Women and their families were

given time with the baby they had lost.

Feedback showed 90% of bereaved parents felt they were given the opportunity to spend the time

they wanted with their baby. The service had a memorial frame for bereaved parents to let them

know they were not alone. Parents could write their baby’s name on a wooden butterfly and place

it in the memorial frame. The hospital held an annual service of remembrance for bereaved

families who had lost a child before or after birth. Women had access to other support services

who provided both practical advice and emotional support. Examples included local and national

baby loss charities, such as Aching Arms and Sands (Stillbirth and neonatal death), and TAMBA

(twins and multiple births association).


Staff supported and involved women, partners and families to understand their condition


Staff made sure women and those close to them understood their care and treatment. All the

women and partners we spoke with felt involved in their care and had received the information

they needed to make informed decisions about their care. Feedback we read confirmed this. For

example, one woman wrote, “We felt so supported in every decision we made and were given time

to make these”. Feedback from bereaved parents showed 90% felt they were involved in any

decisions about their baby, and 100% felt they were given time and an opportunity to express their

wishes regarding funeral and memorial arrangements for their baby.

Staff talked with women, families and carers in a way they could understand, using communication

aids where necessary. Staff clearly explained planned care and treatment with women and their

partners. We observed this during the inspection. We saw staff made sure women understood

what was said to them and took time to answer any questions they had.

Staff supported women to make informed decisions about their care. Women were involved in

decisions about their choice of birth at booking and throughout their pregnancy. Staff encouraged

them to make birth plans which met their individual needs. Partners were included and involved

where possible. For example, they could cut their baby’s cord at delivery where appropriate and

have skin-to-skin contact with their baby. Professional midwifery advocates were also available to

support women to develop care plans that met their individual needs. Bereaved women and

families had the opportunity to create memories with their baby if they wished, such as bathing

and dressing them. Feedback from bereaved parents showed 100% felt they were given the

opportunity to create memories with their baby in the time they needed without feeling rushed.

Women and their families could give feedback on the service and their treatment and staff

supported them to do this. Staff sought feedback from women and those close to them through a

range of methods, including national patient survey schemes such as the Friends and Family Test

and local surveys. For example, the specialist bereavement midwife sent a questionnaire to all

bereaved parents, so care provision could be improved where needed. The survey included


questions on their experience of the environment, how they were communicated with and if their

individual needs and wishes were met. Feedback showed most parents were very positive about

all aspects of care and support they received.

A high proportion of women gave positive feedback about the service in the Friends and Family

Test survey. In September 2019, 98% of women who completed the survey after the birth of their

baby would recommend the service to their family and friends.





to plan care. However, the service did not have the capacity to meet national requirements

for ultrasound scanning services. The service was acting to address this.


population. The service was working with local stakeholders and neighbouring hospitals within the

trust to establish a local maternity system (LMS) to improve maternal and neonatal safety across

the clinical network. The purpose of the LMS was to deliver the national priorities for maternity

care provision (National Maternity Review, Better Births: Improving outcomes of maternity services

in England (2016)). Priorities for the LMS included delivering all five aspects of the Saving Babies’

Lives care bundle (version two) and achieving 35% continuity of carer by March 2020 (Source:

Additional Evidence Request, DR66).

Managers identified where people’s needs and choices were not being met and acted to develop

and improve services. For example, the service did not have transitional care for babies who

needed more nursing care and monitoring than that routinely provided on a postnatal ward. Babies

had to be taken to the neonatal intensive care unit (NICU) if they needed treatment such as

antibiotics. This meant babies could sometimes be separated from their mothers if the mother was

unable to attend NICU with them for any reason. Managers told us they were developing a

transitional care model to minimise the number of babies that had to leave their mother for

treatment. This model would enable babies to receive treatment on the postnatal ward next to their

mother. Managers had set aside two beds on the postnatal ward for transitional care and were

recruiting for neonatal nurses to staff the service at the time of our inspection.

Women did not always have access to ultrasound scanning services in a timely manner.

Managers recognised this was a risk and added the lack of scanning availability to the service’s

risk register in May 2019. Managers told us the radiology department had developed an action

plan to address this risk, which included the recruitment of additional sonographers. Minutes of the

women’s and children’s risk register review meeting held in October 2019 reported scans were

currently being undertaken in line with national recommendations. However, the current capacity

would not enable them to meet the recommendations of Saving Babies’ Lives care bundle (version

two), which must be implemented by March 2020 (Source: Additional Evidence Request, DR83).

Feedback from bereaved parents showed they were not able to access counselling services when

they needed it. Counselling services were provided by another provider and we were told by a

lead midwife the waiting list was eight months. The specialist bereavement midwife had acted on

this feedback and funding had been secured for a pilot counselling service at the hospital. This

would be provided by the hospital’s psychotherapy and counselling services department.


Antenatal care was accessible to pregnant women. Women accessed maternity services through

their community midwife or GP. Women could also email the service to arrange their first booking

appointment. Women were given an informed choice about where they gave birth, and with

consideration of their risk. Midwifery led models of care were offered to women with an

uncomplicated pregnancy. This included home birth or delivery in either the standalone birthing

units or hospital-based midwife led unit (MLU). This was in line with national guidance (NICE,

Antenatal care: QS22, statement 2 (April 2016)). Women with an existing medical condition,

complication of pregnancy or previous complications in pregnancy and/or labour were advised to

have their baby in the consultant led unit (CLU) (delivery suite).

The service was developing continuity of carer models at the time of our inspection. Managers told

us 11% to 19% of women on average received continuity of carer throughout their pregnancy, birth

and postnatal period. The service hoped to increase this to 35% by March 2020, in line with

national recommendations (National Maternity Review, Better Births: Improving outcomes of

maternity services in England (2016)). Actions taken to increase continuity of carer included the

recruitment of a lead midwife for Better Births and additional midwives. Community midwives we

spoke with told us they tried to provide continuity of carer for at least two women per midwife per

month. They told us they prioritised vulnerable women for continuity of carer where possible. A

named midwife cared for women throughout their pregnancy. Care was shared with a named

consultant if the woman was considered high-risk. Most women we spoke with told us they had

seen the same midwife throughout their pregnancy.

The service had systems to help care for women in need of additional support or specialist

intervention. Specialist midwife clinics were provided for women with diabetes, multiple

pregnancies and who were morbidly obese (body mass index over 40). Specialist consultant

clinics were provided for diabetes, fetal medicine and maternal medicine. The service had a

midwife led birth after caesarean section clinic. This meant women who have had a previous

caesarean could explore birth choices for their current pregnancy. This was in line with national

guidance (NICE, Caesarean section: QS32, statement 1 (June 2013)).

Staff could access emergency mental health support 24 hours a day, seven days a week for

women with mental health problems and learning disabilities. Staff working at the hospital or in the

community could contact the crisis team for urgent support when needed. The service had a

specialist perinatal mental health midwife. They held weekly clinics at either the hospital or

standalone birthing units for women with moderate or high mental health risks. They worked

closely with the local perinatal mental health liaison team to plan care, treatment and support for

women who needed it. There was a mother and baby unit located close to the hospital for mothers

who had severe mental health concerns and needed admission for specialist care and treatment.

The trust had a learning disability hospital liaison nurse who was available to support women with

learning disabilities.

Facilities and premises were mostly appropriate for the services being delivered. The service had

a dedicated bereavement room to ensure women and families were cared for while grieving. The

room was decorated and furbished to create a homely environment, with double bed, sofa,

nursery, kitchen and bathroom facilities. However, the room was located at one end of the delivery

suite. This meant bereaved parents could hear other activity. This was not in line with national

recommendations (Stillbirth and neonatal death charity (Sands), Stillbirth: how professionals can

make a difference (2015)). Staff were mindful of this and told us they would not use the

neighbouring delivery room if the bereavement room was in use, wherever possible. Staff also met

women with a known pregnancy loss at the entrance to delivery suite and escorted them to their


room. Feedback from bereaved parents showed 100% felt they were cared for in an appropriate

environment. One woman wrote’ “The memory room was a very special room in helping us to

make memories with [our baby]”.

Women attending for antenatal appointments did not have to pass through the postnatal ward. The

MLU had two static birthing pools to enable women to labour and/or birth in water if they wished.

However, the CLU did not have a birthing pool. This meant women who do not meet the criteria for

low risk birth on the MLU did not have a choice of labouring and/or birthing in water.

Women’s partners were able to stay with them throughout their admission to the CLU and MLU.

However, they were unable to stay overnight on the antenatal and postnatal wards. Visiting times

for partners and their children were 8am to 9pm, and 3pm to 4pm and 7pm to 8pm for other

visitors. Staff told us partners of women admitted for induction of labour could stay with them until

midnight. Managers told us they hoped to purchase reclining chairs to improve partners’

experience and enable them to stay if wished.

Information about maternity services was provided on the trust’s website. Many patient information

leaflets covering a wide range of maternity, obstetric and mental health related topics were also

available online or as hard copies in clinical areas. Information could be provided in different

languages, easy read and audio.

Bed Occupancy

From January 2018 to June 2019 the bed occupancy levels for maternity were consistently higher

than the England average, with the trust having 74.1% occupancy in quarter 1 2019/20 compared

to the England average of 58.4%. Research suggests that bed occupancy rates of higher than

85% can increase the risk of harm and quality of care provided (Dr Foster, 2012).

The chart below shows the occupancy levels compared to the England average over the period.




The service was inclusive and took account of women’s individual needs and preferences.

Staff made reasonable adjustments to help women access services. They coordinated care

with other services and providers.

Staff made sure women in vulnerable circumstances and those with mental health problems and

learning disabilities, received the necessary care to meet all their needs. Staff spoke sensitively

and confidently about the differing needs of women in vulnerable circumstances and described

arrangements to help them access services. Staff referred women to specialist midwives when

needed. The service had specialist midwives for safeguarding, perinatal mental health and

vulnerable women, such as teenagers and women for whom English was not their first language.

Staff could also refer to other health care professionals or agencies for additional support and

advice. These included the trust’s learning disability liaison nurse, local substance misuse teams,

the link outreach worker for Gypsy, Roma, Traveller (GRT) communities and independent

domestic violence advisors. The specialist perinatal mental health midwife worked in partnership

with the local perinatal mental health service. This service provided community-based treatment

and support to women who had a moderate to severe mental health issue or had in the past

experienced a serious mental health issue.

Staff made sure women, partners and families who experienced the death of their baby during

pregnancy, birth or soon after, received bereavement care and support to meet their needs. A

specialist bereavement midwife provided care and support to all bereaved parents, as well as

training and education for staff. Specialist equipment was available to enable bereaved parents

time with their baby, such as cold and cuddle cots. These slow down the natural deterioration

process and mean stillborn babies can stay longer with their parents. Baby and remembrance

items were provided to help parents create memories with their baby. These included story books,

a baby bath, pram, baby clothing and blankets. Parents could choose remembrance items, such

as ‘hand in heart’ keyrings and olive wood hearts. Comfort teddy bears had been gifted by other

bereaved parents. These helped signpost parents to support agencies, as well as being a physical

comforter and a means for staff to discuss the mental and emotional needs of parents following

their baby’s death. Each bear had been gifted by a bereaved family, to remind parents they were

not alone. A local professional photographer volunteered their photography services and created

personalised photo boxes of their baby for them. Memory boxes were also offered to all bereaved

families. Parents who had experienced a stillbirth or neonatal death were offered a post-mortem

examination to enhance future pregnancy counselling. Parents were supported with making

funeral arrangements. A chaplaincy service was available which provided spiritual care and

religious support for women, partners and families when needed. The chaplaincy team supported

all faiths and beliefs and could facilitate visits from local faith group leaders when asked. Staff

asked women who had experienced the loss of a baby if a sticker could be placed on their medical

records to alert health professionals to their loss. These are advocated by baby loss charities

because they help bereaved parents show rather than have to repeat their story to different health

professionals and signify to staff that the woman and her partner may need additional

understanding and support.

Staff understood and applied policy on meeting the information and communication needs of

women with a disability or sensory loss. The trust’s website had a ‘Browsealoud’ function. This

added speech and reading support tools to online content for people that required reading support,

such as those with dyslexia, learning disabilities, mild visual impairments and those with English

as a second language. Women could access information about maternity services through this


function. Staff wore badges with their name clearly displayed in large font against a yellow

background. This made the name badges easier for visually impaired women and visitors to read

and promoted open communication across all levels of staff.

Managers made sure staff and women, relatives and carers could get help from interpreters or

signers when needed. Staff accessed interpreting services for women with English as a second

language. These were provided face to face or through a dedicated telephone translation service.

Sign language interpreters were available for women with hearing difficulties.

Information leaflets were available in languages spoken by women and the local community.

Leaflets could be provided in different languages and Braille, for blind or partially sighted women

through the patient advisory liaison service (PALS). The trust’s website had a translation function

which translated online content into any recognised world language.

Staff had access to communication aids to help women become partners in their care and

treatment. The trust worked with local providers to ensure communication guides were available

for people with sight and hearing difficulties, such as the Royal Association for Deaf people and

the Royal National Institute of Blind People. Information leaflets could be provided in easy read

formats. Pictorial aids were available to help women position and attach their baby correctly when

breastfeeding. Special dolls were offered to siblings of babies who had died to help them talk

about their lost brother or sister.

The service was accessible to women and visitors with mobility difficulties and wheelchair users.

Lifts were available to the fourth floor, where all maternity departments were located. Disabled

access bathroom and toilet facilities were available. Hearing loop was available for women and

visitors with hearing difficulties.

Women were given a choice of food and drink to meet their cultural and religious preferences.

Access and flow

Women could access the service when they needed it and received the right care promptly.

Managers made sure women could access services when needed and received care and

treatment within agreed timeframes and national targets. Women could access maternity services

through their GP, community midwife or by contacting the hospital directly. From January to

October 2019, 94.8% of women on average had accessed antenatal care by 12 weeks and six

days gestation. This was in line with the trust target of 95%. Routine antenatal care appointments

were scheduled in line with national guidance (NICE, Antenatal care for uncomplicated

pregnancies: CG62 (February 2019)). The maternity care records we reviewed confirmed this.

National guidance recommends that women should ideally be able to access antenatal care by 10

weeks so screening tests can be provided in a timely manner (NICE, Antenatal care: QS22,

Quality statement 1 (April 2016)). The service had an action plan to improve access to antenatal

care by 10 weeks. This included piloting a drop-in clinic for early screening bloods. The maternity

pages on the trust’s website had also been updated to make it easier for women to self-refer. An

audit of antenatal booking figures was being undertaken at the time of inspection. This was due to

be completed in January 2020. Data reported quarterly showed an upward trend (improvement) in

the percentage of women who had screening bloods taken by 10 weeks; from 42.8% in quarter 1

2018/19 to 51.6% in quarter 1 2019/20. The national acceptable threshold was 50% (Source:

Additional Evidence Request, DR100a and DR100b).


The newborn and infant physical examination (NIPE) was performed on babies within 72 hours of

birth. In quarter 4 (January to March 2019), 99.5% of babies born at the trust had the NIPE within

72 hours. This was in line with the national achievable threshold of 99.5% and was better than the

England average of 96.7% (Public Health England, Screening KPI data summary factsheets

(August 2019)).

Women who were concerned or thought they were in labour could call the telephone triage service

24 hours a day, seven days a week for advice. This was staffed by midwives on the antenatal day

assessment unit (ADAU). Staff advised women to attend the unit when indicated by the symptoms

and/or concerns described. Staff told us they aimed to see all women within 30 minutes of arrival.

From July to October 2019 2,249 women attended triage. Of these, 91.5% were seen within 30

minutes of arrival, 5.5% within 60 minutes and 2.6% within 120 minutes. Staff took over 120

minutes to see the remaining 0.4%.

From November 2018 to October 2019 there was no suspension of the homebirth service or

maternity services at the hospital However, there were 23 occasions when one of the two stand-

alone midwifery led birthing units were suspended. Neither of the units were closed at the same

time (Source: Additional Evidence Request, DR64).

Managers worked to keep the number of delayed transfers and procedures to a minimum. When

women had their procedure cancelled at the last minute, managers made sure they were

rearranged as soon as possible. Planned caesarean section operating lists were scheduled daily,

Monday to Friday. They were staffed by a dedicated team to minimise cancellations or delays due

to staffing issues. Staff told us planned caesareans were rarely cancelled on the day. From August

2018 to July 2019 the average time (in hours) from admission to delivery for all planned

caesareans at term was 3.8 hours (Source: Routine Provider Information Request – Maternity

overview tab). From 20 November 2018 to 19 November 2019 one planned caesarean section

was cancelled and rescheduled. From August 2018 to August 2019, seven incidents regarding

delayed transfers from the ADAU to delivery suite were reported through the National Reporting

and Learning System (NRLS). All incidents resulted in no harm. Up to four inductions of labour

were commenced daily. These were mostly for women whose pregnancy had extended 10 days or

more past their expected due date. Staff told us low-risk women whose induction was commenced

on the antenatal day assessment unit were usually transferred to delivery suite two to four hours

after their waters were broken for ongoing treatment. From August 2018 to July 2019 the average

time (in hours) from admission to delivery for all inductions at term was 22.2 hours for women who

had their baby in the CLU and 18.1 hours for women in the MLU (Source: Routine Provider

Information Request – Maternity overview tab). Women were offered an induction of labour 24

hours after their waters had broken if they were not in labour and with consideration of risks.

Women rarely gave birth in areas not designated as labour ward. From August 2018 to August

2019 two incidents of this were reported through NRLS. Both incidents resulted in no harm. From

January to October 2019, 18 babies were born before arrival or in transit to the hospital. This

equated to 0.5% of total births.

Managers and staff worked to make sure women did not stay longer than they needed to and

started discharge planning as early as possible. Women were offered an early discharge where

appropriate. Staff told us women and babies suitable for early discharge were generally

discharged home within six hours after birth. Women who had a caesarean section were

discharged home one to two days after birth where appropriate. Eligible women were offered an

induction of labour as an outpatient. This meant they could return home to await labour for up to

23 hours after the induction was started if all observations were normal. Staff told us antenatal


clinics generally ran on time, which we observed. Staff informed women if the clinic was running

late. Women could arrange an appointment on the ADAU on a day and time that suited them if

they needed regular monitoring during their pregnancy. We saw most women who attended were

seen promptly and did not stay longer than needed.

Staff planned women’s discharge carefully, particularly for those with complex mental health and

social care needs. Postnatal care was arranged with community midwives as part of the discharge

process. A discharge letter was also sent to each woman’s GP and health visitor to enable

continuity of care. Other professionals were informed when women with complex mental health

and social care needs were discharged, such as social workers and the perinatal mental health

team. Women were routinely seen by a midwife at home on day one, day five and day 10, when

they were discharged to the health visiting service if all observations were normal. Staff told us

they would continue to visit women up to 28 days after birth when needed, such as those in

vulnerable circumstances.

Staff supported women when they were referred or transferred between services. Women who

required transfer in labour to the hospital from the standalone birthing units or home were escorted

by the midwife caring for them.

Managers monitored and acted to minimise missed appointments. Women were offered future

appointments prior to leaving their consultation. This helped ensure appointments were not missed

because they were jointly agreed. Community midwives held clinics at the hospital at weekends

and Monday evenings for women who had difficulty attending their GP surgery during the week.

Staff ensured that women who did not attend appointments were contacted. Staff followed trust

policy if a woman did not attend their appointment. Women were offered a further appointment,

and/or their community midwife was informed who contacted or visited the woman at home. Staff

told us they would escalate to the safeguarding team if two or more appointments were missed.


It was easy for women to give feedback and raise concerns about care received. The


learned with all staff.

Staff understood the policy on complaints and knew how to handle them. They told us that where

possible complaints were resolved when raised. If concerns could not be resolved informally,

women and/or those close to them were supported to make a formal complaint. The service had

processes to ensure complaints were dealt with effectively. This included prompt acknowledgment

of the complaint, written response to the complaint and whether changes had been made because

of the complaint.

Women, relatives and carers knew how to complain or raise concerns. Women we spoke with

confirmed this.

The service clearly displayed information about how to raise a concern in all maternity wards and

departments. Leaflets regarding the complaints process were available for women and details of

how to raise a complaint was published on the trust’s website. Women were also signposted to the

trust’s patient advice and liaison service (PALS). PALS provided advice and support to women

(and those close to them) who wished to raise a concern or complaint.



