The Care Quality Commission
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East Suffolk and North Essex NHS Foundation Trust

This is an organisation that runs the health and social care services we inspect

Overall: Requires improvement read more about inspection ratings
Important: Services have been transferred to this provider from another provider

All Inspections

11 Jun to 18 Jul 2019

During an inspection of Community health inpatient services

Our rating of this service stayed the same. We rated it as good because:

  • The service had enough staff to care for patients and keep them safe. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people, took account of most patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
  • Leaders ran services well and supported staff to develop their skills. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services.

However:

  • Managers did not always make sure all staff completed required mandatory training. Not all staff had training on how to recognise and report abuse.
  • The ward environment in all three community hospitals did not support patients living with dementia and other complex needs

11 Jun to 18 Jul 2019

During a routine inspection

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

  • We rated the overall key questions of safe and responsive as requires improvement and effective, caring and well-led were rated as good. Our rating for the trust took into account the current ratings of the core services we did not inspect this time.
  • We rated four of the 14 core services we inspected as requires improvement and nine as good. We rated children and young people’s services as outstanding overall.
  • Our decision on the overall ratings take into account the relative size of the service and we use our professional judgement to reach fair and balanced ratings.
  • We rated well-led of the trust overall as Good.

25-27 July 2017 and an unannounced on 2 August 2017

During a routine inspection

The Care Quality Commission (CQC) carried out an announced comprehensive inspection of Colchester General Hospital on the 25 to 27 July 2017. This was to review care provided at the trust since the new senior management team had come into post in May 2016.

The inspection team also undertook a further announced inspection on 2 August 2017 at the outpatients department at Essex County Hospital. At the time of inspection Essex County Hospital was in the process of deregistering.

Colchester Hospital University NHS Foundation Trust is comprised of two main hospital sites which are Colchester General hospital and Essex County Hospital. The Essex County Hospital is scheduled to close during 2018 and the only services currently provided on site are outpatient services and ophthalmic eye surgery under local anaesthesia. Colchester General hospital has 763 beds, spread across various core services, and provides district general hospital care to 370,000 in Colchester and the surrounding area of North East Essex and South Suffolk.

Colchester Hospital University NHS Foundation Trust was placed into special measures in November 2013 following an inspection into cancer waiting times. At the May 2014 inspection the trust well led aspect was rated as inadequate. The trust as a whole was rated inadequate following a comprehensive inspection in September 2015. The CQC undertook a further focussed unannounced inspection of Colchester General Hospital on 4 and 5 April 2016 looking specifically at the safety and caring elements of surgery, medicine and end of life care. The trust was not rated following this inspection. Overall findings were that significant improvements had not been made.

The CQC undertook regulatory action and imposed conditions under section 31 (1) (2) (a) of the Health and Social Care Act 2008 in December 2014, in respect of the emergency department, emergency assessment unit (EAU) and the operating theatres and the following regulated activities:

• Surgical Procedures

• Diagnostic and Screening

• Treatment of disease, disorder or injury

The trust reported regularly to the CQC to provide information and assurance that these conditions were adhered to, including exception reporting and risk assessments should the conditions be breached. We reviewed all aspects of the conditions during the inspection in July 2017 and the trust was compliant with imposed requirements following our previous inspection. The trust applied to have these conditions removed following this inspection.

A long-term partnership between Colchester General Hospital and Ipswich Hospital NHS Trust was recommended jointly by the CQC Chief Inspector of Hospitals, Professor Sir Mike Richards, and the Chief Executive of NHS Improvement as the only way of securing services for patients long into the future. Mr Nick Hulme was appointed as Chief Executive and Mr David White as Chair of the trust board on 17th May 2016. A managing Director was put in place to manage the trust on a day to day basis in June 2017. The respective boards are considering a Partnership between the two trusts The recommendation from the outline business case, 17 August 2017, was to form a single combined organisation with fully integrated clinical services.

We have been advised that subject to the boards approving the case, the Trusts will go on to develop detailed plans for the combined organisation. A final decision to form a single organisation will then be taken by both Trust boards around June 2018. This decision will also require approval from regulators NHS Improvement and the Competition and Markets Authority (CMA).

During this inspection we found that significant improvement had been made across all services at the Trust. The chief executive and managing director had created stability in the senior executive team that had not been previously in place. The executive team understood the challenges to good quality care and the wider challenges faced by the NHS, and could see the importance of exploring solutions such as the long-term partnership with Ipswich Hospital.

The team in place now worked together with more structured disciplines being embedded around executive and performance behaviours and responsibilities. Within the every patient, every day programme (EPED), the responsibility, accountability and ownership of service improvement had been given back to the local leaders. We saw many examples of local leaders and senior staff being highly motivated, engaged in seeking solutions to drive improvements locally.