Broomfield Hospital

Managers investigated complaints and identified themes. Managers told us most complaints were

managed promptly and in line with trust policy.

From August 2018 to July 2019 the trust received 26 complaints in relation to maternity at

Broomfield Hospital. The trust took an average of 32.8 working days to investigate and close

complaints. This was not in line with their complaints policy, which states complaints should be

closed within 25 working days. However, complex complaints could take up to 60 working days to

close.

Managers routinely monitored performance for complaints response times. In October 2019, 100%

of complaints received for maternity were responded to in line with trust policy. This exceeded

(was better than) the trust target of 85%.


Type of complaint Number of complaints Percentage of total

Clinical treatment - Obstetrics and gynaecology

23 88.5%

Values and behaviours (staff) 2 7.7% Clinical treatment - paediatric group 1 3.8% Total 26 100.0%


Staff knew how to acknowledge complaints and women received feedback from managers after

the investigation into their complaint. We reviewed three complaint responses and saw thorough

investigations of the concerns raised had been conducted. The response letters were sensitively

written and included an apology. A detailed response was provided to each concern raised. Any

learning or action taken in response to the complaint was included. Women and those close to

them were also offered a debriefing session known as a birth reflection. This enabled them to

review their maternity notes and gave them the opportunity to discuss their birth experience with

an experienced midwife. Women and/or those close to them who were dissatisfied with the

response to their complaint were signposted to the Parliamentary and Health Service Ombudsman

(PHSO). From August 2018 to July 2019 no complaints received by the service were referred to

the PHSO (Source: Routine Provider Information Request (RPIR) - Complaints overview tab).


service. Learning from complaints and feedback was shared with staff through a variety of means

such as newsletters, team meetings and noticeboards. Staff confirmed they received feedback on

complaints. Action was taken in response to complaints received to improve patient experience

and care provision. Where individual members of staff were the cause of the complaint, managers

discussed the concerns raised with them, so they could reflect and make changes to their practice

accordingly.


Broomfield Hospital


From August 2018 to July 2019 there were 11 compliments received for maternity at Broomfield

Hospital (1.0% of all received trust wide).

A breakdown of compliments by ward/team is shown below:

Ward/team Number of compliments Percentage of total Maternity 9 81.8% Postnatal ward 1 9.1% Antenatal clinic 1 9.1% Total 11 100.0%


pathway and women and relatives thanking staff for their kindness and compassion during difficult

and stressful times. These related to all staff from housekeepers, porters and midwives to

consultants.


patient and carer experience group and with individuals and their managers during appraisal. The

trust used its electronic incident reporting and risk management system to analyse themes from

compliments.


Managers shared compliments received with staff. The divisional quarterly newsletter included

examples of positive comments and thank you letters received.


Leadership

Leaders had the skills and abilities to run the service and deliver high-quality, woman-

centred care. They understood and managed the priorities and issues the service faced.

They were visible and approachable in the service for women and staff.

There was a clear management structure with defining lines of responsibility and accountability.

The maternity service formed part of the women’s and children’s division, which was led by the

divisional clinical director, associate director of operations, head of midwifery (HOM) and head of

children. They were supported by a clinical director for obstetrics, service manager, lead midwife

for clinical governance, consultant lead for labour ward, matrons, ward managers and specialist

midwives. We met with the senior leadership team who demonstrated knowledge of the service’s

performance, challenges they faced and priorities for their service. They had the right skills,

knowledge and experience required to deliver high-quality, woman-centred sustainable care.

The senior leadership team had direct access to the trust board when maternity was under

consideration. Minutes of board meetings we reviewed for June and September 2019 showed the

trust board had oversight of the service. The executive lead for maternity services at board level

was the chief nursing officer. The trust’s maternity safety champions were the head of midwifery

and clinical director for obstetrics. They met regularly with the chief nursing officer to monitor

information about quality, including safety and to escalate any concerns to the board which

required necessary action. There was also a non-executive director (NED) with responsibility for

maternity services. This was in line with national recommendations (National Maternity Review,

Better Births: Improving outcomes of maternity services in England (2016)). The senior leadership


team told us the chief nursing officer and NED were actively engaged with the service and they felt

maternity services were a priority for the trust and were well represented at board level. For

example, in September 2019 a report was presented to the board to provide assurance that the 10

maternity safety actions required by the Clinical Negligence Scheme for Trusts (CNST) had been

evidenced by the service and through review by the Quality Committee and the maternity safety

champions. Staff we spoke with confirmed the chief nursing officer was visible and were aware of

visits to the unit by the NED.

At the time of our inspection, the HOM had been in post approximately two months. All staff we

talked to spoke very highly of the HOM and described them as being “dynamic”, “very supportive”

and “really open”. Staff told us leaders were very visible, approachable and they felt well

supported. We observed the HOM frequently visited the wards to check-in with staff during our

inspection.

The service’s maternity safety strategy included a focus on leadership and creating strong

leadership at every level. This was in response to concerns raised by band 7 midwives who felt

disempowered to challenge some staffing issues. Actions to address this had been taken. For

example, two band 7 leadership workshops were held, as well as bi-monthly manager’s meetings

to support staff with management duties. A designated daily ‘bleep holder’ was also introduced.

They were responsible for monitoring and managing any staffing issues.

The delivery suite was coordinated by an experienced senior midwife who, wherever possible, was

supernumerary. This meant they could maintain oversight of activity and risks and could support

staff as needed.

The service had processes to ensure midwives were adequately supervised and received clinical

supervision. The service had nine professional midwifery advocates (PMAs) who provided

restorative clinical supervision and support to staff. Restorative clinical supervision has been found

to reduce stress and has had a positive impact on physical and emotional well-being, job

satisfaction and relationships with colleagues (NHS England, A-EQUIP: a model of clinical

midwifery supervision (2017)).

The trust provided development programmes for staff that supported them to develop leadership

and management skills, which staff we spoke with confirmed. Leadership and development

programmes were available for first line managers, middle managers and senior managers.

Vision and strategy

The service had a vision for what it wanted to achieve and a strategy to turn it into action




The service had a clear vision and strategy, central to which was the ‘provision of the safest and

highest quality care’. The vision for the maternity service was:

• Drive forward the choice and safety agenda, ensure women were central to the service,

work collaboratively with local, regional and national systems, and listen to staff and

women;

• Work in partnership with the multidisciplinary team;

• Foster a culture of learning for improvements in outcomes, using evidence-based practice;


• Increase the use of midwifery-led units and breastfeeding rates and implement continuity of

care;

• Promote health and normality at every opportunity and embrace women to achieve a

positive experience;

• A cohesive and supportive team, a culture of support and respect and visible clinical

leadership (Source: Additional Evidence Request, DR245).

In addition to the local vision, the senior leadership team and managers were working

collaboratively with senior staff from the other hospitals within the trust to establish a local

maternity system (LMS). The LMS strategy detailed 12 national planning deliverables which were

aligned with national recommendations and ambitions for maternity care services. These included

full implementation of the Saving Babies’ Lives care bundle (version two) and increasing the

number of women on continuity of care pathways by March 2020 (National Maternity Review,

Better Births: Improving outcomes of maternity services in England (2016)). Progress against

achieving the national planning deliverables was regularly monitored and reported. The

September 2019 LMS highlight report showed one of the 12 national planning deliverables had

been completed within the specified timeframe. This was achievement of the Clinical Negligence

Scheme for Trusts (CNST) maternity incentive scheme. Of the 11 remaining deliverables, eight

were ‘on track’ and three were ‘at risk’ of not being completed within the specified timeframe.

These were mostly in relation to providing continuity of care pathways and an inability to deliver all

five aspects of the Saving Babies’ Lives care bundle because of gaps in the sonography workforce

(Source: Additional Evidence Request, DR66). We saw these risks were detailed on the service’s

risk register.

The trust had an established values statement which was, “We are a kind, professional, positive

team”.

Staff we spoke with knew and understood what the vision, strategy and values were and their role

in achieving them.

Culture

Staff felt respected, supported and valued. They were focused on the needs of women

receiving care. The service had an open culture where women, their families and staff could

raise concerns without fear.

All staff we met were welcoming, friendly and helpful. It was evident that staff were passionate

about the care they provided to women and babies and were proud to work at the trust. Staff told

us they loved their job and loved working at the trust.

Multidisciplinary teams worked collaboratively and were focused on improving women’s care and

service provision. During our inspection, we observed positive and respectful interactions which

were focused on meeting women’s needs and providing safe care and treatment.

Staff told us they felt well supported, valued and respected. All staff we spoke with felt the culture

of the service had improved since the new head of midwifery had started. One staff member felt

there was, “a real buzz about the place”. None of the staff we spoke with raised any concerns

about bullying or other inappropriate behaviours from colleagues. Leaders promoted an ‘open

door’ culture and staff were encouraged to speak up and raise concerns. Trust policies and

procedures positively supported this process. We saw information on how staff could raise


concerns and who the trust freedom to speak up guardians were detailed in multiple editions of the

women’s and children’s newsletter. An independent guardian service was also available to staff 24

hours a day, seven days a week. This was a confidential service for staff to discuss matters

relating to patient care and safety, whistle-blowing, bullying and harassment and work grievances.

The culture encouraged openness and honesty. The trust had processes to ensure the duty of

candour was met. Where incidents had caused harm or could have significant caused harm, we

saw the duty of candour was complied with.

The senior leadership team and managers spoke with pride about the work and care their staff

delivered daily. They celebrated staff success by sharing positive feedback received and positive

contributions made by staff. We saw many examples of these in the newsletters we read. Staff

were invited to nominate colleagues for ‘Star of the Month’. This was awarded to staff who had

gone the extra mile. In August 2019, the lead midwife for governance won the award for working

tirelessly and selflessly to keep women safe and free from harm. In September 2019, the

bereavement lead midwife won the ‘improving patient experience’ award at the trust’s annual

Outstanding Care and Service Awards (OSCAs).

There were arrangements in place to promote the safety and wellbeing of staff. Staff could contact

the trust’s security team for support and assistance if women or visitors became verbally and/or

physically abusive. Staff who worked alone and within teams spread across the community had

mobile phones and some community midwives had personal safety devices, but not all. Managers

told us they planned to replace all mobile phones with smart phones, which would enable them to

track staff when needed. Professional midwifery advocates provided a formal mechanism for

debriefing and supporting staff when needed, such as if they were involved in an incident. Staff

could also access the trust’s occupational health, physiotherapy and counselling services if they

needed additional support at any time.

There were mechanisms for providing staff with the development they needed. These included

personal development reviews and appraisals. Staff spoke positively about the training and

development opportunities available. However, some staff told us they felt the appraisal process

was not constructive and described it as a ‘tick box exercise’. Action was taken to address

behaviour and performance that was inconsistent with the vision and values, regardless of

seniority. Managers gave examples of when this had occurred.

Governance

Leaders operated effective governance processes, throughout the service. Staff at all levels

were clear about their roles and accountabilities and had regular opportunities to meet,

discuss and learn from the performance of the service.

The service had a clear governance structure and processes to support the delivery of quality

services and safeguard high standards of care. There was an up to date policy which detailed the

clinical governance structure for the women’s and children’s division. All staff could access this

through the trust’s intranet. The policy included the governance strategy and objectives, the

meetings, forums and groups with responsibility for governance and risk management, and staff

roles and responsibilities.

The service had a lead midwife for clinical governance. They were responsible for coordinating

and implementing clinical risk management, audit, clinical effectiveness and midwifery practice

developmental processes within the maternity service. They reported to the head of midwifery.


Monthly governance meetings were held at service and divisional level. These included the

maternity multidisciplinary risk management group meeting and the women’s and children’s

divisional governance and board meeting. Matters which required escalation to the board were

done so through direct reporting to the executive lead for maternity, trust mortality meetings and/or

the trust’s risk and compliance group meetings. This meant there was oversight of the service at

ward to board level.

Monthly and divisional governance meetings followed standing agendas. We reviewed six sets of

meeting minutes which confirmed governance matters such as incidents, risks, performance,

guidance, audits and complaints were discussed. Minutes were sufficiently detailed however, the

lead person responsible for ensuring any required actions were followed up was not always

documented. The more recent copies of minutes we were sent did include this detail (Source:

Additional Evidence Request, DR80 and DR81).

Managers reviewed all incidents reported daily at the safety huddle, Monday to Friday. This

ensured any immediate action required to address safety concerns was identified and promptly

shared with staff through handovers and ‘hot topics’. Where necessary, investigations were

undertaken to identify learning and actions needed to address incidents and minimise recurrence.

Incidents were also reviewed to ensure they had been graded in terms of harm appropriately. Any

potential serious incidents were brought to the trust’s serious incident for review which met three

times a week.

The clinical governance facilitator prepared an incidents and clinical effectiveness report monthly.

The purpose of the report was to update the women’s and children’s governance group on matters

which required note or response with actions to facilitate service improvement and/or compliance

with legislative and regulatory requirements. We reviewed the October 2019 report which included

details of incidents, risks, audits and guidelines, including those which were overdue and required

action. The report also included a list of all National Institute for Health and Care Excellence

(NICE) advice and guidance published in the previous month and all active national and trust

patient safety alerts (Source: Additional Evidence Request, DR89), with identified actions where

needed.

Staff at all levels were clear about their roles and understood their accountabilities and who they

reported to. They confirmed they were kept informed about governance matters and performance

of the service.


Leaders and teams identified and escalated risks and issues. They identified actions to

reduce their impact. They had plans to cope with unexpected events.

There were clear and effective processes for identifying, recording, managing and mitigating risks.

The trust had an up to date risk management policy and related policies, such as the business

continuity policy and plan. Staff used an electronic incident reporting and risk management system

to record and manage risks. A clinical governance facilitator supported managers to ensure risks

were appropriately described, assessed and recorded. Risk registers were managed at

department, division, divisional and/or trust level, depending on the level of risk identified. We

reviewed the maternity risk register. It included a description of each risk, the named risk owner

and review date, alongside mitigating actions and controls in place to minimise the risk. Each risk

was scored according to the likelihood of the risk occurring and its potential impact.


The risk register was reviewed at governance meetings. Managers told us they had also

introduced a divisional risk register meeting. We reviewed the minutes of the women’s and

children’s risk register review meeting held in October 2019. Each risk was updated, and actions

identified had a named person responsible for ensuring they were completed. Risks were

regraded when indicated and closed when they had been addressed.

There was alignment between the recorded risks and what staff identified as risks within the

service. Staff told us they were kept informed about risks in a variety of ways, including team

meetings, staff noticeboards and emails. We saw posters displayed which detailed the top three

risks for the trust and the women’s and children’s division. The top three risks for the maternity

service concerned:

• The service’s inability to archive cardiotocography traces electronically;

• The lack of scanning availability which meant the service was unable to meet national

recommendations;

• The service’s inability to provide continuity of care in line with national recommendations.

(Source: RPIR and SHIPP Landing Pad, RQ8 documents – P106; Additional Evidence Request,

DR63a)

The trust had an up to date business continuity and emergency planning policy which was

accessible to staff and detailed what action should be taken and by who in the event of a critical

incident, such as fire or loss of utilities.




The information systems were integrated and secure. Data or notifications were

consistently submitted to external organisations as required.

There was a holistic understanding of performance which sufficiently covered and integrated

people’s views with information on quality, operations and finances. Clear service performance

measures were reported and monitored. For example, staff had access to quality and performance

data through the maternity dashboard which was used to monitor activity, workforce, outcomes

and performance. Areas of good and poor performance were highlighted and used to challenge

and drive forward improvements, where indicated. Performance thresholds and targets had been

set in agreement with clinical commissioning groups and were in line with national targets where

available. A traffic light Red, Amber, Green (RAG) rating was used to flag performance against

agreed thresholds. This meant staff could identify at a glance, areas that required investigation

and improvement. Managers regularly discussed performance at governance meetings and

actions were taken to investigate and address areas of concern where indicated. For example, in

response to the ‘red rated’ caesarean section rate, managers were auditing all caesarean sections

that occurred in November 2019 to identify if all sections were indicated and whether

improvements could be made to reduce the section rate.

Staff mostly had access to up to date and comprehensive information regarding women’s care and

treatment. However, the service was unable to archive cardiotocographs (CTGs) electronically.

This meant there was a risk CTGs would fade and could not be used in the event of a medico-

legal case. This risk was listed on the service’s risk register and an electronic solution had been


requested. All CTGs related to a serious incident were photocopied to reduce this risk. There were

arrangements to ensure the confidentiality of patient information held electronically and staff were

aware of how to use and store confidential information. The electronic patient record system was

password protected. We observed computer terminals were locked when not in use to prevent

unauthorised persons for accessing confidential patient information.

There were effective arrangements to ensure data was submitted to external bodies as required,

such as local commissioners, Public Health England and M-BRRACE-UK. This enabled the

service to benchmark performance against other maternity providers and national outcomes.

Engagement

Leaders and staff actively and openly engaged with women, staff, the public and local

organisations to plan and manage services. They collaborated with partner organisations

to help improve services for women.

Women’s views and experiences were gathered and acted on to shape and improve the service

and culture. Women and partners were encouraged to share their views to help improve services.

For example, women who used maternity services were encouraged to give feedback on the

quality of service they received through the Friends and Family Test (FFT). Feedback was

reviewed by staff and used to inform improvements and learning, where possible. Information

about making a complaint and the patient advisory liaison service (PALS) was available in all

areas of the service. Feedback was also gathered through social media forums.

Parents whose baby had died during pregnancy, birth, or soon after were sent a questionnaire to

help identify any areas where bereavement care and support could be improved. The

questionnaire had been designed collaboratively with members of the Sands charity and bereaved

families. The questionnaire was posted to parents with a blossom sticker on the envelope, so they

knew what it was and could open it if and/or when they wanted. We reviewed 20 feedback forms

which showed most parents rated their care and the service very highly. Any areas of care that did

not meet family’s needs were acted on by the bereavement lead midwife. For example, feedback

from bereaved parents showed they were able to access counselling services when they needed

it. In response, the service had secured funding to pilot a counselling service at the hospital.

Women were involved in decision-making and activities to help shape services and the culture.

For example, the service worked collaboratively with the local Maternity Voices Partnership (MVP).

This user group was made up people involved in planning, providing and receiving maternity care,

such as midwives, health visitors, GPs, parents, parents-to-be and maternity service stakeholders.

An ‘in your shoes’ event was held to understand women’s, partner’s and staff views and feedback

from this event was used to develop action plans to improve the service.

The service participated in events to engage women, families, the public and staff. For example, in

September 2019 the service participated in the World Health Organisation’s annual world patient

safety day. The aim was to raise public awareness about patient safety and improve the quality of

healthcare. Staff had a stand in the hospital’s main foyer to share work that had been done to

improve services. The trust promoted baby loss awareness week. The external lights of the

hospital were changed to blue and pink, memory trees were placed in the foyer along with

information stands and singers were invited in to perform. The bereavement lead midwife ran a

social media group for bereaved parents. This acted as a means of support and helped parents

form social support connections with others who understood what they were going through.

Feedback from the service’s community of bereaved families was, “one you’d never choose to join


but it’s the best and most supportive group you could be part of”. In the Summer, staff held their

first maternity festival (“MatFest”) at a staff member’s farm. Everyone in the unit was invited for an

evening of food and music under the stars. Staff told us the event had been great for staff morale

and they hoped to make it an annual event.

Staff’s views and experiences were gathered and acted on to shape and improve the service and

culture. Staff were encouraged to share their views to help improve services. For example, the

service had introduced breakfast meetings where the leads for the service provided breakfast to

staff on duty and gave them an open forum to discuss any issues they wished to raise. The

meetings were colleague-led with no fixed agenda to ensure conversations flowed. Managers

reported the breakfast meeting had already proven to mitigate grievances and work-related stress,

as well as providing key target areas for increased training (Source: Routine Provider Information

Request, Innovation tab – P65). Feedback from restorative clinical supervision and staff feedback

sessions was used to develop an action plan for maternity and neonatal safety. Safety concerns

identified by staff were aligned to five key drivers; leadership, learning and best practice, teams,

data and innovation. We saw actions to address each concern were identified. For example,

managers ensured staff had support from their line manager, psychotherapy and/or restorative

clinical supervision in response raised to concerns about psychological trauma experienced by

staff following an incident or stressful situation (Source: Additional Evidence Request, DR69).