We have rated Colchester Hospital University NHS Foundation Trust as requires improvement overall despite significant improvement being seen at the trust. The trust recognises that it is on a journey to Good and senior and local leaders are aware of where actions are still required to improve services.

Our key findings were as follows:

We saw several areas of outstanding practice including:

  • The service’s dedicated childrens transition team was the only one in the region and other trusts sought advice from them. The transition team worked with other teams to meet the more complex individual needs of patients at the age of transitioning to other services. For example, they ran a joint clinic with the epilepsy specialist nurse three to four times a year.

  • The neonatal unit (NNU) was piloting a ‘discharge passport’ to empower parent involvement in ensuring a timely discharge for babies.

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

Importantly, the trust must:

  • The trust must ensure that nursing and medical staff complete all safeguarding and mandatory training including basic life support.

  • The trust must ensure that all equipment is maintained and fit for purpose.

  • The trust must ensure that initial assessments within the emergency department are undertaken and documented to maintain an accurate clinical record based on clinical judgement, and that initial assessments in the emergency department are documented.

  • The trust must ensure access to a designated mental health assessment room.

  • The trust must take action to ensure that patients are clinically risk assessed as safe to wait for outpatient appointments.

  • The trust must ensure that medical records contain completed risk assessments relevant to patient care

  • Ensure that patient’s records are appropriately stored in accordance with legislation at all times.

  • The trust must ensure that staff administering contrast for diagnostic imaging investigations use a patient group direction or have it prescribed.

  • Ensure that do not attempt cardiopulmonary resuscitation (DNACPR) decisions are undertaken in accordance with national guidance and best practice.

  • The trust must ensure that the design and layout of the paediatric emergency department enables effective oversight of paediatric waiting areas to ensure patient safety.

  • The trust must ensure that there is an effective governance and risk management framework in place to identify and assess all risks relevant to the emergency department.

  • The trust must ensure that patient’s dignity is protected in changing cubicles in In Beta X-ray.

  • The Trust must ensure that the doors for Beta X-ray are fully fitted and a risk assessment is in place to ensure patients are not a risk of unnecessary exposure ofionising radiation.

  • The trust must ensure there is an effective process in place for timely review of policies and procedures and that these comply with national guidance and best practice.

Action the hospital SHOULD take to improve

  • The trust should improve its overall performance in the management of referral to treatment times.

  • The trust should ensure that clinics are not cancelled without exploring every option in order to contribute to reduced waiting times.

  • The trust should ensure the clinics start on time.

  • The trust should ensure that all staff are aware of translation services for non-English speakers.

  • The trust should ensure that clinical audit is undertaken and where data is not submitted, that it is followed up.

  • The trust should ensure that all staff have received an appraisal and frequent supervision.

  • The trust should review admission times and fasting periods for patients awaiting surgery to meet the nutritional and hydration needs of the patient.

  • The trust should ensure managers and senior staff have the relevant level of skill and experience to perform their roles.

  • The trust should ensure that staffing levels reflect the needs of patients at all times.

  • The trust should ensure that it reviews its existing staff practice in relation to MCA and DoLS specifically in relation to the cohorting of patients in supervised bays.

  • The trust should ensure that domestic staff follow infection control procedures, wear correct uniform, identification and personal protective equipment at all times.

  • The trust should improve its overall performance in the management of patient falls.

  • Continue to work to improve delayed discharges and discharges that occur between the hours of 10pm and 7am.

  • Continue to work to improve attendance and documentation of meeting minutes at mortality and morbidity meetings.

  • To ensure that patients diaries are being completed in line with guidance, and that these diaries are used throughout the patient journey.

  • To improve the recording of actions following governance meetings and ensure that these are followed up and that evidence of learning or changes in practice are recorded.

  • Ensure there are appropriate formal systems to share actions and learning from incidents consistently among all staff in the service.

  • Update the policy for safeguarding children in line with best practice and national guidance, for example to ensure all child protection cases are overseen by a paediatrician.

On the basis of this inspection, I have recommended that the trust be removed from the special measures process.

Professor Edward Baker

Chief Inspector of Hospitals

4th, 5th, and 13th April 2016

During an inspection looking at part of the service

The Care Quality Commission (CQC) carried out an unannounced inspection of Colchester General Hospital on the 4th and 5th April 2016. The purpose was to look specifically at safety and caring elements of the surgery, medical care and end of life care services, which were some of the key areas of concern from the September 2015 inspection. These areas were reflected in the section 29A warning notice served on the trust on 30th December 2015; the trust was required to have complied with the warning notice by 18th February 2016. This focused inspection was to assess if significant improvements had been made.

The areas inspected in April 2016 included a selection of wards/departments that were identified as a concern in the September 2015 inspection, as well as areas where concerns were not identified during the previous inspection but local intelligence suggested that risks may have increased in those areas. This included concerns regarding risks of patients deteriorating without appropriate monitoring or escalation. The local inspection team had also received six complaints specifically regarding end of life care in the previous six months, which was a higher number than would be expected. An inspection of the emergency department was also included due to an increased number of complaints from the public, poor performance on the trust’s quality metrics dashboard and an increased rate of serious incidents with four deteriorating patient deaths and five reported misdiagnosis incidents.

The inspection team also undertook a further announced inspection on 13th April 2016. During this inspection they met and interviewed members of the board and trust executive management team. The purpose of this announced inspection was to assess whether improvements had been made to the overall governance systems and processes within the trust. We also needed to assess whether any improvements were sustainable or had been sustained since our previous inspection.

Colchester Hospital University NHS Foundation Trust is comprised of two main hospital sites which are Colchester General Hospital and Essex County Hospital. Essex County Hospital is scheduled to close during 2017 and the only services currently provided on site are outpatient services and ophthalmic eye surgery under local anaesthesia. Colchester General hospital has 560 beds and provides district general hospital care to 370,000 people in North Essex. For this inspection The local inspection team focused on a selection of inpatient wards and the emergency department only.

Colchester Hospital University NHS Foundation Trust and the Colchester General Hospital location were rated as inadequate at our last inspection in 2015. Following the publication of our inspection report in January 2016 I informed the trust they were required to make significant improvements, or a further decision would be taken with regards to the future of services at the Trust.

I will not be providing a rating to Colchester Hospital University NHS Foundation Trust or Colchester General Hospital for this inspection. The reason for not providing a rating was because this was a very focused inspection carried out to assess whether the trust had made significant improvement to services within the prescribed time frame.

In medical care our key findings were:

  • The inspection team noted that on the Emergency Assessment Unit the conditions imposed on them on 29 January 2015 were being met.

  • The inspection team identified significant concerns regarding the nursing leadership on Peldon ward with concerns raised to us regarding the bullying culture of the ward. Nurses on this ward were treated as either “English” or “Foreign” nurses with staff raising examples of unfair treatment by service leads.

  • Patients spoken to on Peldon Ward were aware of the poor culture of the ward and reported to us that they were aware staff could be “sharp at times”.

  • Two members of staff formally raised concerns to the inspection team using the whistleblowing policy. One of these concerns was of such a serious nature they were escalated to the director of nursing and medical director for immediate action and support for those involved.

  • Poor culture for safeguarding patients were noted on Peldon ward, with practices noted to prevent or limit the movement of people with dementia on the ward who were referred to as ‘wanderers’. The practice involved placing a patient in bed and tilting the head back and feet up to prevent them from getting out of bed. We subsequently raised two safeguarding alerts to the local safeguarding authority following this inspection.

  • The inspection team were concerned about the care provided to patients on Peldon ward and requested that the trust take immediate action to ensure that patients were protected from the risk of harm or abuse.

  • The culture and levels of staff support in endoscopy had improved. However the disrepair of endoscopy equipment resulted in delays and cancellations to patient care and treatment due to the equipment being out of service.

  • There were observed improvements in how patients on Birch ward were cared for, with more positive staff interactions with patients.However the quality and recording of patient care in the records of patients on Birch ward was identified as a concern.

In surgery our key findings were:

  • The inspection team noted improvements in previous wards of concern including Aldham ward and the allocated staffing on Mersea Ward. However, due to high rates of sickness this improved level of staffing could not be achieved.

  • There was a notable decline in the care and safety of Brightlingsea ward where there was poor record keeping, care planning, medicines management and risk assessment. This ward has been raised as a concern by CQC on previous inspections, and the concerns about the ward’s deterioration were raised to the executive team again on this inspection.

  • Poor practice with safer surgery checklists was found on the previous inspection in 2015. A review was undertaken to see if improvements had been made. Serious concerns with the completion of the safer surgery checklist were noted. Staff do not routinely complete the 5th step by undertaking a debrief. Staff were observed to have completed post operation checklists prior to procedures commencing. Staff were also not routinely checking anaesthetic machines.

  • The audit rates show 100% compliance for previous three months yet several incidents had been recorded where the checklist were not completed. The inspection team checked the audit data and incident reporting but these did not correlate, therefore the data for the audits was not accurate.

In end of life care service our key findings were:

  • The inspection team found that awareness amongst the staff regarding end of life care had improved, e-learning training had been provided, though not all staff had completed it.