More flexible working and core staff had also been introduced in response to staff feedback, which

all staff spoke very positively about.

From the conversations we had with staff and observations were made during our inspection, it

was evident staff were engaged in the service and felt empowered to help improve services.

Information was shared with staff in a variety of ways, such as daily handovers, email,

noticeboards and staff events. The service also used social media forums to engage with staff.

The service engaged with external partners to build a shared understanding of challengers within

maternity, the needs of the local community and to deliver services to meet those needs. The

service was working collaboratively with service users, neighbouring hospitals and commissioners

by means of the local maternity system to ensure national recommendations for maternity services

were implemented across the region.


Staff were committed to continually learning and improving services. They had a good



Staff of all grades were committed to continually learning and improving services. Staff we spoke

with told us they were encouraged to share any ideas or suggestions they had for service

improvement. Staff gave examples of new initiatives within the service. For example, all

preceptee’s were given a blue flower badge to wear to discretely signify to other staff they were

newly qualified and may need additional support and help. This innovation was developed by

preceptee’s. The service was participating in the Maternity and Neonatal Safety Improvement

Programme to reduce the postpartum haemorrhage rate of births of 1,500mls or more by 50% by

May 2020. A recognised quality improvement tool known as Plan, Do, Study, Act (PDSA) cycles

was being used to trial the model for improvement (Source: Additional Evidence Request, DR98).

The service had employed a lead midwife for quality improvement.


The service participated in research projects which contributed to learning, continuous

improvement and innovation. For example, the service was trialling a non-medicinal method of

labour induction. The benefits of which included a very low risk of uterine hyperstimulation, which

is a serious complication of induction where the uterus contracts for longer or more frequently than

normal and can lead to uterine rupture or fetal distress.

Staff were committed to giving high quality care to women and their families and had improved

services to meet their needs. For example, we heard many examples of improvements made to

bereavement care. The service was actively recruiting for an additional midwife to support the

bereavement team. Once recruited, their focus would be rainbow pregnancies (pregnancies that

follow the loss of a baby).

In December 2019, the maternity bereavement team were awarded a Judge’s Award at the NHS

Elect Patient Experience and Quality Improvement Awards. The team were praised for

demonstrating leadership and compassion for women, partners and families and inspiring their

colleagues. Their nomination was described as “moving” and “made unforgettable reading”.

The service was committed to training and staff development. Staff told us they were encouraged

and supported to complete additional training.


Gynaecology


The trust provides a range of gynaecology services including the early pregnancy unit, acute

gynaecology, outpatient services including colposcopy, fertility, hysterosalpingo contrast

sonography (HyCoSy), urodynamics and hysteroscopy clinics as well as a specialist oncology

service.

The service has eight obstetrics and gynaecology consultants who covered both specialties. Each

consultant has area of expertise in women’s health to provide a range of specialist clinic services.

The gynaecology service offered the following specialist clinics:

• Colposcopy Clinic

• Early Pregnancy Assessment Unit

• Fast Track Clinic

• Fertility Clinic

• Gynaecology Outpatient’s

• Gynae-oncology

• Hysteroscopy Clinic

• Menstrual Disorder Clinic

• Outreach Clinics

• Pre-assessment Clinic

• Termination of Pregnancy Clinic

• Uro-gynaecology Clinic

• Urodynamics Clinic

Gynaecology services has one inpatient ward, Gosfield Ward is a 10-bedded inpatient ward for

gynaecological services at Broomfield Hospital. There is 24-hour consultant coverage for the

service with close working with two other hospitals in relation to the oncology patient care

pathways.

The gynaecology ambulatory care unit has four trolleys for patient assessments and accepts direct

referrals from the emergency department and GP’s. The gynaecology ambulatory care unit and

the early pregnancy unit were located on Gosfield ward.

The trust has undertaken a number of service developments, including specialist nurse training

courses to allow the introduction of nurse-led ultrasound scanning in the early pregnancy unit on

completion of the training. The training has been completed by an advanced nurse colposcopist

and is being rolled out to other nurses.

The trust is developing an outpatient endometrial ablation clinic to reduce the pressure on

inpatient services. The trust is also in the final phase of implementing manual vacuum aspiration


procedures in outpatient settings to minimise delays in patient care, reduce pressure on theatre

capacity and improve patient experience.


During the inspection we spoke with 19 members of staff including doctors, nurses, therapists,

health care assistants and non-clinical staff. We spoke with seven patients and their relatives,

reviewed 12 patient records and considered other pieces of information and evidence to come to

our judgement and ratings.





Mandatory training


completed it.


training. Staff we spoke with told us that managers reviewed mandatory training completion and

helped staff to arrange any face-to-face training.

Nursing staff received and kept up-to-date with their mandatory training. The table below shows

that nursing staff who worked in gynaecology had completed all mandatory training modules and

exceeded the trust’s target. The Gosfield ward manager had developed team meeting days for all

ward staff every two months. Ward staff were split into two teams and had alternate team meeting

and clinical supervision days. Staff had time to complete eLearning and face to face mandatory

training during these days.




Please note that the trust’s medical staff work across both maternity and gynaecology services.

The trust provided training data for maternity services based at Broomfield Hospital which included

gynaecology services.

Broomfield Hospital


staff in gynaecology at Broomfield Hospital is shown below:


Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)

Equality and diversity 10 10 100.0% 85% Yes Hand hygiene 10 10 100.0% 85% Yes Health and safety 10 10 100.0% 85% Yes Information governance 10 10 100.0% 95% Yes Medicine management training 10 10 100.0% 85% Yes


Moving and handling 10 10 100.0% 85% Yes Moving and handling for people handlers

10 10 100.0% 85% Yes


Adult immediate life support 9 10 90.0% 85% Yes Fire safety 9 10 90.0% 85% Yes

In gynaecology, the trust target was met for all 10 of the mandatory training modules for which


Medical staff received and kept up-to-date with their mandatory training. The average completion

rate for mandatory training was 89.5% which was above the trust completion target. Although

medical staff had not completed two modules to the trust’s target of 85%.


gynaecology at Broomfield Hospital is shown below:


Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)

Health and safety 21 21 100.0% 85% Yes Information governance 21 21 100.0% 95% Yes

Medicine management training 2 2 100.0% 85% Yes Waste management 21 21 100.0% 85% Yes Moving and handling 20 21 95.2% 85% Yes Adult basic life support 6 7 85.7% 85% Yes Fire safety 18 21 85.7% 85% Yes Hand hygiene 18 21 85.7% 85% Yes

Equality and diversity 16 21 76.2% 85% No Adult immediate life support 14 21 66.7% 85% No

In gynaecology, the target was met for eight of the 10 mandatory training modules for which



Clinical staff completed training on recognising and responding to patients with mental health

needs, learning disabilities, autism and dementia. The completion rate for Mental Capacity Act and

Deprivation of Liberty Safeguards training was 100% for nursing staff which was above the trust’s

target of 95%. The completion rate for medical staff was 85.7% which was below the trust’s target.

Safeguarding


agencies to do so. Nursing staff had training on how to recognise and report abuse and

they knew how to apply it. Although not all medical staff had completed all elements of

safeguarding training.


with other agencies to protect them. The trust had a safeguarding adults policy and safeguarding

children policy in place which were within the review date. The policies set out staff responsibilities


at all levels and referenced appropriate national guidance and legislation. Staff we spoke with

knew how to identify patients subject to or at risk of abuse. Staff reported concerns of abuse as a

safeguarding referral to the safeguarding team.

Staff knew how to make a safeguarding referral and who to inform if they had concerns. Staff were

able to describe the process of raising their concerns, this included female genital mutilation

(FGM) and child sexual exploitation (CSE).

The trust had a female genital mutilation (FGM) policy in place which included risk assessments to

assist staff with the reporting process. FGM training formed an integral part of safeguarding

children level three training and level two safeguarding training.

The trust had systems and processes in place to report all cases of suspected abuse within the

local safeguarding networks. This included FGM and child sexual exploitation (CSE). The trust had

a named member of the safeguarding team responsible for FGM who had oversight of all risk

assessments. All cases of FGM were reported to the maternity safeguarding team who shared

information accordingly where there were both children and adults within the family network. All

cases of reported FGM in women under 18 years of age were reported to social services and the

police. FGM reporting and prevalence formed part of the quarterly assurance report reviewed by

the trust’s local safeguarding operational group and the trust’s safeguarding committee.


those with protected characteristics under the Equality Act. All staff had access to the CSE toolkit

which was available through the trust’s intranet with referral and risk assessment materials. The

trust had a pathway in place which included CSE but focused on all forms of exploitation, such as

‘county lines’ (a term used to describe the exploitation of children and young people in rural areas

by large organised crime networks). This was available to all staff to assist on any risk assessment

they may undertake. Staff received training about exploitation which was included in safeguarding

children level three framework.

Nursing staff received training specific for their role on how to recognise and report abuse. The

table below demonstrates that nursing staff had completed safeguarding training in line with the

trust’s target.








The trust provided training data for maternity services based at Broomfield Hospital, which

included gynaecology services.

Broomfield Hospital


nursing staff in gynaecology at Broomfield Hospital is shown below:



Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)

Prevent - awareness 10 10 100.0% 85% Yes

Prevent - basic awareness 10 10 100.0% 85% Yes Safeguarding adults (level 1) 10 10 100.0% 95% Yes Safeguarding adults (level 2) 10 10 100.0% 95% Yes Safeguarding children (level 1) 10 10 100.0% 95% Yes Safeguarding children (level 2) 10 10 100.0% 95% Yes Safeguarding children (level 3) 1 1 100.0% 60% Yes

In gynaecology, the trust target was met for all seven safeguarding training modules for which


Medical staff had not completed all training specific for their role on how to recognise and report

abuse. Medical staff had not completed safeguarding training in line with the trust’s target. In

August 2019 only one member of eligible medical staff had completed training for safeguarding

children level three. We raised concerns about the safeguarding training rate for medical staff with

the triumvirate leadership team during our inspection. Managers told us that medical staff had

training booked for November and December 2019 to improve training compliance.


in gynaecology at Broomfield Hospital is shown below:


Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)

Prevent - basic awareness 19 21 90.5% 85% Yes Prevent - awareness 16 21 76.2% 85% No Safeguarding adults (level 1) 16 21 76.2% 95% No Safeguarding adults (level 2) 16 21 76.2% 95% No Safeguarding children (level 1) 16 21 76.2% 95% No Safeguarding children (level 2) 16 21 76.2% 95% No


In gynaecology, the trust target was met for one of the seven safeguarding training modules for

which medical staff at Broomfield Hospital were eligible.


Following our inspection, we requested further information regarding the completion of

safeguarding training completion rates for medical staff. Information provided by the trust showed

an improvement in the completion rates. The completion rate for Prevent awareness was 90%,

safeguarding adults level one was 85%, safeguarding children level one and level two was 90%.

There was no further improvement in the completion rate of safeguarding adults level two and

safeguarding children level three. Managers had booked safeguarding children level three training

for all medical staff and the trust expected this staff group to reach trust compliance by the end of

January 2020.



The service controlled infection risk well. The service used systems to identify and prevent

surgical site infections. Staff used equipment and control measures to protect patients,

themselves and others from infection. They kept equipment and the premises visibly clean.

Ward areas were clean and had suitable furnishings which were clean and well-maintained. We

visited all clinical areas that cared for gynaecology patients, we found all areas were visibly clean

and had disposable privacy curtains. The curtains were dated on commissioning, all of the curtains

we reviewed were dated appropriately.

Cleaning records were up-to-date and demonstrated that all areas were cleaned regularly.

Cleaning records we reviewed showed that cleaning had taken place in ward areas, clinics and

theatres.


In all areas we visited, staff decontaminated their hands appropriately before and after patient

care. Staff wore uniforms with short sleeves and were bare below the elbows. They used personal

protective equipment in line with the trust’s infection prevention and control policy and disposed of

the items correctly.

The service completed monthly hand hygiene audits. We reviewed the hand hygiene audit results

from May to October 2019 which consistently scored 100% compliance.

Staff cleaned equipment after patient contact and labelled equipment to show when it was last

cleaned. We observed reusable medical equipment such as dressing trolleys, intravenous infusion

stands, and commodes were visibly clean and had dated green “I am clean” stickers attached to

signify that the equipment had been cleaned and was ready for use. Clinic staff cleaned

equipment between patients’ appointments, such as examination couches and ultrasound

equipment.

Elective gynaecology patients were screened for hospital associated infections such as methicillin

resistant staphylococcus aureus (MRSA). Elective surgical patients received screening during their

pre-assessment appointment prior to their admission to hospital. Pre-assessment staff referred

any patient that had a positive result to the infection prevention and control team for treatment.

Patients on the emergency gynaecology pathway of care were screened during the admission

process and isolated appropriately if there were any concerns about hospital associated infections.

We reviewed the MRSA screening audits conducted from October 2018 to September 2019 which

showed that gynaecology patients were screened in line with trust’s 95% target for seven out of 12

months. The data showed that screening was just below the trust’s target in October 2018,

November 2018, May 2019 and July 2019, however in February 2019 only 88% of elective

gynaecology patients received screening.

Managers we spoke with told us that the staff completed a fast track MRSA swab test for patients

that had been missed during the pre-assessment process. The ward received MRSA swab results

within two hours.



Staff were trained to use them. Staff managed clinical waste well.


Patients could reach call bells and staff responded quickly when called. Each bed space on

Gosfield ward had a call bell system. We observed call bells were within the reach of patients, and

when patients called for help, staff were prompt responding to their needs.

The design of the environment followed national guidance. Gynaecology had ten protected beds

on Gosfield ward, the gynaecology ambulatory care unit had four trolleys for patient assessments,

two procedure rooms within the gynaecology treatment unit and outpatient clinic rooms.

Gynaecological surgeries were performed within a designated theatre in the main theatre suite.

Staff carried out daily safety checks of specialist equipment. Ward and clinic staff completed daily

checks of the emergency resuscitation trolleys. We reviewed records in outpatient clinics and on

Gosfield ward which demonstrated staff had completed daily and weekly checks. We checked the

resuscitation trolley on Gosfield ward and we found all equipment listed was available and within

their expiry date.

The service had enough suitable equipment to help them to safely care for patients. The service

used a range of single use consumable equipment items such as syringes, needles and

intravenous infusion lines. We randomly checked 32 items of single use equipment and found they

were stored appropriately and were within their expiry date.

The trust had a team of engineers who were responsible for the management of medical device

maintenance. The trust had a medical device database in place for the oversight of medical device

maintenance and safety testing. The biomedical engineering department submitted quarterly

reports of compliance and performance to the health and safety group and the medical device

group. We checked eight items of electrical equipment such as examination couches, diathermy

machines and blood pressure machines. All equipment was up-to-date with electrical safety

testing and servicing in line with manufacturers guidance.

Staff disposed of clinical waste safely. Waste bins were monitored throughout the day and staff

disposed of clinical and domestic waste appropriately. Staff disposed of sharp items, such as

injection needles, in clinical waste sharps bins. We reviewed six sharps bins and found these were

labelled, dated, included the clinical area and were not overfilled.


Staff completed and updated risk assessments for each patient and removed or minimised

risks. Staff identified and quickly acted upon patients at risk of deterioration.


appropriately. Staff used the NEWS2 tool to monitor patients and identify a deteriorating patient.

NEWS2 is a nationally standardised assessment of illness severity and determines the need for

escalation based on a range of patient vital observations. The trust had a central team that

monitored patient vital observations electronically and alerted teams if a NEWS2 score triggered

escalation. The Trigger team had oversight of patients that triggered the NEWS2 assessment

through electronic clinical observation tracking throughout the trust to reduce delays in the

identification and treatment of sepsis. We reviewed 12 patient records and we found that all

patients had vital observations recorded at the right time and staff had escalated patients in line

with trust policy.

Staff had access to the sepsis six care bundle to manage patients with suspected sepsis. Sepsis

is rare but a serious complication to an infection which requires timely identification and antibiotic

management to prevent long term organ damage or death. At the time of our inspections no


patients had triggered the NEWS2 for suspected sepsis. Staff we spoke with knew how to

implement the sepsis six care bundle and escalate their patients when the NEWS2 triggered signs

of sepsis.

Staff had access to consultant support either on site or on-call 24 hours a day, seven days a week

in the event of a deteriorating patient. Consultants worked an on-call rota to ensure staff had

access to consultant support when required.

Staff did not always fully complete all risk assessments for each patient on admission or arrival

and updated them when necessary and used recognised tools. The service did not always

complete venous thromboembolism risk screening in line with the trust’s target. Manages

monitored the completion of venous thromboembolism (VTE) risk screening in gynaecology. The

trust’s target for VTE risk screening was 95% of patients. We reviewed the VTE risk screening

audits from November 2018 to October 2019 which showed that the service only met the target in

December 2018 and January 2019. Managers for the service included VTE risk screening

completion within the weekly safety briefing from October 2019.

Staff completed risk assessments such as the Waterlow pressure ulcer risk, malnutrition universal

scoring tool and fall risk assessments as part of the patient admission process. Staff reviewed

these risk assessments daily and updated the assessments as the patient’s condition changed.

Staff knew about and dealt with any specific risk issues. Theatres had a major haemorrhage

protocol in place. The matron for maternity and gynaecology planned to provide additional major

haemorrhage training for gynaecology ward staff. The matron had additional resources on order to

staff had medications and equipment in place to manage a major haemorrhage once the training

was completed.

All patients admitted for elective gynaecology procedures had pre-admission assessments which

included an anaesthetist review where pre-assessment staff identified increased risks such as

high blood pressure and respiratory abnormalities.

Gynaecological procedures were undertaken within a designated theatre in the main theatre suite.

The theatre teams had completed competencies specific to gynaecological procedures. Theatres

used the World Health Organisation (WHO) five steps to safer surgery checklist. Staff used an

electronic system to audit compliance, with briefing, sign in, time out, sign out and debrief stages

of the World Health Organisation (WHO) five steps to safer surgery checklist in main theatres.

Theatres had local safety standards for invasive procedures in place. Theatre staff had a process

called ‘pause for gauze’ to ensure that all gauze swabs were accounted for before the surgical

wound was closed. Staff followed this safety standard in the allocated gynaecology theatre.

Gynaecology services did not routinely provide termination of pregnancy, a partner private

provider had a contract for the provision of termination of pregnancies. However, the service

carried out a small number of medical termination of pregnancies where foetal abnormalities were

detected through routine pregnancy monitoring.

The service had 24-hour access to mental health liaison and specialist mental health support (if

staff were concerned about a patient’s mental health). Staff could refer their patients for a mental

health assessment if they had concerns that a patient was at risk of harm due to new or existing

mental health condition. Staff contacted the hospital site management team to request either a

mental health review or support.


Nurse staffing

The service now had enough nursing and support staff with the right qualifications, skills,


care and treatment.

The service did not always have enough nursing staff and support staff to care for patients. The

table below shows that the service had a high vacancy rate for gynaecology nursing staff and 36%

of nursing hours were unfilled from August 2018 to July 2019. This had an impact in the ability of

the service to meet the increased demand on gynaecology services and national treatment

targets.

The service had high turnover rates and vacancy rates. The table below shows that gynaecology

nursing had vacancy rates and turnovers rates that were above the trust’s target rates. Managers

we spoke with told us that the trust had challenges with recruitment and retention of nursing staff

due to their proximity to London where nurses were paid a weighting enhancement. They told us

there was a trust wide strategy in place improve the recruitment and retention of nursing staff.

Broomfield Hospital

The table below shows a summary of the nursing staffing metrics in gynaecology at Broomfield


Gynaecology annual staffing metrics

August 2018 to July 2019 July 2018 to June 2019 August 2018 to July 2019

Staff Group


Annual vacancy

rate

Annual turnover

rate

Annual sickness

rate

Annual bank

hours (% of

available hours)

Annual agency

hours (% of

available hours)

Annual unfilled

hours (% of

available hours)

Target 13% 12% 3.8%

All staff 68 8% 12% 2.4%

Qualified nurses

21 27% 16% 2.5% 3,822 (9%)

3,665 (8%)

15,830 (36%)



Nurse staffing rates within gynaecology at Broomfield Hospital were analysed for the past 12

months and no indications of improvement, deterioration or change were identified in monthly

rates for vacancy, turnover, sickness and agency use.

The trust has reported that medical staff work across both maternity and gynaecology services at

Broomfield Hospital. Therefore, the figures for all staff in the table above include medical staff

working in maternity and gynaecology at Broomfield Hospital.

The service had low sickness rates. The table above shows that the sickness rate for nursing staff

in gynaecology was below the trust’s target of 3.8%.


and healthcare assistants needed for each shift in accordance with national guidance. The trust

conducted staffing reviews twice a year in line with the guidance set out by the National Quality


Board (NQB). Managers used the Shelford Group Safer Nursing Care Tool (SNCT) to assess staff

requirements for each clinical area. The last data collection was undertaken in June 2019. At the

time of our inspection Gosfield ward had no staff vacancies.

The trust held bed meetings four times each day where safe staffing levels were reviewed at each

bed meeting, to identify areas that had lower than expected staff or that required further support.

Matrons for the division conducted daily safety huddles to mitigate any risk areas. They escalated

any areas with reduced staffing at a daily staffing meeting with the deputy director of nursing to

ensure that cross divisional support was addressed. Managers reviewed the daily acuity and

dependency risk assessment tool to ensure that managers utilised workforce effectively in clinical

areas.

The ward manager could adjust staffing levels daily according to the needs of patients. The

divisional senior nursing team reviewed ward staffing levels and mitigated staff shortages which

they recorded within the electronic staffing system. Managers had access to bank and agency

staff where they had vacant shifts.

Incident reporting of staffing issues and red flags as described by the NQB are captured within the

trust's incident reporting system and reviewed monthly within the monthly ward staffing review

paper.

Bank staff usage

Monthly bank hours over the last 12 months for qualified nurses show an upward shift from


(Source: Routine Provider Information Request (RPIR) - Nursing Bank and Agency tab)

The service had an increased bank staffing rate from February 2019 to July 2019 to cover vacant

shifts due to staff vacancies. Managers had recruited staff to vacancies during this period and staff

numbers met establishment at the time of our inspection.

The trust introduced a preferred supplier list arrangement for general nursing agencies in 2019,

which adhered to the NHS employer standard checks. This ensured that agency staff had

clearances such as identity checks, references and employment history, qualifications and

professional registration, occupational health and Disclosure and Baring Service (DBS). The ward

manager completed a local induction checklist. We checked completed agency induction

checklists and we found that documents were completed correctly, dated and signed.


Information provided by the trust showed that none of the nursing staff on Gosfield ward had

completed a recognised gynaecology course. However, nine nurses who worked with the

gynaecology treatment centre and outpatient department, including nurse specialists had

completed post graduate qualifications in gynaecology. Gosfield ward staff had to complete

specialist competencies in gynaecology during their preceptorship period.

Medical staffing

The service had enough medical staff with the right qualifications, skills, training and


treatment.

The service always had a consultant on call during evenings and weekends. The trust shared a

consultant team between gynaecology and maternity. There was a consultant on site until 8pm

Monday to Friday and from 9am to 1pm on Saturday and Sunday, with on call outside these times

to provide 24-hour cover. Consultants prioritised maternity which meant registrars and junior

doctors completed the ward round and handed over to consultants later in the morning each day.

Junior doctors we spoke with told us that they sometimes completed ward rounds on their own if

their registrar was called to a maternity emergency. We raised our concerns about consultant

support with the senior leadership team for the trust during our inspection. The trust provided

assurances that all women admitted overnight or required an urgent review were seen either by

the gynaecology registrar or consultant prior to the 8am board round in the maternity unit.

Consultants returned to Gosfield ward for a board round at 10:30am to review non-urgent patients.

The Gosfield ward manager told us that the later consultant ward round worked well for ward staff

and patients, as patients had time to eat breakfast and wake up before consultant rounds. The

ward manager had no concerns about ward round timings, this did not affect patient discharge

plans. Staff we spoke with told us they had timely access to a consultant in the event of an

emergency.

The service had low turnover rates for medical staff. The table below shows that the turnover rate

for medical staff was below the trust’s target of 12%.

Sickness rates for medical staff were low. The table below shows that that the sickness rate for

medical staff in maternity and gynaecology was significantly lower that the trust’s target of 3.8%.

The service had low vacancy rates for medical staff. The table below shows that maternity and

gynaecology had no unfilled vacancies for medical staff.

Broomfield Hospital

The table below shows a summary of the medical staffing metrics in gynaecology at Broomfield


Gynaecology annual staffing metrics August 2018 to July 2019 July 2018 to June 2019 August 2018 to July 2019

Staff Group


Annual vacancy

rate

Annual turnover

rate

Annual sickness

rate

Annual bank

hours (% of

available hours)

Annual locum

hours (% of

available hours)

Annual unfilled

hours (% of

available hours)

Target 13% 12% 3.8%



28 0% 8% 0.3% 1,918 (3%)

2,619 (5%)

0 (0%)


Medical locum tabs)

Medical staffing rates within gynaecology at Broomfield Hospital were analysed for the past 12

months and no indications of improvement, deterioration or change were identified in monthly

rates for turnover, sickness, bank and locum use.

The trust has reported that medical staff work across both maternity and gynaecology services at

Broomfield Hospital. Therefore, the numbers in the table above include medical staff working in

maternity and gynaecology at Broomfield Hospital.

The service had low rates of bank and locum staff. The table above shows that the service had a

5% agency rate and 3% bank staffing rate for medical staff to cover sickness and annual leave.

Vacancy rates

Monthly vacancy rates over the last 12 months for medical staff show a downward trend from

November 2018 to April 2019 and medical staff in gynaecology at the trust were over established

in February, March and April 2019.


Managers could access locums when they needed additional medical staff. Agency staff (locums)

were provided by an agency through a service level agreement. The agency provided locums

following pre-employment checks in line with their service level agreement. Medical rota

coordinators booked locums via approved framework agencies who provided evidence of pre-

employment check standards and reviewed right to work and identity checks for the trust records.

Bank staff doctors applied for a bank positions and were required to complete pre-employment

checks in line with NHS standards. Doctors received a bank assignment number, once the trusts

human resources team had completed the pre-employment checks. Doctors employed by the trust

could also apply for a bank contract in addition to the permanent contract.


Managers made sure locums had a full induction to the service before they started work. An

induction process in place to ensure all agency doctors have access to an induction pack, all bank

doctors were subject to trust’s mandatory training.

The service had a lower proportion of consultants and registrars than the England average. The

table below shows the skill mix breakdown for maternity and gynaecology.

Staffing skill mix


In April 2019, the proportion of consultant staff and registrars reported to be working at the trust

was lower than the England average. The proportion of junior (foundation year 1-2) and middle

career staff was higher.

Staffing skill mix for the 27.2 whole time equivalent staff working in maternity and

gynaecology at Mid Essex Hospital Services NHS Trust.

This

Trust

England

average

Consultant 36% 42%



Junior* 11% 6%



Records

Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date,


Patient notes were comprehensive and all staff could access them easily. Staff used paper patient

records to record patient care. Medical, nursing and therapy staff recorded care in the same

record to ensure a complete and contemporaneous record of information to deliver safe patient

care.

We reviewed 12 patient records from three clinical areas and found that they were legible, signed

and dated. All records contained pre-operative assessments either as part of a pre-admission

assessment or as part of the emergency admission pathway. The records were contemporaneous

and demonstrated an on-going plan of care.


We reviewed seven patient records on Gosfield ward which demonstrated that staff had completed

intentional rounding. All the records we reviewed had up to date risk assessments such as

Waterlow pressure ulcer risk, malnutrition universal scoring tool (MUST) and a falls risk

assessment.

Managers monitored staff completion of medical records and completed monthly patient record

audits on Gosfield ward. We reviewed the audit results for September and October 2019 where

the compliance rate for record keeping was 99% and 100% respectively.


Staff ensured patients records were transferred with patients from one area to another within the

hospital. Medical staff completed discharge summaries electronically which were sent directly to

the patient’s general practitioner (GP) through the electronic system. Staff printed a copy of the

discharge summary, which was given to the patient.

Staff kept records securely within gynaecology services. We observed ward staff kept records

securely in keypad secured trolleys in a staff area. In the gynaecology treatment centre, staff kept

all patient records in a locked office when they were not in use. Staff had access to the office to

retrieve records for patient appointments and they returned records to the office following patients’

treatments.

Medicines


medicines.


storing medicines. Staff used paper prescription records. We reviewed seven prescription records

on Gosfield ward which demonstrated patients had received their medicines at the right time.


about their medicines. We reviewed seven prescription records of Gosfield ward evidenced that

staff reviewed patients’ medicines daily during ward rounds. Staff provided information to their

patients about their medicines when they administered medicine and during patient discharge

process.

Staff stored and managed medicines and prescribing documents in line with the trust’s policy. Staff

kept medicine securely within a swipe access storage room which was only accessed by staff.

Staff stored controlled drugs within a locked wall mounted cupboard in line with legislation. We

reviewed the controlled drug reconciliation records and we found that the stock matched the

records. Records we reviewed demonstrated that staff checked controlled drugs daily in line with

the trust’s policy.

Staff kept medicines securely within the gynaecology treatment unit. The treatment centre did not

hold controlled drugs within the department. We checked a variety of pain-relieving medicines

such as Voltarol (an anti-inflammatory) and paracetamol and found all medicines were within their

expiry date.

We observed that staff kept medicines fridges locked and monitored the temperatures daily. We

reviewed the fridge temperature records on Gosfield ward and in outpatient clinics and found

these were completed daily without gaps.


Staff followed current national practice to check patients had the correct medicines. We observed

staff administering medicines on the wards, they checked medicine prescription, allergies, dosage.

and patients’ wrist identity bands against the prescription chart before they gave patients their

medicines.


received their medicines safely. Staff completed service specific training and competencies which

included areas such as medical management of miscarriage to ensure they administered these

medicines safely. Managers shared key safety messages during daily safety briefing which

included information about safety alerts and medicines incidents.

Incidents



whole team and the wider service. When things went wrong, staff apologised and gave

patients honest information and suitable support. Managers ensured that actions from

patient safety alerts were implemented and monitored.

Staff knew what incidents to report and how to report them. Staff we spoke with knew how to

report an incident or a near miss. Staff gave examples of incidents they had reported such as,

incidents of violence and aggression from patients or their relatives. Staff demonstrated to us the

electronic system they used to report incidents. Staff reported incidents through an electronic

system which alerted managers that an incident had occurred and required follow up and

investigation.

Staff raised concerns and reported incidents and near misses in line with trust policy. The trust

had an incident reporting policy which set out the responsibilities of staff at all levels in reporting

and investigation of safety incidents. The policy was within the review date and referenced

national guidance and legislation. Staff knew how to access the policy via the trust’s electronic

policy library.

The service had no never events in any of the gynaecology clinical areas. The service had no

reported never events from August 2018 to July 2019.

Never Events

Broomfield Hospital





event in gynaecology at Broomfield Hospital.


Staff understood the duty of candour. They were open and transparent, and gave patients and

families a full explanation if and when things went wrong. Duty of candour is a regulatory duty that

relates to openness and transparency and requires providers of health and social care services to

notify patients (or other relevant persons) of certain ‘notifiable safety incidents’ and provide

reasonable support to that person. Staff received training on the duty of candour during their trust


induction training. Staff and managers, we spoke with understood their responsibilities in relation

to the duty of candour.

The trust had a being open and duty of candour policy in place, which set out the responsibilities

of staff at all levels in relation to the duty of candour. The policy was within the review date and

referenced relevant national guidance and legislation.

The trust had process in place to assess incidents in line with the national serious incident

reporting framework. The electronic incident reporting system had a mandatory section that was

triggered if the recorded level of harm is Moderate, Major/Severe, death, or if the incident is

recorded as a serious incident (regardless of the level of harm). Serious incidents reports had

actions with timescales and identified leads to ensure that the duty of candour was completed

appropriately.

The gynaecology service had reported seven serious incidents from August 2018 to July 2019.

The table below shows the breakdown of the serious incidents reported. Although the service had

seven serious incidents there were no themes in the incidents reported.


Broomfield Hospital

In accordance with the Serious Incident Framework 2015, the trust reported seven serious

incidents (SIs) in gynaecology which met the reporting criteria set by NHS England from August

2018 to August 2019. All of the incidents reported within gynaecology occurred at Broomfield

Hospital and represented 5.5% of all serious incidents reported by the trust as a whole.


Incident type Number of incidents Percentage of total Diagnostic incident including delay meeting SI criteria (including failure to act on test results)

2 28.6%

Medical equipment/ devices/disposables incident meeting SI criteria

1 14.3%

Maternity/obstetric incident meeting SI criteria: mother and baby (this include foetus, neonate and infant)

1 14.3%

Surgical/invasive procedure incident meeting SI criteria

1 14.3%

Treatment delay meeting SI criteria 1 14.3% VTE meeting SI criteria 1 14.3% Total 7 100.0%


Managers debriefed and supported staff after any serious incident. Managers investigated serious

incidents thoroughly and identified areas of learning and improvement. We reviewed three root

cause analysis (RCA) investigation reports following serious incidents. In all cases staff had

identified the root cause of the incident appropriately. Each RCA had identified areas of notable

practice and area of learning and improvement which were included within dated action plans.


investigations. RCAs we reviewed demonstrated that managers had supported patients and their

families appropriately through the investigation and the duty of candour process.


The gynaecology service had commissioned an independent consultant case review in response

to an incident and subsequent complaint relating to a complication of gynaecological surgery. The

review agreed the incident was a recognised, but serious, complication. Following the procedure

there were lessons learned in relation to communication and earlier involvement of vascular

surgeons in managing this type of complication. The review was shared with the relevant clinical

teams within gynaecology.

The trust had established systems and processes in place for morbidity and mortality reviews. The

trust used the medical examiner model for the scrutiny of case notes to ensure there were no care

or service delivery issues. Staff completed morbidity and mortality reviews for all cases within

gynaecology to ensure staff delivered care and treatment in line with national guidance. This

process also helped managers identify learning which they use to improve patient care and shared

this with staff during group supervision sessions.

Safety thermometer



The safety thermometer data showed the service achieved harm free care within the reporting

period. We reviewed the safety thermometer data for Gosfield ward from July 2019 to October

2019 which showed that the ward had achieved 100% harm free care during this period.

Safety thermometer data was displayed on wards for staff and patients to see. We saw that

Gosfield ward displayed safety thermometer information on notice board at the ward entrance.





rights of patient’s subject to the Mental Health Act 1983.


and national guidance. Staff had access to policy and guideline documents on the trust’s intranet,

we observed staff accessing them easily.

Policy and pathway documents specific to the gynaecology service were based on national

guidance and best practice. We reviewed policies and pathways such as the management of

gynaecological cancers, ectopic pregnancy and management of miscarriage associated with early

pregnancy. All documents referenced relevant national guidance, best practice and legislation,

they were all within their review date.

The trust had process in place for the clinical audit team to identify new guidance published on the

National Institute for Heath and Care Excellence (NICE) website monthly. All new or updated

national guidance documents were directed to the relevant clinical speciality lead. The lead

conducted a baseline assessment, which included a review of practice against the guidelines.

Speciality leads agreed required implementation plans with the divisional triumvirate leadership

team.


The trust had identified areas where gynaecology services were not compliant with NICE

standards. The service was not compliant with NICE standard NG88, the assessment and

management of heavy menstrual bleeding. The clinical team had assessed the standard and

decided to continue with endometrial biopsies to avoid potential for missing hyperplasia or

endometrial cancer.

Staff had access to evidenced based tools to identify and treat patients with sepsis. The sepsis six

tool was used in conjunction with the NEWS2 assessment tool to identify patients at risk of sepsis.

Staff used the tools in line with the trust’s sepsis in policy, which referred to national guidance and

found this was within the review date. The Trigger team had oversight of patients that triggered the

NEWS2 assessment through electronic clinical observation tracking throughout the trust to reduce

delays in the identification and treatment of sepsis.

Policy and pathway documents were inclusive of patients with disabilities and people with

protected characteristics, for example admission pathways had sections about personal needs

and preferences. Staff made appropriate adjustments for patients with complex needs and

planned individualised care to meet these needs in line with trust policy, such as the consent to

treatment.




adjustments for patients’ religious, cultural and other needs.


hydration needs. Nursing care plans reflected individual requirements and the assessment of

nutritional care needs. There was a protected mealtime policy in place, the ‘mealtime companions’

initiative ensured patients were prepared for their mealtime and supported in eating where

required. Patients could request menu choices that took account of their cultural and religious

beliefs such as vegan foods.

Staff used a nationally recognised screening tool to monitor patients at risk of malnutrition. Staff

completed nutritional assessment tools as part of the nursing care plan. We reviewed seven

patient records and we found all patients had completed malnutrition universal screening tools

(MUST) assessments in place.

Specialist support from staff such as dieticians was available for patients who needed it. Staff had

access to refer their patients to specialist services such as dieticians to provide additional

nutritional support.

The hospital provided meals for patients that met nutritional standards and values which were

reviewed and assessed consistently by the catering department, dieticians and patient

representatives for evaluation purposes.

Staff followed national guidelines to make sure patients fasting before surgery were not without

food for long periods.

Patients waiting to have surgery were not left nil by mouth for long periods. The trust had pre-

operative fasting policy for adults and children in place for staff to follow. The policy was within the

review date and referenced national guidance. Staff we spoke with knew the fasting times of six

hours for food and two hours for clear fluids.


Gynaecology services had systems and processes in place for the management of hyperemesis

gravardium (morning sickness). Consultants managed symptoms of hyperemesis where women

attended the hospital for intravenous fluid hydration on a daily basis.

Gynaecology nurse specialists and anaesthetists provided addition advice in the management of

nausea following surgical procedures. Gynaecology oncology nurse specialists had additional

training in the management of nausea and sickness for cancer patients. Ward staff we spoke with

told us they could access timely support in the management of nausea and sickness for their

patients.

Pain relief





needs and best practice. Staff scored patient pain on a scale of zero to ten, zero meant patients

were not experiencing pain and ten meant extreme pain. We reviewed seven inpatient records

which all documented patient pain scores and actions staff had taken to address patient pain

needs.

Patients received pain relief soon after requesting it. Patients we spoke with told us that nursing

staff had provided pain relieving medicines in a timely way when reported their pain.

Staff prescribed, administered and recorded pain relief accurately. We reviewed seven inpatient

prescription records and we found all medical staff had prescribed pain-relieving medicines

correctly and nursing staff had administered these medicines at the right time.

Staff had access to additional support with patient pain management. Staff could refer patients to

the specialist pain team for a pain management plan. Staff also had access to support from

anaesthetists in the management of acute pain either before or after surgical procedures.

Patients booked for elective gynaecology surgery attended a pre-assessment clinic where

information was given to them on medication and ways to manage discomfort post operatively.

Patient outcomes


improvements and achieved good outcomes for patients.

Managers and staff carried out a comprehensive programme of repeated audits to check

improvement over time. Gynaecology services had a local audit plan in place to monitor and

improve patient care. Managers completed monthly audits to monitor elements of the care

provision in areas such as consultant review time for emergency admission, venous

thromboembolism risk assessment completion and ward controlled drugs.

Managers shared and made sure staff understood information from the audits. The service had

completed patient outcome audit for colposcopy prior to our inspection. The depth of colposcopist

excision rates in women of reproductive age audit identified areas for improvement and had key


actions for further monitoring. The service leads were in the process of developing a full action

plan and audit tools to monitor improvements.

Managers monitored the trust’s compliance with termination of pregnancy reporting in line with

legislation through the termination of pregnancy audit. We reviewed the audit data from November

2018 to October 2019 which showed 100% compliance for each month with the exception of

February 2019 where there was a breach of two days due to confusion whether a patient had a

spontaneous pregnancy loss or a termination of pregnancy.