  • Staff were more engaged in end of life care and were responsive to concerns identified by the inspection team. However, there remained a lack of awareness of when to place a patient on the individual care records for last days of life. The inspection team identified three patients during the first day of inspection who were not on the care plan who should have been.

  • The inspection team also found that where the individual care record for last days of life was in use, the completion of this record was not consistent.

  • There was a lack of recording of discussions with family and patients. There was a lack of evidence that information was provided about what they might expect which had reportedly caused some anxiety.

  • The completion of DNACPR forms had not improved with the many reviewed being completed poorly or incorrectly. Several were seen with reasons for DNACPR given as ‘Dementia’.

  • Use of the Mental Capacity Act was poor in relation to end of life care. The majority of staff in the trust, according to the training matrix, have received training in MCA. However, this is not well reflected in the care being provided.

  • There was a notable lack of syringe drivers available. Staff were reverting to the use of sub cutaneous ports for use when equipment not available. One patient, who died the day prior to inspection, was reviewed post inspection by the trustwide team following concerns about a potential overdose of PRN (as prescribed) medication. We raised our continued serious concerns regarding the care for patients at the end of their life, and those nearing the end of their life to the trust executive team.

In the Emergency Department our key findings were:

  • The inspection team observed that the nursing staff were working more cohesively. However there was a lack of integration with the medical staff.

  • In December 2014 we imposed a condition on the trust’s registration to ensure that streaming occurred within the department. The inspection team noted at our inspection in September 2015 that this was working well and appeared to be embedded in the department. However at this inspection we noted that at times of peak activity this process was abandoned. This impacted upon the risk of harm to patients.

  • There was a noticeable lack of clinical leadership. Nursing leadership was good and was much improved and they were working to manage risks. However the doctors were disengaged in the delivery of a safe, effective and responsive service.

  • The streaming process did not function effectively due to staff shortages. There was there was no contingency plan in place for the event that there was a shortage of staff.

  • The inspection team saw that first assessment of patients was taking up to 50 minutes. However, the 15 minute assessment times were showing at over 95%. This gave rise to concerns that the data provided by the department was not accurate.

  • There were many patients in the corridor area near the ambulance bay, and still in ambulances due to the department being full. There was a lack of clinical oversight in this area from an experienced nurse and a lack of doctors reviewing patients.

  • There was a lack of mobile rapid assessment and treatment process (RAT) leading to a lack of escalation/ recognition of the acutely unwell patient.

  • The inspection team identified and escalated five patients who were not well. These patients had incorrectly calculated NEWS scores. Two further patients were escalated due to a lack of care, hydration and pain relief.

Our key findings from our interviews with the executive management team and trust board were:

  • Whilst improvements had been made in some areas, there remained a lack of robust grip and proactive identification of risk.

  • There was insufficient pace to address the wide range of significant improvements required.

  • There was a lack of action and response by the board on key issues such as A&E performance and safer surgery checks, despite knowing the risks were there and presenting an immediate risk to patient safety.

  • The senior team stated that they felt that there had been significant improvement. However, they also acknowledged that the trust in the longer term would not continue to be able to provide services without the support of an external organisation.

Based on the findings of this inspection I authorised that urgent enforcement action be taken against the trust in respect of the emergency department streaming process and patients’ being cared for in the corridor area. I also authorised for enforcement action to be taken on the surgery service in respect of ensuring that safer surgery checklists are completed and patients are protected from the immediate risk of harm. The trust has been in special measures for more than two years and subsequently based on the inspection findings I cannot recommend a further extension to special measures.

I have recommended to the secretary of state that a solution needs to be found, and a partnership agreement with Ipswich Hospital NHS Trust is being established. CQC will continue to monitor this trust closely to ensure that patients receive safe, effective, responsive and well led care.

Professor Sir Mike Richards

Chief Inspector of Hospitals

15th -18th September, 30th September and 3rd October 2015

During a routine inspection

The Care Quality Commission (CQC) carried out a comprehensive inspection between the 15th and 18th September 2015. We carried out this comprehensive inspection as part of our regular inspection programme to follow up on previous inspections of trusts in special measures where further improvements were required. Colchester Hospital University NHS Foundation Trust was placed into special measures in November 2013 and was fully inspected in May 2014 where it was provided with an overall rating at the trust wide leadership level of inadequate. Further inspections of the trust’s primary location Colchester General Hospital were undertaken in response to concerns in November, December 2014 and July 2015 where urgent enforcement action was taken to protect patients from the risk of harm. Following the November and December inspection the rating for the location Colchester General Hospital was changed from requires improvement to inadequate.