Managers used information from the audits to improve care and treatment. The service had an

action plan in place following a risk summit for the service. The risk summit identified gaps in the

service, which took account of serious incident root cause analysis reports and complaint

investigations. The service had completed actions in response to the audit such as staff

competencies and protected emergency ultrasound scanning appointments. Managers were on

track to complete other action within the proposed time scales with full completion due by April

2020. Each action had a named manager responsible for the completion of the action.

Competent staff

The service made sure nursing staff were competent for their roles. Managers appraised

staff’s work performance and held supervision meetings with them to provide support and

development. Medical staff did not always participate in the appraisal process in line with

the trust’s target.


patients. Staff we spoke with had completed the appraisal process and had individual

development plans. Managers kept records of staff competence and qualifications. Staff on

Gosfield ward had group clinical supervision every two months. Ward staff also had an opportunity

to visit the local sexual assault referral centre, so they understood the evidence gathering process,

to support women if they were admitted to the ward following a sexual assault.

Managers gave all new staff a full induction tailored to their role before they started work. All new

nursing staff on Gosfield ward received a local induction. The local induction followed the

corporate trust induction process and included a competency portfolio that required a mentor sign

off process. The competency portfolio covered skills and knowledge such early pregnancy, patient

admission process and patient escalation.

Managers supported staff to develop through yearly, constructive appraisals of their work. Clinical

staff such as registered nurses, doctors and health care assistants participated in a meaningful

appraisal.


develop their skills and knowledge. All staff we spoke with told us they had participated in the

appraisal process with their manager where they reviewed their educational needs and set

mutually agreed objectives. One member of staff we spoke with had been supported to keep their

skills up-to-date, they completed ‘keep in touch’ clinical sessions during the maternity leave. The

staff member worked with another clinician during the sessions to gain confidence.

The table below shows that nursing and clinical services staff had participated in the appraisal

process from August 2018 to July 2019 in line with the trust’s target of 90%. However, the

appraisal rate for medical staff and administrative and clerical staff was below the trust’s target

completion rate.


Appraisal rates

Broomfield Hospital

As of August 2019, 81.0% of required staff in gynaecology at Broomfield Hospital received an

appraisal, which was below the trust target of 90%.


They provided appraisal data for maternity services based at Broomfield Hospital which included

gynaecology services.


Staff group



Eligible staff

Completion rate

Trust target

Met (Yes/No)

Additional clinical services 11 11 100.0% 90% Yes Nursing and midwifery registered 18 20 90.0% 90% Yes Medical and dental 15 21 71.4% 90% No Administrative and clerical 3 6 50.0% 90% No Total 47 58 81.0% 90% No

Qualified nursing staff and staff working in additional clinical services met the 90% trust target,

however, care should be taken when interpreting the rates as this data only represents a partial

year.



their work. Specialist nurse we spoke with had opportunities to participate in clinical supervision.

Staff we spoke with told us they had opportunities in group and one-one supervision.


not attend. The Gosfield ward manager had implemented a system to ensure all staff members

attended ward meetings and clinical supervision sessions. The ward had two staffing teams, each

team had a team meeting day every two months, the meetings were arranged for an early shift

where staff had group clinical supervision and mandatory training sessions. The ward meeting

section was recorded for staff that were unable to attend due to annual leave, maternity leave or

sickness.


develop their skills and knowledge. Staff we spoke with told us that they had opportunities to

develop their skills and knowledge with funded university courses. Records provided by the trust

following our inspection demonstrated that staff had access to additional training in areas such as

counselling, psychological assessment and no-medical prescribing courses.

Managers made sure staff received any specialist training for their role. Records provided by the

trust following our inspection demonstrated that specialist gynaecology cancer nurses had

completed post graduate courses in gynaecology oncology. Colposcopy clinical nurse specialists

had completed additional qualifications and competencies to undertake their role.

Managers identified poor staff performance promptly and supported staff to improve. Managers we

spoke with told us that they encouraged staff development and often poor performance was


related to gaps in knowledge and experience. They supported staff to improve through the

appraisal and professional development meetings. They told us that in the event a staff member

did not improve they followed the trust’s disciplinary processes.





care. Specialist gynaecology teams worked with consultant teams from other NHS trust to provide

care to patients with gynaecological cancers. This included consultants, specialist nurses,

administration staff and other support staff such as radiologists and radiographers. Staff attended

multidisciplinary team meetings to discuss patients and plan their care. Staff reviewed patients’

lengths of stay and estimated/actual discharge dates and plans of care on a regular basis, to

facilitate timely discharges.

We observed the team’s interactions, they appeared cohesive and respectful of each other’s roles.

The patients were referred to by name and in a professional and respectful manner. Consultants,

junior doctors and nurses discussed patients during board rounds on Gosfield ward every

morning. They shared important information about their patients in order to plan the care in

hospital and forward plan patient discharges.


patients. Gynaecology staff worked with staff from other disciplines such as pain specialists,

oncology services and allied health professionals. The service had links with external

organisations such as local authority safeguarding boards, sexual assault referral centres and

general practitioners (GP). Staff worked well together to provide the best outcomes for their

patients.

Staff referred patients for mental health assessments when they showed signs of mental ill health

or depression. Staff referred patients to local mental health services if they identified signs of

mental ill health. Gynaecology also had access to a range specialist counselling services such as

pregnancy loss, or cancer.

Seven-day services


Consultants led daily ward rounds on all wards, including weekends. The service had eight

obstetrics and gynaecology consultants who worked across both gynaecology and maternity. The

consultants led daily ward rounds across both services. Consultants were on the hospital site at

weekends to complete patient reviews.


diagnostic tests, 24 hours a day, seven days a week. The trust had 24-hour access to diagnostic

tests such as such as blood testing, x-ray, CT and MRI scanning. Staff could gain support for their

patients with deteriorating mental health provided by a local mental health NHS trust.

Operating theatres had processes in place for the provision of emergency procedures 24 hours a

day, seven days a week which included at least one full theatre team.


The gynaecology management team had plans in place increase the provision of ultrasound

scanning as this service was only offered from Monday to Friday. The first group of Gosfield ward

nurses were due to start an external ultrasound scanning qualification in January 2020.

Pharmacy staff attended Gosfield ward twice a week to monitor medicine stock levels. The

inpatient pharmacy opened from 8am to 5:15pm Monday to Friday. On Saturdays, Sundays and

bank holidays the pharmacy was open from 10am to 4pm. Staff had access to an on-call

pharmacist outside of these hours for support and the supply of specialist medicines.

Health promotion


The service had relevant information promoting healthy lifestyles and support on wards/units. We

observed information leaflets about procedures such as cervical screening and colposcopies. Staff

within the service also promoted smoking cessation with their patients.


to live a healthier lifestyle. Nurses, doctors and allied health professional provided patients and

their families with information and support to manage their health at home, this included self-care

during and after gynaecological surgery and cancer treatment. Patients had access to various

information leaflets that enabled them to be actively involved in the surgical recovery phase.

Colposcopy staff we spoke with told us that they educated patients that attended colposcopy

appointments to provide reassurance. Often patients were anxious about the procedure, staff

counselled patients about the procedure and what to expect.





The trust had a consent to treatment policy in place which described the definition of consent,

when consent should be obtained and the principles of the mental capacity act. The policy was

within the review date and referenced legislation and national guidance.



and 2004 and they knew who to contact for advice. Staff had a comprehensive knowledge of the

consent process for different patient groups. Staff completed training in Gillick competence and

Frasier guidelines, they knew how to apply them in their work. Staff could gain support from

specialist nurses and the safeguarding team if they had concerns about a patient’s ability to give

their consent.


guidance. Staff gained written consent for all invasive procedures in line with legislation and local

policy. In the pre-assessment clinic we observed a clinician obtain consent from patients. The

process was thorough, the patients were given plenty of time to ask questions. Ward staff gained

verbal or implied consent from patients before they provided care such blood pressure and

temperature checks.


Staff clearly recorded consent in the patients’ records. We reviewed 12 patient records and in all of

the records staff had correctly completed patient consent forms.

Staff made sure patients consented to treatment based on all the information available. Completed

consent forms we reviewed included information about known complications for the planned

procedures.


Act and Deprivation of Liberty Safeguards. The Mental Capacity Act 2005 is designed to protect

and empower people who may lack the mental capacity to make their own decisions about their

care and treatment. It applies to people aged 16 and over. Staff we spoke with demonstrated a

good understanding of the Mental Capacity Act and Deprivation of Liberty Safeguard

requirements. Staff we spoke with told us that they would complete a mental capacity assessment

for patients with a diagnosis of dementia who were unable to consent to a treatment plan.

Although gynaecology services did not regularly see patients living with dementia due to the

nature of the service. Staff knew that perceived poor decisions did not mean a patient lacked

capacity.

Nursing staff received and kept up to date with training in the Mental Capacity Act and Deprivation

of Liberty Safeguards. The table below shows that the completion rate for Mental Capacity Act and

Deprivation of Liberty Safeguards training was above the trust’s target of 95%. Medical staff had

not completed this training in line with the trust’s target.



stated that Deprivation of Liberty Safeguarding (DoLS) training is included in the MCA training

module.


They only provided training data for maternity services based at Broomfield Hospital.

Broomfield Hospital


nursing and medical staff in gynaecology at Broomfield Hospital is shown below:


Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)

Nursing and midwifery registered 10 10 100.0% 95% Yes Medical and dental 18 21 85.7% 95% No

In gynaecology, the 95% trust target was met for the MCA/DoLS module by qualified nurses but

not met for medical staff as of August 2019.



Compassionate care





patients and those close to them in a respectful and considerate way. Staff demonstrated caring,

respectful and supportive relationships with their patients and those close to them. We observed

staff delivering care to patients on Gosfield ward, outpatients and during their pre-assessment

appointments. Staff interactions with patients were professional, friendly, and kind. Staff

demonstrated an understanding of the importance of treating patients, and those who were

important to them, in a caring and sensitive manner.

Staff followed policy to keep patient care and treatment confidential. Staff treated patients with

privacy, respect, and dignity by closing curtains in ward bays and doors of side rooms whilst

administering physical and or intimate care. We saw staff maintained patient privacy and dignity in

the gynaecology treatment centre where patients had a separate changing area linked to the main

treatment room. All of the treatment rooms had curtains around doors to maintain patient privacy.


how they may relate to care needs. Staff asked patients about their spiritual or religious

preferences on admission and this information was used to support patients to receive visits from

the chaplaincy team if this was their wish. Staff tailored care to meet patients personal, cultural,

social needs and respected their beliefs. Staff ensured they recorded information about patients

such as if they were vegetarian or vegan to ensure they had appropriate menu choices and

products derived from animals were not used in their care.

Patients said staff treated them well and with kindness. All of the staff we spoke with took pride in

their work and were committed to providing the best care they could to their patients. We spoke

with five patients and two relatives who told us they would recommend the service to others.

Patients felt the staff cared about them, had been very kind and attended to their needs in a timely

way. They said, “Staff are fantastic” and “Nurses are lovely”.

The service had a varied response from patients who completed the friends and family test from

October 2018 to September 2019. The percentage of patients that said they would recommend

Gosfield ward to their friends and family scored from 76% to 100%.

Emotional support


They understood patients’ personal, cultural and religious needs.

The trust had a chaplaincy service in place to support patients and those close to them. A team of

trust chaplains and volunteer chaplains delivered spiritual and religious care during daily ward

rounds or following referrals from patients, relatives, staff and community faith leaders.

The trust’s multifaith centre provided resources for those of all faiths for meditation or simply a

quiet space to sit.

The trust had a service level agreement with a mental health service to provide a psychiatric

liaison service to patients when the need for additional support was identified.


it. The service had staff with additional counselling skills to provide emotional support to patients.

Four nurses who worked within the gynaecology service had completed additional training in

counselling skills. Staff had additional skills to support patients in areas such as pregnancy loss

and gynaecological cancer support.



maintain their privacy and dignity. Staff had access to quiet rooms where they could comfort

women and their families when they received distressing news. Staff we spoke with demonstrated

empathy about the importance of supporting patients in a way that maintained their privacy and

dignity both on Gosfield ward and in outpatient clinics.


conversations. Managers had implemented training for nursing staff in breaking bad news for

nursing staff within gynaecology. Managers we spoke with told us they had plans to roll out the

training to medical staff and emergency departments staff as many women who experienced

pregnancy loss presented in the emergency department. Staff spoke compassionately about

patients they had supported emotionally. Two members of staff gave an example of care and

support they had provided to a patient and their family at the end of their life.


on their wellbeing and on those close to them. Staff we spoke with understood the emotional

impact of diagnosis’ and treatments had on patients and those close to them. Staff could signpost

patients and their families to specialist counselling and support services especially in cases of

pregnancy loss and cancer diagnosis and treatment.




Staff made sure patients and those close to them understood their care and treatment. We

observed staff explaining treatments and discharge arrangements with patients. Staff answered

patients’ questions in a way they understood.

Staff talked with patients, families and carers in a way they could understand. We observed staff

used language that patients understood and gave patients time to ask questions if they were

unsure about anything. In gynaecology treatment centre and the pre-assessment department staff

asked patients if they had any questions about their care and treatment, they answered patient

questions and provided reassurance about any concerns for fears raised.


supported them to do this. Where patients or their families raised concerns, staff took time to listen

to the concerns and resolve any issues at the earliest opportunity. Staff we spoke with felt

empowered and able to act on concerns or escalate these to a senior member of the team to

resolve these at the earliest opportunity.

Staff supported patients to make advanced decisions about their care. Specialist gynaecology

oncology nurses coordinated care for patients with a cancer diagnosis and supported patients to

make decisions related to their care. Staff supported patients to make decision about care at the

end of their life.

Staff supported patients to make informed decisions about their care. All patients we spoke with

told us staff had provided information about their care and treatment, so they could make

decisions. Patients felt they had input into decisions about their care and treatment. We observed

that pre-assessment staff prepared patients well for their admission and gynaecological

procedure.


Staff could give examples of how they used patient feedback to improve daily practice. Managers

had provided training in counselling skills following feedback from patients. Staff we spoke with

found the training had helped them to hold difficult conversations with patients and their families.





to plan care.

Managers planned and organised services so they met the changing needs of the local population.

The trust had plans to merge with two other local NHS trust in April 2020. Managers from both

trusts were in the process of mapping services across both trusts in preparation for the merger.

The trust worked closely with other providers within the sustainability and transformation

partnership.


service was developing an outpatient endometrial ablation clinic to reduce the pressure on

inpatient services. The trust was also in the final phase of implementing manual vacuum aspiration

procedures in outpatient settings to minimise delays in patient care, reduce pressure on theatre

capacity and improve patient experience.

Facilities and premises were appropriate for the services being delivered. The ward, outpatient

clinics, the gynaecology treatment centre and theatres were well equipped and complied with

department of health guidelines. The layout of all clinical areas meant that all areas were

accessible for people using a wheelchair or walking aids.

Staff could access emergency mental health support 24 hours a day, 7 days a week for patients

with mental health problems, learning disabilities and dementia. The trust worked closely with the

local mental health NHS trust in the provision of mental health assessments and treatments that

patients required while they were in hospital. Staff had access to mental health support for their

patients 24 hours a day either face-to-face of by telephone out of hours.


intervention. The gynaecology service worked closely with local termination of pregnancy

providers. The service had arrangements in place to treat women with complex termination of

pregnancy needs and accepted referrals from local providers to meet the needs of women.

The service worked with local NHS trust in the provision of gynaecological cancer services. The

service worked within the local cancer multidisciplinary network to assess and plan cancer care for

women based on their individual needs and preferences.

Managers monitored and took action to minimise missed appointments. The service used a text

message reminder service for all hospital appointments. The trust sent patient’s a text message

two days before their appointment with information about how to cancel an appointment if they

were unable to attend.

Managers ensured that patients who did not attend appointments were contacted. Managers we

spoke with told us that gynaecology staff contacted patients that did not attend their appointments,

however, this was rare. They told us that the service also advised the patient’s general practitioner

(GP) if they did not attend their appointment.







received the necessary care to meet all their needs. The trust had dementia and delirium nurse

specialist in post to support staff to meet the needs of patients living with dementia. The electronic

patient records system had flags for staff to easily identify patients living with dementia, learning

disabilities and mental health diagnosis. The flags provided staff with information about individual

patients with cognitive impairment, which prompted staff that reasonable adjustments may be

required.

The service did not routinely care for patients living with dementia due to the age of the women

that used the service. Staff knew how to support patients living with mental health problems,

dementia and learning disabilities. Staff we spoke with knew how to gain support from specialist

teams to make adjustments to meet the complex needs of their patients.


patients with a disability or sensory loss. Patients with a diagnosis of dementia were assessed

using tools like the 'This is me' document to personalise and individualise care. Staff we spoke

with knew about the personalised care document, although they did not routinely care for patients

with complex needs.


community. Staff had access to information leaflets in different languages, provided by third-party

provider through a service level agreement. They printed leaflets in different languages when they

needed them.


signers when needed. Staff had access to full translation services provided by third-party provider

through a service level agreement with the trust. This service included full translation and

interpreting services including face to face, spoken, written, Braille and sign language. Contact

information was on display in the consulting rooms and available on the staff intranet site.

Gynaecology patients could choose Gosfield ward to provide their end of life care. Staff we spoke

with told us that patients had chosen to be on the ward at the end of their lives because of the

relationships they had built with patients. Staff coordinated end of life care with oncologists, the

pain team and specialist nurses.

The Gosfield ward manager had contributed within the working group that produced the disposal

of fetal remains and other human tissue policy. The policy provided women and their families

choice about what happened to pregnancy loss remains. This meant that women and their families

could arrange cremations and memorial services following pregnancy loss.

The gynaecology service followed up all women after third and fourth degree vaginal tears during

child birth in the perianal assessment clinic. Consultant gynaecologist and urogynaecology

specialists reviewed women in a specialist clinic following vaginal tears to monitor healing and any

complications.



Patients had access to a range of menu choices which met their religious and cultural beliefs. Staff

understood and respected the beliefs of their patients and ensured they had access to food and

drink which supported their beliefs.

Access and flow

We could not assess if people could access the service when they needed it and received

the right care promptly. The trust had suspended the reporting of waiting times from

referral to treatment and arrangements to admit, treat.
















Patients did not always receive treatment within agreed timeframes and national targets.

Managers provided information regarding the national two week and 62 day referral to treatment

targets. The service did not consistently meet the national referral to treatment target within 62

days for suspected gynaecology cancers. Although the trust consistently met the two week urgent

referral target from November 2018 to September 2019.

The percentage of people seen by a specialist within 62 days of an urgent GP referral from

November 2018 to September 2019 ranged from 0% (in January 2019 and March 2019) to 100%

(in November 2018, February 2019 and August 2019). The trust met the 85% operational standard

in five of the 11 months.


Cancer waiting times – Percentage of people seen by a specialist within 62 days of an

urgent GP referral (suspected gynaecological cancers)

The percentage of people seen by a specialist within two weeks of an urgent GP referral for

gynaecological cancer from November 2018 to September 2019 ranged from 91.3% (in the most

recent month, September 2019) to 99.1% (in February 2019). The trust met the 93% operational

standard in nine of the 11 months.

Cancer waiting times – Percentage of people seen by a specialist within 2 weeks of an

urgent GP referral (suspected gynaecological cancers)

(Source: Trust inspection data requests DR174 DR175)


Following the agreement of the board, a programme of work was established, with a dedicated

programme management team, reporting through the services elective care group (ECG) as a sub

group of the senior management group (SMG). Key workstreams included validation, data quality,

training, demand and capacity. The implementation of the programme was supported by a

dedicated resource from the NHS Improvement elective intensive support Team (IST).

Gynaecology managers internally monitored RTT rates for routines referrals and urgent referrals.

Senior managers monitored the number of patients seen in each clinic to ensure the referral

booking management centre (RBMC) team booked procedures for patients or discharged patients

after their attendance. Outpatient administration staff booked follow up clinic appointments and

ward administration staff booked follow up appointments for patients as part of the discharge

process. Managers we spoke with told us that this this process reduced the risk that patients were

not followed up (lost to follow up).

Senior managers for the trust monitored patients who were overdue for their follow-up

appointment every weekly.


The trust was unable to accurately record and submit data to NHS England on its referral to

treatment time (RTT) for admitted pathways. The trust outlined a number of local controls in place

to tackle this issue.


Referral to treatment (percentage within 18 weeks) – non-admitted performance


treatment time (RTT) for non-admitted pathways. The trust outlined a number of local controls in

place to tackle this issue.


The service had plans to implement nurse led services for hysteroscopy procedures and early

pregnancy unit care in 2020. Managers we spoke with told us the implementation of these

services would reduce the pressure on inpatient services and increase capacity for elective

procedures.

Managers monitored waiting times and made sure patients could access emergency services

when needed and received treatment within agreed timeframes and national targets. Patients with

emergency gynaecology conditions either presented to the trust’s emergency department or a

direct referral from their GP. Gosfield ward had four trolleys in the gynaecology assessment unit

where medical staff made clinical decisions about whether patients required admission to the ward

or could be safely followed up as outpatients. The service had emergency admission pathways in

place such as the per vaginal bleeding pathway.

Managers worked to minimise the number of gynaecology patients on non-gynaecology wards.

The Gosfield ward manager and the matron for Gynaecology told us that patients sometimes went

to the surgical assessment ward during emergency admissions. If a patient was found to have a

gynaecology diagnosis, they were moved to Gosfield ward. The trust did not have gynaecology

patients on non-gynaecology wards during our inspection.

Information provided by the trust prior to our inspection showed that gynaecology did not move

ward at night from August 2018 to July 2019.


Managers and staff worked to make sure patients did not stay longer than they needed to. Staff

reported delays to patient discharges through the trust’s electronic incident reporting system.

Managers we spoke with told us that discharge delays were infrequent.


Staff started discharge plans either in pre-assessment appointments or on the day of admission

for patients that were admitted in an emergency. Records we reviewed evidenced discharge plan

development at the point of admission.

Managers made sure they had arrangements for Gynaecology staff to review any gynaecology

patients on non-gynaecological wards. Gynaecology teams reviewed patients in the emergency

department or on the surgical assessment unit when patients were diagnosed with a

gynaecological disorder. Staff arranged for gynaecology patients to be moved to Gosfield ward.

Managers worked to keep the number of cancelled appointments, treatments and operations to a

minimum. Managers we spoke with told us that the waiting list team booked all patients that

required planned procedures and allocated dates for clinic appointments or admissions. The

waiting list team and consultants discussed any cancellations and the waiting list team

communicated any decisions about cancelled procedures.





Patients, relatives and carers knew how to complain or raise concerns. Patients we spoke with told

us they knew to discuss their concerns with a member of staff or contact the complaints team.

The service clearly displayed information about how to raise a concern in patient areas. We saw

that information leaflets about complaints were readily available in all the areas we visited. The

leaflets provided information about how patients could make a complaint and information about the

patient advocacy and liaison service (PALS).

Staff understood the policy on complaints and knew how to handle them. Staff we spoke with

understood their responsibilities in handling complaints. Staff told us they listened to patient

concerns and would address issues immediately. They also told us that they escalated any issues

they could not address to their manager.

Managers investigated complaints and identified themes. The gynaecology matron attended the

monthly divisional governance meetings where managers discussed complaints and any theme

identified from complaints. The main theme of complaints was staff communication. The service

had taken steps to improve communication between staff and patients. The service had provided

training in sensitively breaking bad news for nursing staff. The service planned to extend this

training to medical staff.


Broomfield Hospital

From August 2018 to July 2019, the trust received 27 complaints in relation to gynaecology at

Broomfield Hospital (4.5% of the total complaints received by the trust). The trust took an average

of 26.6 days to investigate and close complaints. This was not in line with their complaints policy,

which states complaints should be completed within 25 working days



Type of complaint Number of complaints Percentage of total Clinical treatment - obstetrics and gynaecology 24 88.9% Facilities services (including; access for people with a disability, cleanliness, food, parking, maintenance and portering)

1 3.7%

Communications 1 3.7% Clinical treatment - surgical group 1 3.7% Total 27 100.0%



Broomfield Hospital

From August 2018 to July 2019 there were 21 compliments received for gynaecology at

Broomfield Hospital (1.9% of all compliments received trust wide). Over half (52.4%) of the

compliments received for gynaecology at Broomfield Hospital related to the gynaecology

outpatients department.

A breakdown of compliments by department at Broomfield Hospital is shown below:

Department Number of compliments Percentage of total Gynaecology outpatients 11 52.4% Gosfield ward 8 38.1% Gynaecology surgery 2 9.5% Total 21 100.0%




consultants.


patient and carer experience group and also with individuals and their managers during appraisal.

The trust used its Datix system to analyse themes from compliments.



the investigation into their complaint. We reviewed two complaints investigation reports and the

response letters. In both cases the trust apologised about the circumstance of the complaint.

Response letters sent by managers to patients following a complaint evidenced that the patients

had been involved in the complaints process.


service. The ward manager from Gosfield ward used anonymised complaints for role play learning

on team meeting days. The manager told us that the aim of this learning was to encourage staff to

view events from a patient’s perspective.

Staff we spoke with gave examples of changes to ward processes which were developed following

patient complaints. Staff checked each bed space for hazards following a patient discharge, this


included checks to ensure there were no sharp objects on the floor. Another initiative introduced

was staff training in breaking bad news.


Leadership

Leaders had the skills and abilities to run the service. They understood and managed the

priorities and issues the service faced. They were visible and approachable in the service

for patients and staff. They supported staff to develop their skills and take on more senior

roles.

The service was within the division for women and children which had changes within the

leadership team since February 2019. The service had appointed a new matron in February 2019

and the head of midwifery in September 2019.

The senior leaders for the service knew their strengths and challenges in relation to service

demands, resources and the provision of safe good quality care. Leaders had clearly defined

plans for service improvement and succession planning. Gosfield ward had succession plans in

place for the development of future leaders.

The service had a dedicated and proactive ward manager and matron that supported the service

leadership team. Staff we spoke with praised their managers and felt they were supported well.

Each manager was fully versed in the challenges and areas of good practice in their individual

areas and committed to making positive change. Staff stated that they felt valued and supported in

their role.

We observed strong leadership at a local level staff praised their local managers and said they

supported them and communicated with them regularly. Staff we spoke with told us the matron for

the service was routinely visible and approachable.

Vision and strategy





The trust had a vision to be a healthcare organisation that puts patients care first and whose

reputation for excellence and innovation inspires, patients, staff and the population they served.

The trust had four strategic objectives in place to achieve their vision.

• Deliver clinical and service excellence

• Maintain business excellence

• Build effective relationships

• Develop high quality leadership

The trust’s overarching plan was to merge with another local NHS trust, within the sustainability

and transformation partnership. The merger was planned for April 2020, where Broomfield hospital

was identified as the hospital site to manage surgical procedures within the partnership.


The service had a vision to expand nurse led pathways for the early pregnancy unit and

hysteroscopy. The leadership team aimed to free consultant capacity to meet referral to treatment

times. Managers of the service had implemented training programmes for staff, this included

nationally recognised external courses in specialist skills such as ultrasound sonography.

The service strategy aligned with the trust’s strategy for the recruitment and retention of staff as

managers had provided opportunities to develop a more diverse skill set and further career

progression within the speciality.

The trust had a shared set of staff values. All staff we spoke knew the trust’s values of ‘we are

kind, professional, positive team’.

Culture


receiving care. The service promoted equality and diversity in daily work and provided

opportunities for career development. The service had an open culture where patients, their

families and staff could raise concerns without fear.

Staff reported an open and honest culture and said they felt able to raise any concerns with their

managers. All staff we spoke with confirmed that the needs and experience of their patients was at

the centre of the service. Staff told us they could raise concerns without fear or reprimand and

they were confident action would be taken as a result.

Staff had access to independent freedom to speak up guardians to express any concerns outside

of their immediate teams if they needed to.

Staff we spoke with told us morale was good and staff we spoke with confirmed they felt valued

and well supported by colleagues and managers within their roles. Managers praised staff for their

commitment and team working to meet the needs of patients and the service.

The trust had an active programme of recognition and reward for staff including Star of the Month

and the annual OSCARS.

The trust had the rainbow badge scheme in place to promote inclusion and equity.

Governance




The service set out clear roles, responsibilities, and systems of accountability to support the

governance and management of the service. Staff we spoke with described the service’s

management and governance structure and their specific roles and responsibilities.

The service had data collection processes, which provided the management team with service

level assurance. The gynaecology governance committee was responsible for reviewing clinical

governance information from audits, and safety and quality improvement initiatives. The

gynaecology governance committee reported into their divisional board chaired by the divisional

director. Senior managers discussed the overarching finance, performance, quality and workforce

issues for their division.


The divisional board reported to performance, safety and quality reports to the trust board through

sub committees such as performance and accountability meetings, risk and compliance committee

and patient experience committee.

Managers we spoke with told us, there were additional specialty governance meetings across the

division and organisation which provided opportunities for shared learning including the mortality

and morbidity meetings and local audit meetings.

Ward managers for the whole trust met monthly to discuss incidents, learning, key messages and

audit results. This provided peer support and networking opportunities for ward managers.

The Gosfield ward manager shared key messages and safety updates during daily safety briefings

with staff. The briefing sheet was updated weekly to ensure all staff were updated and did not miss

key information. All ward staff were expected to attend ward meetings and update days every two

months. Gosfield had monthly team meetings, the ward Manager had allocated staff into two

teams which attended ward meeting on alternate months. This way of working ensured all staff

had the opportunity to attend the meetings and clinical supervision sessions.


Leaders and teams used systems to manage performance effectively. They identified and

escalated relevant risks and issues and identified actions to reduce their impact. They had

plans to cope with unexpected events. Staff contributed to decision-making to help avoid

financial pressures compromising the quality of care.

The service had clear processes for managing risks issues and performance. The service had an

electronic risk register linked to the incident reporting system. The trust used risk registers based

on the potential consequence of the risk and the likelihood of the risk happening again. The trust

used a red, amber, green risk rating system, to denote the extreme, high, medium and low risk.

Each risk had a rating on entry to the register and a rating once mitigations were in place. All risks

had a review date, a named owner, and an action plan.

The gynaecology service had three risks on their risk register. Each risk entry had a clear

description of the risk and mitigation in place to reduce the impact of the identified risk. There were

regular updates added to the risk register by the risk owner. The service had one risk rated as high

for ultrasound scanning which were not available in the early pregnancy unit on Saturday and

Sunday. Managers had plans in place to mitigate this risk with ultrasound sonography training

secured for nursing staff.

Service leads had identified that colposcopy referral to treatment (RTT) rates were not in line with

national targets due to a high demand for the procedure. They acknowledged that changes to the

cervical screening process had increased urgent referral rates. Managers had implemented extra

clinics to meet the additional demand. Divisional board meeting minutes noted that the trust

performed better than the other trusts in the RTT despite not meeting the national target.

Managers had not included external RTT reporting on the service risk register. However this was

on the trust’s risk register.

Gynaecology service risks were on the women and children’s divisional risk register. Senior

managers discussed the divisional risks within the divisional risk register review meeting. We

reviewed the divisional risk register review action log from October 2019 which evidenced all risks

were reviewed and discussed. The action log also evidenced that risk closed appropriately, for


example, managers had closed the risk for Gosfield ward staffing as the ward was fully

established.

Wards and clinical areas did not hold an individual risk register, all risks were held on a service

wide risk register. Ward managers took ownership of risks directly related to their area of

responsibility, they monitored risks and discussed risk mitigation actions taken with their

managers.

Managers made sure staff knew the risks for the gynaecology service. We saw posters displayed

in staff rooms in all clinical areas we visited. The poster’s provided information about the top three

risks and what action managers had taken to reduce the impact of the risk. Managers we spoke

with told us that it was important that staff knew and understood the service risks, to encourage

team ownership and team working to address the risks.

The division board monitored the performance of the service against key local safety and quality

safety measures. We reviewed the division board meeting minutes from July 2019 to October

2019 which showed managers had discussed areas such as staffing, mandatory training

compliance and incidents. The gynaecology service had a risk summit in September 2019 which

identified areas for improvement within the service. Managers had action plans in place to address

issues identified such as the availability of ultrasound scans at weekend in the early pregnancy

unit staff recruitment.




The information systems were integrated and secure. Although the trust did not submit

data against national treatment targets.






Staff across the trust accessed information from the trust intranet which included policies and

national guidance. Staff knew how to access information through the intranet in each of the areas

we visited.

The service used both paper and electronic patient records. Care planning, records of care and

medicine prescriptions were hand written in paper records, the patient admission discharge

system were electronic. Staff had access to up-to-date, accurate, and comprehensive information

about their patients’ care and treatment. They knew how to use and store confidential information.

Staff kept paper records in locked trolleys within staff areas, to prevent visitor and members of the

public access to confidential information. Electronic records were secured through individual login

and passwords.

The service had arrangements in place which ensured data was submitted to external

organisations as required for example, serious incidents and never events.

Engagement





Staff had opportunities to engage at work through a range of team meetings and wider trust wide

meetings. The senior leadership team for the trust held daily ‘Moving Forward @ Mid’ meetings to

update staff with what was happening within the trust. Staff could attend these meetings from

Monday to Friday which brought corporate, clinical and non-clinical staff together.

Managers shared information about service performance on wall displays in the staff rooms of all

clinical areas we visited. Staff also received key messages and safety updates during the daily

safety briefing on Gosfield ward.

The trust participated in the NHS staff survey. The 2018 staff survey showed 67% of staff felt

supported by their immediate manager and 67% of staff felt managers were invested in their

health and wellbeing, and the hospital took positive action in this area.

Divisional managers had regular engagement with other stakeholders in the local sustainability

and transformation partnership. Stakeholders included service commissioners, partner

organisations such as termination pregnancy services, community services and GPs, who worked

collaborative to provide patient care.

The service actively sought feedback from their patients to improve the quality and safety of care

provided. Patients could provide their feedback through the NHS friends and family test or through

the patient advocacy and liaison service. Managers used feedback during clinical supervision

sessions for staff learning.

Gynaecology services had links with patient support services such as counselling and support

groups for both patients and their relatives.





The service had undertaken a risk summit of gynaecology services to identify areas of the service

which required improvement in service provision and delivery. The service leads had actions in

place to improve these areas of the service.

The ward manager on Gosfield ward had developed monthly team meeting and clinical

supervision shifts. The ward had two teams which alternated so that all staff attended a team

meeting shift every two months. The organisation of this style of team meetings had improved staff

compliance with mandatory training, clinical supervision and enabled managers to complete staff

appraisals.

Gynaecology had a nurse-led colposcopy service and had plans to increase nurse-led pathways to

include hysteroscopy and the early pregnancy unit. Managers had booked specialist training

courses for staff in specialist skill such as ultrasound sonography.


Outpatients


Outpatient services at Mid Essex Hospital Services NHS Trust cover multiple sites including:

Broomfield Hospital, St Peter’s Hospital, St Michael’s Hospital and Braintree Community Hospital.

The main outpatient area of Broomfield Hospital is located in the atrium. This was purpose-built

and opened in 2010 with interactive self check-in kiosks throughout and a co-located pharmacy.

There is also an information pod which opened in 2013 for cancer and other life limiting illnesses.

This is delivered in collaboration with Macmillan and Farleigh Hospice.

The remainder of the outpatient services are located in the older part of the building. The trust

covers a wide range of specialities such as ophthalmology, musculoskeletal, surgical and medical,

in addition to the St Andrew’s burns and plastics regional unit at Broomfield hospital.

The trust had over 600,000 outpatient attendances from April 2018 to March 2019, with the

majority undertaken at the Broomfield Hospital site. Outpatient appointments are available Monday

to Friday between 8.30am and 5.00pm with regular evening and weekend clinics.

The trust is delivering a transformation programme to streamline patient pathways, reduce the

number of follow-up appointments and improve the patient experience.


During our inspection, we visited the outpatient department located at Broomfield Hospital. We

inspected and observed areas across main outpatients including; gynaecology, ophthalmology,

ear, nose and throat (ENT), phlebotomy, booking team and the St Andrews burns and plastics

centre.

In addition to consultant-led clinics, there are nurse-led clinics across a range of specialities. We

spoke with patients, relatives, and members of staff. During our inspection we spoke with 32

members of staff including; nurses, healthcare assistants, receptionist staff, medical staff, service

managers, bookings team administration assistants, and directors of nursing.

We observed interactions between patients and staff and considered the environment. We also

reviewed national data and performance information about the trust, and a range of policies,

procedures and other documents relating to the operation of the outpatient department.

The service was last inspected in September 2018, where safe, responsive and well-led were

rated as requires improvement and caring was rated as good. We do not rate effective for

outpatients. This led to an overall rating of requires improvement.

Total number of first and follow up appointments compared to England

The trust had 528,816 first and follow up outpatient appointments from March 2018 to February

2019. The graph below represents how this compares to other trusts.


(Source: Hospital Episode Statistics - HES Outpatients)

Number of appointments by site

The following table shows the number of outpatient appointments by site, a total for the trust and

the total for England, from March 2018 to February 2019.

Site Name Number of spells

Broomfield Hospital 580,200

Braintree Community Hospital 25,558 St Peter's Hospital 23,463 William Julien Courtauld Hospital (St Michael’s Hospital) 16,051 Other locations 22,324 This Trust 667,596 England 109,324,322


Type of appointments

The chart below shows the percentage breakdown of the type of outpatient appointments from

March 2018 to February 2019.


Number of appointments at Mid Essex Hospital Services NHS Trust from March 2018 to

February 2019 by site and type of appointment.

Note: William Julien Courtauld Hospital is also known as St Michael’s Hospital.






Mandatory training


completed it.




Broomfield Hospital


staff in outpatient services at Broomfield Hospital is shown below:


Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)

Adult immediate life support 5 5 100.0% 85% Yes

Equality and diversity 43 43 100.0% 85% Yes



Medicine management training 40 40 100.0% 85% Yes

Paediatric basic life support 1 1 100.0% 85% Yes



Information governance 42 43 97.7% 95% Yes

Moving and handling 41 43 95.3% 85% Yes

Moving and handling for people handlers 34 36 94.4% 85% Yes

Fire safety 38 43 88.4% 85% Yes

Adult basic life support 31 36 86.1% 85% Yes

In outpatient services at Broomfield Hospital, the targets were met for all 12 of the mandatory

training modules for which qualified nursing staff were eligible.

The mandatory training was comprehensive and met the needs of patients and staff. Training was

delivered both electronically and face to face.


training. In addition, all staff received e-mail reminders and were given time to complete training.

Senior managers we spoke with were aware of individual staff members who were required to

complete mandatory training and told us time would be allocated for completion on return from

sick or maternity leave.


During the inspection, leaders of the outpatient department (OPD) told us that all medical staff

working in outpatients were assigned to the specific specialities and not OPD. Therefore, there

were no applicable medical staff within outpatients at Broomfield Hospital who completed

mandatory training from July 2018 to August 2019.

Safeguarding


agencies to do so. Staff had training on how to recognise and report abuse and they knew

how to apply it.


The trust set a target of 95% for the completion of safeguarding modules, with the exception

of safeguarding children (level 3) which had a target of 60%.

The tables below include prevent training as a safeguarding course. Prevent works to

stop individuals from getting involved in or supporting terrorism or extremist activity. The trust set a


Broomfield Hospital


nursing staff in outpatient services at Broomfield Hospital is shown below:


Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)


Safeguarding adults (level 1) 43 43 100.0% 95% Yes

Safeguarding adults (level 2) 43 43 100.0% 95% Yes





In outpatient services the targets were met for all six safeguarding training modules for which






safeguarding training from July 2018 to August 2019.

Outpatient department staff received training on level 1 and level 2 safeguarding modules,

however this did not meet recommendations of the Safeguarding Children and Young People:

Roles and Competencies for Healthcare Staff Fourth edition: January 2019 Intercollegiate

document which states that all clinical staff working with children, young people and/or their

parents/carers and/or must be trained to level three.

We raised this during our inspection with department senior staff who were reviewing children

safeguarding training trust wide.

Safeguarding policies and procedures were available for staff to access electronically and we saw

posters in place across the outpatient departments, providing information on who to contact, staff

responsibilities and a flowchart detailing safeguarding principles.

Staff we spoke with knew how to make a safeguarding referral and who to inform if they had

concerns. The names and contact details of the safeguarding team were displayed in the staff

room and staff confirmed that the safeguarding team were responsive and provided support when

needed.

Staff we spoke to knew how to identify adults and children at risk of, or suffering, significant harm

and worked with other agencies to protect them.