Prior to this inspection the trust was identified as having seven elevated risks and twelve risks on the Care Quality Commission’s (CQC) Intelligent Monitoring system in May 2015. The overall percentage score of risk, which is how these reports and organisational risk is calculated, increased from 4.8% in March 2014 to 11.5% in May 2015.

Colchester Hospital University NHS Foundation Trust is comprised of two main hospital sites which are Colchester General hospital and Essex County Hospital. The Essex County Hospital is scheduled to close during 2016 and the only services currently provided on site are outpatient services and ophthalmic eye surgery under local anaesthesia. Colchester General hospital has 560 beds and provides district general hospital care to 370,000 people in North Essex. For this inspection we inspected both sites but have reported on both in the one main location report.

During this inspection we found that the trust had capacity issues and were having to reassess bed capacity at least three times a day. We found that staff shortages meant that there was a high use of agency staff which did impact on the quality of care provided to patients. We found that required improvements, identified at previous inspections since May 2014, had not been undertaken, this included the service, maintenance and repair of equipment which was found to be poorly undertaken throughout the trust. Outpatient service provision had deteriorated and the trust had lost grip on the number of patients who required treatment through outpatients. End of life care provision had also deteriorated since it was last inspected in May 2014 with patients not receiving safe or effective care at the end of their life.

We have rated Colchester Hospital University NHS foundation Trust as inadequate overall, the location Colchester General Hospital as inadequate although we found that the trust employed staff were highly motivated and were working through many issues to drive improvements locally, they were however impacted by the high use of agency, some of whom were poor in quality of care, which caused them real frustration. We have rated the overall trust as inadequate as there was a lack of management oversight and robust governance systems in place to highlight the concerns we found during this inspection.

Our key findings were:

  • There was a significant and substantial shortfalls in registered nursing staff in a number of areas. Overall the trust had a shortfall of 244 (20%) registered nurse vacancies from Band 5 to Band 7 in May 2015.

  • There were wards throughout the trust which had very high agency usage noted with staffing on five wards ranging between 80-100% agency use at weekends and at night time. A further 6 wards had agency use above 30% continuously.

  • There were significant medical staffing vacancies with a shortfall of 81 WTE (15.8%), which meant that there was a high use of locum medical staff. The shortages of junior, trainee and middle grades was especially notable across medical and surgical specialties during the inspection.

  • We found the executive leaders in the trust were not always aware of the risks or significant issues within the trust and required inspections to identify these for them. Where risks were identified they had they either did not consider them to be significant or follow them through to completion.

  • The trust was reactive to risk when it was identified, such as taking action to improve services that were previously inspected however the high level of focus on one area was not always proportionate and worked to the detriment of other areas in the trust with risk.

  • Concerns with the equipment not being electrical safety tested, serviced, maintained or calibrated was identified during previous inspections in May, November, December 2014. During this inspection we identified that the equipment within critical ward and departments such as A&E, critical care, theatres and maternity was out of date. The trust was aware of this issue but failed to take appropriate action in a timely way. We raised this with the trust during the inspection and they provided us with a plan to ensure the equipment concerns were resolved by 31 March 2016.

  • Pressure on surgical services meant routine operations were frequently cancelled and patients were waiting longer than the 18-week referral to treatment target for operations. The reasons provided for cancellations were linked to bed availability and administration reasons but in many cases patients were not being rebooked quickly.

  • Pressure on the cancer services meant that there were many reported incidents of patients who had gone more than 100 days without treatment for their cancers. Cancer performance on the RTT was also poor and showed a downward trend noted between July 2014 and May 2015, though some improvement was noted between May and September 2015.

  • The disjointed approach to the management and booking of outpatients placed pressure on the service with some bookings going through the division and some going through the central booking team. The trust executive team were not clear on what their risks within outpatients were without the numbers for each service. There was also a real lack of understanding at the trust board level of what was required for the monitoring and management of admitted and non admitted referral to treatment times.

  • The trust was not aware of the current patient backlogs and active patient waiting lists in outpatient services. Following the inspection we were informed about the issues with validating outpatient data and the backlog of pathways. It was subsequently found that there were in the region of 370,791 open patient referrals that required review of which around 149,000 were high risk. This backlog and pressure meant that there were long and in some cases severe delays for some specialties and not all patients being followed up appropriately.

  • The longest wait noted on the 18 week pathway was in the region of 116 weeks.

  • As of January 2016 the trust confirmed that they had commenced the validation of the open referrals on their system to assess if there had been any adverse impact of this issue on patients, and ensure patients receive appropriate treatment.