Staff followed safe procedures for children visiting the service /department. The trauma and

orthopaedic outpatients held specific clinics for children twice weekly. Similarly, ophthalmology

had clinics led by a children’s nurse with the level three of safeguarding training.


The service mostly controlled infection risk well. Staff generally kept themselves,

equipment and the premises visibly clean. They used control measures to prevent the

spread of infection.

Most clinical areas were clean and had suitable furnishings which were clean and well-maintained.

Each outpatient area displayed the cleaning schedule for the month on the wall. The schedules

had signatures against the daily cleaning performed. Most areas we visited used ‘I am clean’

stickers to indicate that equipment and rooms had been cleaned. However, in the chemotherapy

day unit staff did not routinely label equipment with ‘I am clean’ stickers. Staff confirmed that they

cleaned equipment after patient contact but did not label equipment to show when it was last

cleaned. This meant it was not clear which pieces of equipment had been cleaned and were ready

for use.


We saw an area used for the lung function test in the main outpatients which was not visibly clean

with the lung function equipment covered in dust. We highlighted this to the staff present and on

our unannounced inspection 20 November 2019 we found the equipment was visibly clean.

In the chemotherapy unit, the area where chemotherapy drugs were prepared appeared to be an

office and storage area and not a formal clinical treatment room. The work surfaces where the

drugs were being prepared were cluttered with consumables and we were concerned regarding

infection prevention control in this area. We escalated our concerns to the senior leadership team.

Hand sanitiser was generally available throughout the departments. We saw posters displaying

the five moments of hand hygiene near handwashing facilities.

Staff used personal protective equipment (PPE). We observed staff were bare below the elbows

and used gloves and aprons where indicated and washed their hands between patient contacts.

All clinic rooms had disposable aprons, gloves in various sizes, hand washing facilities including

filled soap dispensers, paper towels, disposable bed sheets, hand sanitiser, and clinical waste

disposal.

Staff in the ear, nose and throat (ENT) clinics cleaned naso-endoscopes using the three-wipe

system between patients before sending to the decontamination unit at the end of clinics.

Infection prevention and control was monitored by senior staff and the audit results reported

monthly. We viewed the audit reports from January to June 2019 for general outpatients,

ophthalmology and St Andrews burns OPD clinic and saw that the hand hygiene compliance was

100%.


The design, maintenance and use of facilities, premises and equipment did not always keep

people safe. Staff managed clinical waste well.

The outpatient service generally had suitable facilities to meet the needs of patient’s and their

families. The outpatient clinics were well signposted. The majority of clinics took place in the main

outpatients department, some clinics were spread throughout the hospital in different departments.

The chemotherapy day unit had its own reception and waiting area. The treatment area was

designed 10 years ago to treat 14 patients simultaneously, on 12 chairs and two beds. However,

due to high demand for the service, the service now treated 30 patients simultaneously. At the

time of our inspection the treatment room was very busy. There was very limited space between

patients, no screens to maintain patient privacy and dignity and in an emergency, there was

limited space for the emergency trolley. Staff told us in an emergency they would have to move

the patient safely to the middle of the room, and put a screen around the patient. We escalated our

concerns with the overcrowded area with the senior leadership team, they acknowledged the issue

and had already put a protocol in place to ensure patient’s safety, should a patient require

emergency support following a hypersensitivity or anaphylaxis reaction to their treatment.

Each outpatient clinic area had its own reception and waiting area. On occasions some clinic

areas could become overcrowded and did not always have enough space to seat all patients and

their families/carers. During the inspection, we observed the waiting area for the phlebotomy clinic

and the eye clinic were overcrowded during busy periods.

The service had enough suitable equipment to help them to safely care for patients. We saw that

equipment was stored appropriately and neatly. Consumable items, for example, dressings were


stored in cupboards and drawers. We randomly checked a number of consumable items and were

within date. We checked a number of electrical equipment and all had evidence of electrical safety

testing and maintenance testing.

There were processes in place to ensure that equipment was maintained and serviced.

Equipment servicing, and repairs were undertaken by the trust’s clinical engineering department,

who were responsible for monitoring when equipment was due for servicing. Staff could contact

the department to highlight concerns about any items of equipment and told us that they were

responsive.

During our inspection we checked resuscitation equipment in all the outpatient areas we visited.

Resuscitation trolleys or emergency grab bags were easily accessible and locked with anti-tamper

tags. We reviewed resuscitation trolley records and saw that daily checks and weekly checks were

completed from August to November 2019. This showed a consistent and regular approach to

safety checks.

Staff disposed of clinical waste safely. The trust had a waste segregation system in place and we

found separate bins and bags in place throughout outpatient clinics. Staff disposed waste correctly

and followed the trust’s policy. Sharps bins were correctly assembled dated and labelled and not

overfilled. The outpatient departments stored control of substances hazardous to health (COSHH)

materials correctly in locked cupboards which ensured patients and the public could not access

substance.


Staff completed and updated risk assessments for each patient and identified and quickly

acted upon patients at risk of deterioration.

A policy was in place to identify deteriorating patients. Staff we spoke with told us that they

responded promptly a patient suddenly deteriorated. As per trust policy, outpatient staff told us

they would call the trust’s resuscitation team to any patient or relative who collapsed or escort

them to the emergency department if appropriate. Medical staff arranged admission for patients if

required.

Each clinic room had an emergency call bell to summon assistance if needed in an emergency

situation.

Staff completed risk assessments for each patient on arrival where appropriate and used

recognised tools.

Staff were trained to provide life support to patients. This ranged from basic life support and

immediate life support for adults and children, depending upon staff grade. Out of the 36 staff in

the main outpatients 31 (86.1%) had an up to date basic life support training. In addition, five

senior members of staff in the main outpatients had an up to date immediate life support training.

Staff knew how to deal with any specific risk issues. For example, staff told us that if a patient was

known to have an infectious disease, to minimise infection risk to others attending clinic, they

would be treated in a separate room preferably at the end of clinic

Systems and process were in place to ensure patients with urgent clinical needs were seen in a

timely manner. Staff tracked referrals through the electronic patient information management

system. Referrals were triaged by the outpatient appointment booking team and this was overseen

by the outpatient bookings manager.


Staff shared key information to keep patients safe when handing over their care to others. We saw

clinic staff completing routine assessments for patients attending clinics, including blood pressure,

pulse, and weight. Staff reported abnormal results to the consulting clinician, details were also

included in letters sent to the patients GP for monitoring and follow up as required.

A modified ‘World Health Organisation (WHO) five steps to safer surgery checklist’ was used in

the procedure rooms for invasive procedures. We reviewed four checklists used in the eye

treatment unit and two for dermatology procedures, all six checklists were completed appropriately

as per trust policy and procedures. The outpatient service audited the WHO checklists every six

months.

Nurse staffing

The service had enough nursing staff with the right qualifications, skills, training and


treatment. Managers regularly reviewed staffing levels and skill mix, and gave bank and

agency staff a full induction.

Broomfield Hospital

The table below shows a summary of the nursing staffing metrics within outpatient services at

Broomfield Hospital compared to the trust’s targets, where applicable:

Outpatients annual staffing metrics



Staff Group


Annual vacancy

rate

Annual turnover

rate

Annual sickness

rate

Annual bank

hours (% of

available hours)

Annual agency

hours (% of

available hours)

Annual unfilled

hours (% of

available hours)

Target 13% 12% 3.8% All staff 134 19% 5% 5.6% Qualified nurses

45 30% 0% 4.2% 2,457 (3%) 0

(0%) 38,365 (44%)



Nurse staffing rates within outpatient services were analysed for the past 12 months and no

indications of improvement, deterioration or change were identified in monthly rates for turnover.

The trust reported that no agency staff were used in outpatients at Broomfield Hospital from

August 2018 to July 2019.

At the time of inspection, the service leads provided us with updated information regarding

staffing. Qualified nursing establishment was 12.1 whole time equivalent (WTE) and data from

November 2019 showed actual staffing was 9.09 WTE. The vacancy was for band 5 registered

nurses and the OPD matron told us that interviews were scheduled for later on in November.


Therefore, we were assured that the trust was taking the right actions to address the staff vacancy

rate that was reported earlier in the year.

The service had enough nursing staff of all grades to keep patients safe. There are no agreed

national guidelines as to what constitutes ‘safe’ nurse staffing levels in outpatient departments.

Managers calculated and reviewed the number and grade of nurses, healthcare assistants and

nursing apprentices according to the needs of the clinics.

We reviewed staffing rotas and saw that all clinic specialities were covered with the band six and

seven senior nurses stepping in to cover gaps when needed.

In the outpatient clinics nurses, health care assistants and apprentices worked in several different

clinic specialities and were rostered based on their expertise and areas of interest.

Vacancy rates

Monthly vacancy rates over the last 12 months for qualified nurses show an upward shift from



Sickness rates

Monthly sickness rates over the last 12 months for qualified nurses show an upward shift from

January 2019 to June 2019 in line with an upward shift in vacancy rates.



Bank usage

Monthly bank hours over the last 12 months for qualified nurses show an upward shift from

February 2019 to July 2019 in line with upward shifts in vacancy and sickness rates. This could be

an indicator of change.


There was an induction programme in place for all new bank staff. Managers told us bank staff

that worked in the outpatient areas worked regular shifts and were familiar with the processes and

procedures. The outpatient clinic areas did not use agency staff.

Medical staffing


working in outpatients were assigned to the specific specialities and not OPD.

Allied health professional staffing

During the inspection, leaders of the outpatient department (OPD) told us that all allied health

professional staff working in outpatients were assigned to the specific specialities and not OPD.

Records

Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date,


The trust used a combination of electronic and paper patient records. In outpatients staff

completed written notes of consultations on a continuation sheet. Access to the electronic records

system was password protected. Patient information was kept confidential and protected their

privacy.


We reviewed 10 sets of patient records including electronic records and found that the records

were legible, signed and dated. Results from pathology and diagnostic imaging were available

electronically meaning staff could readily access to up to date results.

Staff told us when patients transferred to a new team, there were no delays in accessing their

records.

Medicines


medicines.

Staff in the outpatient clinics stored medicines securely in locked cupboards in key coded locked

clinical rooms. We reviewed two medicines cupboards and had no concerns regarding medicines

storage in these areas. We looked at 15 medicines and saw that they were within their use by

date. Staff consistently recorded maximum / minimum temperatures on medicines fridges and

ambient room temperatures of clinical rooms where medication was stored.

Controlled drugs (CDs) were not stored in outpatient clinics. Controlled drugs are prescription

medicines that are controlled under the Misuse of Drugs legislation (and subsequent

amendments).

The outpatient clinics did not regularly use external (FP10) prescriptions. In exceptional

circumstances when FP10 prescriptions had to be used, the trust had clear processes and

procedures in place. When an FP10 was used the prescription number was recorded and

reconciled in the trust pharmacy. An FP10 is an external green prescription that can be dispensed

by a high street pharmacy as well as the hospital pharmacy.

In the eye clinic, staff used patient group directives (PGDs) for some medications. PGDs provided

a legal framework which allowed some registered health professionals to supply and/or administer

specified medicines, such as painkillers, to a predefined group of patients without them having to

see a doctor. We reviewed the PGDs used in the eye clinic and saw that they were within date and

were signed off by both a doctor and a pharmacist.

Incidents

The service managed patient safety incidents well. Staff recognised incidents and near

misses and reported them appropriately. Managers investigated incidents and shared

lessons learned with the whole team and the wider service. When things went wrong, staff

apologised and gave patients honest information and suitable support. Managers ensured

that actions from patient safety alerts were implemented and monitored.

From June to November 2019, the OPD reported 112 incidents. Of these 15 were recorded as

near miss, eight as low harm and 89 as no harm. The most common reported incident was to do

with administrative/clerical, followed by delay/failure to treatment or procedure and data quality.

Staff reported all incidents that they should report. Staff we spoke with knew what incidents to

report and how to report them on the trust’s electronic reporting system. They gave us examples

of when they had reported incidents and were satisfied that they had a good understanding of

what incidents should be reported and how to report.


Staff understood their responsibility to raise concerns, to record safety incidents, concerns and

near misses.

Outcomes from incidents and associated trends and themes were communicated to staff face to

face by the senior nurses. The outpatient teams held daily safety huddles, learning from incidents

was shared.

All action plans from incidents were monitored through the relevant business unit meetings and

reported to the quality and risk management group.


investigations. We reviewed four recently reported and investigated incidents which showed

detailed description of incident, actions taken and recommendation for lessons learnt.

Staff received feedback from investigation of incidents. Staff told us that they received feedback

after reporting an incident. There were processes to share learning from incidents which included;

staff meetings, emails and notices to ensure that action was taken to improve safety.

Never Events




From August 2018 to August 2019, the trust did not report any never events for outpatient

services.



In accordance with the Serious Incident Framework 2015, the trust reported two serious incidents

(SIs) in outpatient services which met the reporting criteria set by NHS England from August 2018

to August 2019. This represented 1.6% of all serious incidents reported by the trust as a whole.

Both of the incidents occurred at Broomfield Hospital.

One serious incident reported in outpatient services related to a diagnostic incident including delay

meeting SI criteria (including failure to act on test results) and occurred in September 2017. The

other incident which occurred in July 2017 was still pending review at the time of data submission.

(Source: Strategic Executive Information System (STEIS)


families a full explanation when things went wrong. Duty of candour is a regulatory duty under the

Health and Social Care Act (Regulated Activities Regulations) 2014 that relates to openness and

transparency and requires providers of health and social care services to notify patients (or other

relevant persons) of certain ‘notifiable safety incidents’ and provide reasonable support to that

person.







The service followed up to date policies and staff delivered care according to best practice and

national guidance. Staff accessed a range of guidelines through the trust intranet. Staff we spoke

with said that it was easy to access the information.

We reviewed several guidelines and found they followed National Institute for Health and Care

Excellence (NICE) best practice where relevant. For example; breast care services clinical

operational policy, which referred to Improving Outcomes in Breast Cancer –NICE health &

wellbeing guidance (CSG1) and the diabetes care clinical operational policy which referred to the

Type 2 diabetes in adults: management (2015) NICE guideline (NG28).

Staff had access to a range of information which was displayed on staff notice boards in the staff

room and in the sister’s office. For example, in the staff area of the fracture clinic, we saw

information on safeguarding and wound care.

The outpatient department did not have an overall audit plan. However, all clinical services which

provided care in outpatients had their own specialty audit plans.

Staff protected the rights of patients subject to the Mental Health Act and followed the Code of

Practice by ensuring that they had access to services. Staff told us that patients were given extra

time in clinics and referred to other organisations when appropriate for specialist help.


Staff ensured patients who required it had enough food and drink to meet their needs.

Water dispensers were available throughout the outpatient’s departments and were clearly

signposted.

There were shops and café facilities, where patients and visitors could purchase refreshments.

Staff told us they would provide hot drinks and sandwiches to those who had to wait a long time

and had specific nutritional needs such as patients who had diabetes.

Pain relief

Staff assessed and monitored patients to see if they were in pain and gave pain relief in a

timely way. They supported those unable to communicate using suitable assessment tools

and gave additional pain relief to ease pain.

Pain relief was prescribed and used within some of the outpatient departments. In the

ophthalmology and dermatology clinics, staff had access to both oral and local analgesia where

patients were undergoing minor procedures.

In the ophthalmology clinic and fracture clinic (plaster room), during treatment we observed staff

asking patients about their pain and comfort levels. Patients we spoke with raised no concerns

about their pain management during appointments.

Patient outcomes


Staff monitored the effectiveness of care and treatment and reported this in patient

records. There was minimal evidence of staff using the findings to make improvements and

achieve good outcomes for patients.

There were no specific national clinical audits for outpatient services, but within the division staff

contributed to relevant local and national audits and collected information on patient outcomes.

For example, the ophthalmology department took part in the national ‘Patient Reported Outcome

Measures’ (PROMS) ophthalmology audit, the orthopaedic team took part in the ‘National Hip

Fracture’ audit and Joint Registry programme and staff in neurology clinic participated in the

‘National Parkinson's UK’ audit. Further details are reported in the surgery and medicine sections

of this report.

The national clinical audits are used to benchmark the quality of the trust’s services compared with

other NHS trusts, and highlight both best and substandard practices to drive continuous

improvement across services.

Follow-up to new rate

Broomfield Hospital

From March 2018 to February 2019 the follow-up to new rate for Broomfield Hospital was

marginally higher than the England average in all months and followed the same trend.

Follow-up to new rate, Mid Essex Hospital Services NHS Trust.



Competent staff

The service made sure staff were competent for their roles. Managers held supervision

meetings with staff to provide support and development. Although not all nursing staff had

an annual appraisal.



patients. Managers made sure staff received any specialist training for their role and nurses within

the outpatient areas had developed specific competencies. For example; in the dermatology clinic

nurses had undertaken training to remove small lesions.

We spoke with specialist nurses who had their own patient case load and ran their own nurse led

clinics. The specialist nurses told us of the importance of having autonomy in their role and the

ability to manage their own workload.

All staff received an annual appraisal, where they had the opportunity to discuss professional

development. Staff told us they were encouraged to develop professionally and were supported to

attend internal and external training programmes.

Nursing staff told us that they were supported in the process for revalidation. Revalidation is a

process by which nurses demonstrate they have the credibility to remain registered with the

nursing and midwifery council and have the knowledge and skills to continue to practice safely.

The trust also provided newly qualified nurses a preceptorship programme, which offered role

specific training and support.

New staff received a full induction programme which was personalised to their role. We reviewed

an induction pack and saw that it was comprehensive and covered all relevant areas of the

outpatient department. The induction pack also included specific learning and timelines to

complete.

Appraisal rates

Broomfield Hospital

As of August 2019, 64.2% of staff within outpatient services at Broomfield Hospital received an

appraisal compared to a trust target of 90%.

The breakdown by staff group can be found in the table below.

Staff group

As of August 2019


Eligible staff

Completion rate

Trust target

Met (Yes/No)

Healthcare scientists 9 9 100.0% 90% Yes

Administrative and clerical 18 23 78.3% 90% No

Additional professional scientific and technical

4 6 66.7% 90% No


Additional clinical services 27 47 57.4% 90% No

Estates and ancillary 0 1 0.0% 90% No

Total 88 137 64.2% 90% No

Healthcare scientists in outpatient services met the 90% target. Only 58.8% of registered nursing

staff had received an appraisal as of August 2019, however, care should be taken when

interpreting the rates as this data only represents a partial year.


At the time of our inspection, managers told us that 89.5% staff in the main outpatients department

had received an appraisal, this included nursing and administrative staff.


Managers made sure all staff attended team meetings or had access to full minutes when they

could not attend. We saw that team meeting minutes were displayed in the departments for staff to

read.


develop their skills and knowledge.

Staff told us that they had the opportunity to discuss training needs at their appraisals and were

supported by their line manager to develop their skills and knowledge.

Staff received specialist or additional training that was needed for their role. Staff in the

orthopaedic and fracture clinic told us that they received training in wound recognition as they

were often responsible for checking and redressing wounds post-surgery or on removal of plaster

casts.




Staff held regular multidisciplinary meetings to discuss patients and improve their care. Outpatient

teams worked together to plan and deliver care and treatment. Staff in different teams and

services worked together to assess, plan and deliver co-ordinated care.

Staff in the outpatient department told us that specialist nurses attended clinics to support staff

and patients. These included; dementia nurses, breast care nurses and diabetes nurses.

Outpatient clinics were run by multidisciplinary teams (MDTs). We saw nursing staff, healthcare

assistants and doctors working collaboratively in all of the OPD clinics we visited.

We saw in the patient medical records clear evidence of outcomes and decisions from MDT

discussions and staff told us these were shared with patients and their relatives.

During clinics, doctors were always supported by a healthcare assistant or registered nurse.

The service provided one-stop clinics so that patients could see all the health professionals

involved in their care at the same time. We saw this in the breast clinic, rheumatology and

diabetes clinics.

Seven-day services

Key services were available five days a week to support timely patient care.

Outpatients’ clinics operated from 8.30am to 5pm Monday to Friday. There were no regular

weekend clinic appointments in the outpatients department. None of the services offered any

evening clinics or regular weekend clinics.

Staff reported that some specialties ran the occasional additional weekend clinics to address

patient backlogs.