  • We observed several examples of patients who should have been receiving dedicated end of life care who were not because staff had not identified that they were at the end of their life.Due to the lack of identification of patients at the end of their life the standard procedures for end of life care plans were not given priority or utilised when needed.

  • Operational management of the beds, capacity, and flow was not organised well by the leaders of the services and did not provide effective outcomes which delivered support to services in need to capacity including the emergency department and intensive care.

  • The approach from the trust the monitoring of mortality including the undertaking of mortality and morbidity meetings to review trends and improve patient care was inconsistent. There were areas where these meetings and reviews were not taking place.

  • The trust has seen a steady increase in mortality over the last six months. At the time of the inspection the last Hospital Standardised Mortality Ratio (HSMR) for the trust was 103 and their Summary Hospital-level Mortality Indicator (SHMI) was 106.7 however their weekend mortality ratio was 113.6.

  • The way in which responses to complaints and concerns were handled by the trust was not consistent, with some poorly investigated and non-supportive responses being issued, which resulted in further complaints being raised about the complaints process. This was evident with the trust being highlighted as one of the top reported trusts in England where complaints management and responses are referred to the Parliamentary Health Service Ombudsman.

  • The four hour standard was only being achieved for around 80% of patients, with significant numbers of patients waiting more than 4-12 hours for admission.

  • Overall there had been some improvement in the care delivered on the medical wards.However, Safety was rated as inadequate.

  • Care on some medical and surgical wards as well as the postnatal ward was poor with patients not being treated with sufficient dignity and respect and call bells not always being answered promptly.

  • There was improvement in the culture of being open in some areas of the hospital, however staff in many areas still felt unable to speak up about concerns they had regarding services and care.

However, we also found examples of innovation and good practice including:

  • There was notable desire from the staff to make the changes needed to improve their departments and services to ultimately provide good care to patients. The enthusiasm of staff to deliver this was positive.

  • The core permanent employed trust staff working on the frontline were, in the majority, dedicated professionals who wanted to provide the best care possible to their patients and were caring, however they felt let down because the agency staff employed did not all show the same commitment to values of good care.

  • There were areas were good and innovative practice was taking place particularly in maternity with hypnobirthing and in critical care with staff being involved in research, which has led to national and international publication of their research.

  • The mortuary team worked exceptionally well to provide a service when capacity for patients was limited and were innovative and resourceful to cope with demand.

  • The creation of the role of the pharmacy intern was innovative and an area of outstanding practice.

There were areas of poor practice where the trust needs to make improvements.

Importantly, the trust must ensure that:

  • Ensure that mandatory and statutory training rates through the trust are improved.

  • Ensure that staff are assessed and signed off as competent to use equipment which is used to deliver patient care.

  • Ensure that appraisal rates in surgery improves and that clinical supervision rates improve throughout the trust.

  • Ensure that equipment is service, maintained and calibrated so that it is safe to use on patients.

  • Ensure that the culture within the organisation of poor staff morale, staff not being willing to raise concerns openly and concerns around bullying are given sufficient priority by the board with.

  • Ensure that all staff in operational roles within the trust are educated in understanding the requirements and fundamentals of referral to treatment times.

  • Ensure that improvements are made to the classification of incidents to ensure that they are reported, escalated and graded appropriately.

  • Ensure that the conditions imposed by the Commission on the Emergency Assessment Unit are effectively implemented.

The trust should also:

  • Review the process for mortality and morbidity in the trust to make the process more robust so that trends are identified and lessons are shared and learned.

  • Review the process for the management and response to complaints received from patients and members of the public to address and respond to the concerns they raise appropriately.

  • Review the process for the board assurance framework and the links between the divisions and ensure that the top risks are fully discussed and addressed at board meetings.

  • Review the operation management arrangements for the trust to ensure that the operational support functions effectively in supporting wards, departments and services.

Following our inspection at Colchester Hospitals University NHS Foundation Trust a new chief executive was appointed and a new action plan drawn up against the feedback provided at the inspection. We note that since our inspection there has been some limited progress against our areas of concern. I am therefore recommending that the trust remain in special measures for a period of three months during which time they will submit a weekly dashboard of key improvement indicators to relevant stakeholders in order that we continue to monitor improvements. Based on the findings of this inspection I have recommended that further regulatory action be taken and required the trust to make significant improvements on the care and service they provide to patients.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Comprehensive inspection May 2014, Focused inspection 12, 27 Nov & 23 Dec 2014

During an inspection looking at part of the service

Colchester Hospital University NHS Foundation Trust operates from two main sites - Colchester General Hospital and Essex County Hospital. The trust provides healthcare services to around 370,000 people from Colchester and the surrounding area of north east Essex. The trust employs around 4,168 staff.

In addition, the trust provides radiotherapy and oncology services to a wider population of about 670,000 people across north and mid-Essex.

The trust owns and manages Colchester General Hospital, which opened in 1984, and Essex County Hospital, which was established in 1820. In addition, the trust also provides some services, such as outpatient and maternity services, at the community hospitals in Clacton and Harwich – run by Anglian Community Enterprise (ACE) – and Halstead Hospital, which is run by Central Essex Community Services (CECS). The trust also runs a limited range of community services.

For the purposes of the comprehensive inspection, we focused on the Colchester General Hospital and Essex County Hospital, given the majority of services are delivered from these sites.

The Care Quality Commission (CQC) carried out a comprehensive inspection between the 6 and 8 May 2014. The inspection was undertaken as part of the review undertaken by Sir Bruce Keogh. The Keogh Mortality Review looked in detail at those trusts whose Standardised Hospital Mortality Indicator (SHMI) suggested possible concerns around quality of care. The CQC was asked to inspect all of the Keogh trusts in order to make a judgment on the quality of care being provided by these organisations.

The comprehensive inspection involved an on-site review of:

  • Accident and emergency (A&E)
  • Medical care
  • Surgery
  • Critical care
  • Maternity
  • Children and young peoples services
  • End of life care
  • Outpatient services.

The on-site element of the inspection involved a team of experts by experience (service users), clinical associates (experienced healthcare professionals) and CQC inspectors. The team is divided into subteams, each of which looked at one the service lines described above. The subteams were led by an experienced inspector, supported by clinical experts.

Prior to the CQC on-site inspection, the CQC considered a range of quality indicators captured through our intelligent monitoring processes. In addition, we sought the views of a range partners and stakeholders. A key element of this is the public listening events and focus groups with healthcare professionals.

 

We returned on 12 and27 November and 23 December 2014 to follow up on concerns raised to inspect the A&E department and the Emergency Admissions Unit.

The inspection team make an evidenced judgment on five domains to ascertain if services are:

  • Safe
  • Effective
  • Caring
  • Responsive
  • Well-led.

The comprehensive inspections result in a trust being assigned a rating of ‘outstanding’, ‘good’, ‘requires Improvement’ or ‘inadequate’. Each section of the service receives an individual rating, which, in turn, informs an overall trust rating. The inspection found that overall the trust had a rating of requires improvement following the comprehensive inspection but was rated as overall inadequate following our responsive inspection in November and December 2014.

Our key findings were as follows:

  • The leadership of the trust had undergone significant change, resulting in a lack of stability and clear direction at board-level.
  • Patients and relatives spoke very highly of services.
  • Caring and compassion was evident in all clinical areas.
  • Nurse staffing levels, particularly in medical elderly wards, were lower than safe staffing guidance recommended.
  • There were good standards of cleanliness and good systems and processes for infection prevention and control were in place.
  • The trust benefited from a very committed and loyal workforce.

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

Importantly, the trust must:

  • Take action to recruit a substantive and credible board of directors.
  • Put in place a clear strategy for leadership development at all levels.
  • Incorporate the patient voice in a systematic way into the workings of the board.
  • Undertake an independent review of the management of elective waiting lists in all areas
  • Improve the systems and processes for the storage and management of all medicines, including controlled drugs. Assure itself that ‘five steps to safer surgery’ (the NHS Patient Safety First campaign adaptation of the World Health Organization – WHO – surgical safety checklist) procedures were undertaken consistently and compliance audited.

 

Essex County

  • Review the decontamination procedures within the orthodontic clinic to ensure that these comply with the required national standards.
  • Ensure that the use of the World Health Organisation (WHO) checklist is fully embedded in surgical practice, including the ‘sign out’ and debrief.
  • Ensure that all staff have appropriate supervision and appraisal.
  • Ensure that staff have access to training and development opportunities to ensure that they maintain the necessary skill for their role, this is to include management, leadership and professional development training.
  • Ensure that there is a robust incident and accident reporting system in place and that lessons learnt from investigations of reports are shared with staff to improve patient safety and experience.
  • Ensure that there are appropriate waste disposal procedures in place and these are implemented, particularly in the outpatients department.
  • Ensure that all cleaning products are stored in accordance with manufacturing guidance and complies with legislative requirements.
  • Ensure that all sterile equipment and products are appropriately stored to ensure that there sterility is maintained, including an adherence to expiry dates.
  • Review the numbers and skill mix in the outpatients department to ensure that there are sufficient qualified and skilled staff to meet patient needs.
  • Review the cancellation of outpatient appointments and take the necessary steps to ensure that issues identified are addressed and cancellations are kept to a minimum.
  • Review waiting times in outpatients’ clinics and take the necessary steps to ensure that issues identified are addressed.
  • Review access into clinics to ensure that they are suitable for people with mobility problems.
  • Ensure that information on how to complain is accessible to patients in all patient areas within the hospital.
  • Review the involvement of staff in trust-wide issues to ensure that staff are fully conversant with the trust vision, strategies and objectives and can contribute to the development of services.
  • Review the information provided to staff regarding future development of services and how staff can be involved and engaged in this process.