Health promotion



The service had relevant information promoting healthy lifestyles and support in patient areas. We

saw throughout the outpatient clinic areas we visited smoking cessation and healthy eating were

promoted. Posters were displayed in waiting areas and leaflets were also available.

From patient records, where appropriate, we saw staff assessed patient’s health at every

appointment and provided support for any individual needs to live a healthier lifestyle. This

included discussion about smoking cessation, healthy eating and alcohol consumption.





Staff we spoke with understood how and when to assess whether a patient had the capacity to

make decisions about their care.

We saw staff gain consent from patients for their care and treatment in line with legislation and

guidance. Staff we spoke with understood the need to obtain consent and we observed staff

checking patient details and seeking consent prior to minor procedures, for example in the eye

clinic and dermatology clinic. We saw consent forms were completed for patient appointments in

the notes we reviewed.

Staff told us that when patients could not give consent, they made decisions in their best interest,

taking into account patients’ wishes, culture and traditions. Staff gave an example where the

patient was living with dementia and was unable to consent.


The trust set a target of 95% for the completion of Mental Capacity Act (MCA) training. The

trust stated that Deprivation of Liberty Safeguarding (DoLS) training is included in the MCA

training module.

Broomfield Hospital


nursing staff in outpatient services at Broomfield Hospital is shown below:

Staffing group

As of August 2019

Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)


In outpatient services, the 95% target for MCA/DoLS training was narrowly missed by qualified

nursing staff as of August 2019.





MCA/DoLS training from July 2018 to August 2019.


Staff we spoke with understood the relevant consent and decision-making requirements of

legislation and guidance, including the Mental Health Act, Mental Capacity Act 2005 and the

Children Acts 1989 and 2004 and they knew who to contact for advice.

Staff knew how to access the trust’s policy on Mental Capacity Act and Deprivation of Liberty

Safeguards.


Compassionate care



Staff were discreet and responsive when caring for patients. We observed staff treating patients

with dignity, courtesy and respect. We observed that staff introduced themselves and interacted

well with patients.

Patients we spoke with said staff were friendly and treated them well and with kindness. All six

patients and the one relative we spoke with described positive experiences of care.

We observed patients being greeted when arriving in the department and staff taking the time to

interact with patients. Staff introduced themselves and took time to interact with patients. We

observed that staff were respectful and considerate during consolations.

Staff respected patient’s dignity. For example, we saw staff knocking before entering consultation

rooms and covering patients with blankets during procedures.

All outpatients’ clinics had nursing staff available to chaperone patients and staff commented that

this was always available. In the 10 patients’ records we reviewed, a stamp was used to indicate

that chaperone was present with the patient.

Emotional support


They understood patient's personal, cultural and religious needs.


it. Staff were sensitive and respectful of patients. Staff supported patients who became distressed

or anxious and spent time discussing their concern.

Patients’ privacy was observed when speaking with receptionists on arrival. Patients waited

behind a line to book in to ensure information could be communicated with the reception staff

without being overheard.

The hospital had a multi-faith chapel available with prayer facilities. A chaplain was present within

the hospital to provide support to patients, carers and staff. The chaplains were available to

provide support for managers in breaking bad news to other staff, offer listening and support for

staff, and hold short acts of remembrance for staff members who passed away.

Patients we spoke with told us they had received support from staff, emotionally, as well as

physically where there had been bad news following diagnostic results.


Staff signposted patients to other support organisations. For example, on the hospital site there

was a Macmillan cancer support service, and a volunteer service to help support patients

undergoing cancer treatment.


Staff supported patients, families and carers to understand their condition and make

decisions about their care and treatment.

Staff made sure patients and those close to them understood their care and treatment. Care was

planned and delivered in a way that involved patients and their carers. We saw Staff gave patients

and their relatives time to explain their symptoms and they were encouraged to ask questions. We

observed that staff answered patients’ questions appropriately, and in a way they could

understand.

Staff talked with patients, families and carers in a way they could understand. For example, we

saw staff using communication aids where necessary. Staff also simplified medical terminology to

ensure the patient understood what they were explaining.

Staff used communication aids for patients with learning difficulties and those with communication

needs, these included picture cards. Staff also had access to the learning disabilities nurse to

support patients where appropriate.

Patients told us that staff kept them informed of what was happening with their care, including

waiting times. We saw staff informing patients of current waiting times for their clinic.

Staff supported patients to make informed decisions about their care. Patients we spoke with said

they felt comfortable asking questions about their care and that they had been given time with the

nurses and doctors to ask questions.




communities served.


population.

The hospital site was accessible by public transport and the main entrance had an electronic

board with ‘live’ public transport timetable information. There was also an on-site car park,

however both staff and patients stated that it was difficult to find parking space .

The facilities in the main outpatient was appropriate for the services being delivered. The main

outpatient department was on the ground floor main atrium of the hospital. Clinics were clearly

signposted from the main entrance throughout the reception area.

The outpatient areas generally had enough seating for patients and relatives, but we did see

congestion and patients standing at the phlebotomy clinic during busy times during the day.

There were suitable toilet facilities in all clinic areas we visited. In the waiting areas, magazines

and water dispensing machines was available for patients to use.


The service provided ‘one stop clinics’ to minimise the number of times patients needed to attend

the hospital, by ensuring patients had access to the required staff and tests on one occasion for

example in the breast clinic and in orthopaedic and fracture clinics where patients had diagnostic

procedures performed and then had a consultation to discuss results or treatment plans.

Did not attend rate

Broomfield Hospital

From March 2018 to February 2019, the ‘did not attend’ rates for Broomfield Hospital were similar

to or lower than the England average, with the exception of March 2018 where they were

marginally higher.

The chart below shows the ‘did not attend’ rate over time.

Proportion of patients who did not attend appointment, Mid Essex Hospital Services NHS

Trust.



The trust access policy outlined the process to be followed if a patient did not attend their

appointment. A review was required by the patient’s clinician to ensure there is no clinical risk in

not treating the patient, before an appointment was rebooked, cancelled or the patient was

referred to their GP.





Staff ensured patients, relatives and carers could access support from interpreters or sign

language interpreters when needed. Staff had access to telephone language line and there also

facilities to book face to face interpreters for patients who required them.

The department had processes in place to allow the identification of patients’ individual

communication needs and provide them with appropriate support. The trust had an electronic


flagging system in place for all patients known to have a formal diagnosis of dementia or learning

disabilities (LD).

Within each clinic area staff confirmed that they tried to reduce the impact on patients living with

dementia or with learning disabilities by offering a quiet space to wait prior to appointments. Staff

also confirmed that they had access to support from the learning disability and dementia nurses,

and they prioritised patients to reduce their waiting.

The outpatient departments had hearing loop in place. This is a special type of sound system for

use by people with hearing aids.

Staff were aware of the support available and knew how to access it for patients presenting with

mental health conditions.

The service had access to information leaflets in languages spoken by the patients and local

community. An interpreting service was available for patients whose first language was not

English. The interpreting service was available through a telephone line service or face to face and

was arranged for patients requiring it.

There were volunteers located at the front entrance to the hospital to direct patients to the correct

outpatient area.

Access and flow
















A standard operating procedure (SOP) was in place relating to clinic cancellations. All clinics

cancelled at short notice (within six weeks) had to be signed off by the appropriate management

team.

Managers told us that they ensured that there was full utilisation of the outpatient clinic rooms.

Booking staff and clinical teams worked together to ensure that additional clinics were

accommodated, and all clinic rooms were used.

Referral to treatment (percentage within 18 weeks) – non-admitted pathways



treatment time (RTT) for non-admitted pathways. The trust outlined a number of local controls in



Referral to treatment (percentage within 18 weeks) – incomplete pathways


treatment time (RTT) for incomplete pathways. The trust outlined a number of local controls in



The trust reported no referral to treatment (RTT) data for non-admitted patient pathways to NHS

England from January 2018. Following the implementation of the trust electronic patient record

system in May 2017, management of access for patients on RTT pathways “lost visibility”

(meaning patients with appointments due were not being flagged up for booking). In response the

trust requested and received approval from NHS Improvement to pause reporting. The trust

developed a recovery plan to return to reporting through data validation for every patient on an

RTT pathway. The trust reported that this plan was due to complete and return to reporting by

April 2020.

Referral to treatment times was monitored by the senior management team and actions were

taken locally to address backlogs. Booking teams worked closely with the service managers and

clinicians in each speciality to monitor waiting times and put actions in place to address backlogs.

There were effective systems in place to monitor waiting lists. Managers were aware of the areas

with the biggest back logs and there were actions in place to address this. For example, in

ophthalmology and dermatology, additional clinics were being put up as well as utilising clinics

within the MSE hospital groups, to help reduce the waiting time in these specialities.

Divisional department managers and clinicians were informed on a weekly basis of any overdue

patients in their specialities and clinicians reviewed patient safety whilst patients were waiting for

review.

The total number of patients on the trust backlog waiting list for follow up appointment as of

November 2019 was 28,428 and there was acknowledgement that long waits remained a high risk

for the organisation. Please see below table for the breakdown by speciality.

Speciality No timeframe

0-5 wks 6-12 wks 13-24 wks 25+ wks Total

Cardiology 328 101 97 194 145 865

Dermatology 523 531 451 863 1,613 3,981

Gastroenterology 0 214 188 316 1,034 1,752

Neurology 0 377 219 539 1,358 2,493

Ophthalmology 38 867 735 1705 3,899 7,244

Rheumatology 0 227 230 340 1,188 1,985

Trauma and orthopaedics

0 235 192 283 1,120 1,830

Total 1,877 4,602 3,270 5,839 12,840 28,428

Cancer waiting times – Percentage of people seen by a specialist within 2 weeks of an

urgent GP referral (All cancers)


The trust performed worse than both the 93% operational standard for people being seen within

two weeks of an urgent GP referral and the England average in all four quarters from July 2018 to

June 2019. Performance at the trust was generally consistent across each quarter.

The performance over time is shown in the graph below.

Percentage of people seen by a specialist within 2 weeks of an urgent GP referral (All

cancers), Mid Essex Hospital Services NHS Trust

(Source: NHS England – Cancer Waits)

Cancer waiting times – Percentage of people waiting less than 31 days from diagnosis to

first definitive treatment (All cancers)

The trust performed worse than both the 96% operational standard for patients waiting less than

31 days before receiving their first treatment following a diagnosis (decision to treat) and the

England average in all four quarters from July 2018 to June 2019. Performance across the first

three quarters at the trust was consistent, before declining in the most recent quarter (Q1

2019/20).


Percentage of people waiting less than 31 days from diagnosis to first definitive treatment

(All cancers), Mid Essex Hospital Services NHS Trust



Cancer waiting times – Percentage of people waiting less than 62 days from urgent GP

referral to first definitive treatment

The trust performed worse than the 85% operational standard for patients receiving their first

treatment within 62 days of an urgent GP referral and the England average in all four quarters

from July 2018 to June 2019. Performance at the trust declined in Q4 2018/19 before improving in

Q1 2019/20 in line with the first two quarters.


Percentage of people waiting less than 62 days from urgent GP referral to first definitive

treatment, Mid Essex Hospital Services NHS Trust





learned with all staff.

Staff understood the policy on complaints and knew how to handle them. The trust had an up to

date complaints policy which was available to all staff through the trust’s intranet. The policy set

out the process for investigating, responding to and learning from complaints.

Staff told us they usually tried to address complaints or concerns at the time the concern was

raised. However, If the complaint could not be resolved by the team, patients were provided with

the contact details of the patient advice and liaison service (PALS). Patients we spoke with knew

how to complain or raise concerns.

Information about how to raise a concern was clearly displayed in patient areas. We saw posters

and leaflets displayed in all outpatient areas and information about how to feed back to the service

was readily available in the outpatient department.

Managers we spoke to told us that they had received the appropriate training to investigate

complaints. Outpatient staff told us that mangers feedback from complaints and concerns at the

team meetings and during daily safety huddle.


Staff we spoke with could give us good examples of learning from complaints and concerns and

genuinely viewed these as an opportunity for improvement.


Broomfield Hospital

From August 2018 to July 2019 the trust received 48 complaints in relation to outpatient services

at Broomfield Hospital (8.1% of the total complaints received by the trust). The trust took an

average of 30.4 days to investigate and close complaints. This was not in line with their complaints

policy, which states complaints should be completed within 25 working days.


Type of complaint Number of complaints Percentage of total Clinical treatment - surgical group 17 35.4% Communications 10 20.8% Appointments including delays and cancellations 5 10.4% Values and behaviours (staff) 4 8.3% Clinical treatment - general medicine group 4 8.3% Clinical treatment - clinical oncology 3 6.3%

Clinical treatment - anaesthetics 3 6.3% Admissions, discharge and transfer arrangements excluding delays due to absence of care package

2 4.2%

Total 48 100.0%



Broomfield Hospital

From August 2018 to July 2019 there were 56 compliments about outpatient services at

Broomfield Hospital (4.1% of all compliments received trust-wide). Of these, 35.7% were received

by the main outpatient department, followed by breast care (17.9%) and audiology (16.1%).

A breakdown of compliments by department is shown below:

Department Number of


Main outpatients 20 35.7% Breast care 10 17.9%

Audiology 9 16.1% Physiotherapy 6 10.7% Fracture clinic 3 5.4% Plastic surgery outpatients 3 5.4% Pain service 3 5.4% Ear, nose and throat outpatients 2 3.6%

Total 56 100.0%


pathway with patients and relatives thanking staff for their kindness and compassion

during difficult and stressful times. These related to all staff from housekeepers,

porters and nurses to consultants.



and carer experience group and with individuals and their managers during appraisal. The trust

uses its Datix system to analyse themes from compliments.



Leadership

Leaders had the integrity, skills and abilities to run the service. They understood and

managed the priorities and issues the service faced. They were visible and approachable in

the service for patients and staff.

The main outpatient department (OPD) was within the division of burns, plastics and outpatients.

The division was managed by the triumvirate team which consisted of a divisional director,

associated director of operations and an associated director of nursing supported by the OPD

service manager and matron.

Specialist staff were managed by their own divisions, for example, the head and neck unit and the

orthopaedic and fracture clinics were managed by similar systems within the surgical division.

Outpatient clinics were managed on a day to day basis by band six or band seven nurses. The

outpatient teams were made up of nurses, healthcare assistants, administration and clerical staff.

The OPD frontline clinical managers reported to the matron of the division in which the outpatient

department belonged to. Matrons were allocated to variety of areas within the OPD based on their

skills, experience and expertise.

All of the outpatient leaders and senior staff we met demonstrated understanding of the issues in

their service and appeared knowledgeable about their service and competent in their roles.

All staff we spoke with knew who their local leaders were and felt supported. Staff commented that

local leaders were approachable and supportive.

Vision and strategy

The service had a vision for what it wanted to achieve and a strategy to turn it into action.


The outpatient vision and strategy were based on the trust’s vision “patient care first…always” and

the values.

The outpatient strategy identified eight key areas of focus for 2019/2020. These were; improve

patient experience and safety, right size clinic templates, improve clinic utilisation, reduce

unnecessary follow ups, streamlining the booking process, reduce less than six weeks clinic

cancellations, review non-medical workforce and going digital.

Culture


receiving care. The service promoted equality and diversity in daily work and provided


opportunities for career development. The service had an open culture where patients, their

families and staff could raise concerns without fear.

All staff we spoke with said they felt supported, respected and valued by their line managers. We

observed good teamwork in the outpatient clinics between all staff groups.

Staff of all grades confirmed that they were encouraged to be open and transparent, reporting

adverse events and incidents in a way which helped improve things within the service.

Staff told us that they were able to raise any concerns with their managers and said that they

received support from local leadership team and their peers.

Staff were aware of the trust’s ‘Guardian’ service, an independent service commissioned by the

trust to facilitate ‘Freedom to Speak Up Guardian’ (all NHS trusts must nominate a guardian to

ensure staff can raise concerns safely) who was available for confidential advice.

There were processes in place to provide staff with career development opportunities. Staff told us

that they received regular appraisals and these included discussions around career development.

Staff told us that the trust was supportive of training and they felt encouraged to undertake

additional training when funding and scheduling allowed.

Governance




There were effective processes and systems of accountability within outpatients. Outpatient

specialities were split over different clinical divisions. There was a central outpatient function for a

number of general clinics in surgery and medicine. Specialist clinics were run from specific areas

across the trust. The management of these specialist clinics were within the division responsible

for the service such as gynaecology, trauma and orthopaedics, ENT, dermatology, ophthalmology

and oncology.

Governance systems were in place to support the functions of outpatient services. Monthly

meetings were conducted to allow oversight of the service which reported into divisional

governance meetings. All senior outpatient managers and clinical managers were encouraged to

attend these meetings. Governance meetings had a set agenda and we saw this was followed

during meetings. We reviewed the minutes from June, July and September 2019.

There was an effective process to share governance systems and updates with staff. Daily safety

huddles were held in the OPD. We reviewed a sample of the daily huddle sheet from August,

September, October and November 2019 and saw that they had a list of items to discuss and

governance was included. Items discussed included incidents, complaints, clinic start times and

changes in processes (new policies or procedures).

Staff of all grades appeared clear about their roles and what they were accountable for and to

whom.


The trust had systems for identifying risks, planning to eliminate or reduce them, and

coping with both the expected and unexpected.


OPD clinical delivery unit had a risk register in place. Each risk was rated and had a named

manager responsible for overseeing the risk and there were details of the actions taken to mitigate

the risk and updates provided as the risks were reviewed. The risk register was reviewed and

updated at the monthly clinical governance meeting. Specialist clinics risks, where reported within

the division responsible for the service.

Clinical delivery groups held monthly meetings where performance concerns were discussed

addressed and performance reports presented. We reviewed the last three meeting minutes (from

July to September 2019) for outpatients and saw they detailed areas of risk and performance,

including number of referrals received and number of patients waiting for 6 week appointments.

Clinicians undertook clinical harm reviews for follow up patients and a risk assessment was

completed for patients waiting over six weeks beyond their due date. There were robust processes

in place to give leaders oversight of patients waiting for appointments and RTT performance and

these were used to plan to deliver improved access for patients.

The trust had not reported against the national 18 week referral to treatment (RTT) standards

since January 2018. The trust had established a programme of work with key workstreams

including validation, data quality, training and demand and capacity. At the time of our inspection

the programme was in progress and likely to return to national reporting in April 2020.

The monthly OPD performance dashboard enabled senior staff to oversee and monitor key

performance information including but not limited to; service demand, activity and productivity.

Senior staff attended monthly meetings to discuss the dashboard data.

The service carried out regular audits provide assurance on safety and effectiveness in the OPD

areas, including but not limited to; medicines management, chaperone audit, environment and

safety, availability of notes and quality of documentation.


The service did not always collect reliable data and analyse it. Staff could not always find

the data they needed, in easily accessible formats, to understand performance, make

decisions and improvements. Information systems were not always integrated but were

secure. Data or notifications were not always consistently submitted to external

organisations as required.






Staff had access to policies, standard operating procedures and patient information leaflets

electronically through the document pages on the intranet. Staff confirmed that this ensured that

information was easily accessible and up to date.

Patient information was managed securely. Computer terminals were secured when not in use to

protect patient confidentiality. Reception desk terminals were not visible to the public. All paper

patients’ record was stored in secure locked cabinets when not in use.

Engagement





Patients were encouraged to complete the NHS Friends and Family Test (FFT). This is a national

programme that gives patients the opportunity to feedback on the care they have received.

Staff working in outpatients felt they were involved by their managers about plans for the services

they delivered.

Staff at all levels told us that senior leaders were visible and offered opportunities to listen and

feedback to staff.

Service leaders were working with clinical commissioning groups (CCGs) and primary care to

assess and reviewed patient pathways across a number of specialities to improve access and

care for patients.



understanding of quality improvement methods and the skills to use them.

In the last 12 months the outpatient department had a programme of work designed to streamline

pathways of care across the trust. Various clinical specialities including cardiology,

gastroenterology, nephrology, neurology, endocrinology, respiratory, ophthalmology, trauma and

orthopaedics, general surgery, urology, and plastics have reviewed their pathways and

benchmarked their performance against peers in the same speciality to inform pathway changes.

The proposals had been presented to executive team and been approved.

Mid Essex Hospital Services NHS Trust

Documents

Transcript of Mid Essex Hospital Services NHS Trust