Should do:

  • Review the waste disposal bins in toilets designated for people with disabilities.
  • Review issues identified and associated with transport problems when accessing outpatient appointments.

Colchester

  • Ensure that there is a robust incident and accident reporting system in place; including reporting staff shortages and that lessons learnt from investigations of reports are shared with staff to improve patient safety and experience.
  • Ensure that all equipment has safety and service checks in accordance with policy and manufacturer’s instructions and that the identified frequency is adhered to, including emergency equipment requiring daily checks, portable appliance testing and regular maintenance.
  • Ensure that all patients’ records are kept up to date and appropriately maintained to ensure that patients receive appropriate and timely treatment.
  • Review the process for referring safeguarding concerns to the local authority to ensure that these are undertaken appropriately for the safety and wellbeing of patients.
  • Ensure that there are sufficient numbers of qualified, skilled and experienced staff at all times, particularly in A&E, medical wards and children’s services including the high dependency unit.
  • Review handover arrangements to ensure that they are effective and the necessary information is passed to the next responsible staff team so that patients receive appropriate treatment in a timely manner.
  • Ensure that staff complete their mandatory training and have access to necessary training, especially safeguarding and resuscitation, and development to ensure they maintain the appropriate skills for their role.
  • Ensure that patients are assessed by appropriately trained and experienced staff within the A&E department.
  • Review the recording of necessary information such as arrival and discharge times in the A&E department to ensure that the information on performance is robust and correct.
  • Review the patient flow from the A&E department to ensure that patients are assessed to meet their needs and there are no unnecessary delays.
  • Review the complaints process to ensure that appropriate lessons can be learned and improvements made in service delivery.
  • Ensure all staff adhere to the infection prevention and control of infection policy and procedures, particularly with regard to hand washing and cleaning procedures on the maternity unit.
  • Ensure that all sterile fluids and medicines are stored in accordance with manufacturers and legislative guidance and that expiry dates are adhered to.
  • Review the arrangements for dealing with controlled drugs to ensure that they comply with national standards and legislation and that these are implemented and adhered to by staff.
  • Ensure that patients’ records are appropriately stored in accordance with legislation at all times.
  • Ensure that a patient’s mental capacity is assessed appropriately and that records are up dated and maintained in accordance with national guidance and recommendations.
  • Ensure that the assessment for a do not attempt cardio-pulmonary resuscitation complies with best practice and national guidance, involves the patients or their representatives and that these discussions are recorded, including when discussions have been deemed inappropriate.
  • Review the arrangements for internal transfer of patients in the night and ensure that this is kept to a minimum, particularly for frail and elderly patients.
  • Review the involvement of staff in trust-wide issues to ensure that staff are fully conversant with the trust vision, strategies and objectives and can contribute to the development of services.
  • Review the cancellation of outpatient appointments and take the necessary steps to ensure that issues identified are addressed and cancellations are kept to a minimum.
  • Review waiting times in outpatients’ clinics and take the necessary steps to ensure that issues identified are addressed.

Should do:

  • Review the blood testing processes in the A&E department to ensure that they are efficient and timely.
  • Review information given to patients on why they are waiting in the A&E department to allay anxieties.
  • Review the information following clinical audits and ensure that any actions and learning are shared with staff.
  • Review the training available to staff on caring for people living with dementia or with a learning disability and provide training to ensure that staff have the appropriate skills for their role.
  • Review staff communication and engagement to ensure that they are aware of the trust strategies and vision, including new initiatives such as the clinical care strategy for end of life care.

Following our responsive inspection we under took enforcement action which included placing conditions on the providers registration in respect of A&E and EAU departments.

Professor Sir Mike Richards

Chief Inspector of Hospitals

6-8 & 16-19 May & 18 June 2014

During a routine inspection

Colchester Hospital University NHS Foundation Trust operates from two main sites - Colchester General Hospital and Essex County Hospital. The trust provides healthcare services to around 370,000 people from Colchester and the surrounding area of north east Essex. The trust employs around 4,168 staff.

In addition, the trust provides radiotherapy and oncology services to a wider population of about 670,000 people across north and mid-Essex.

The trust owns and manages Colchester General Hospital, which opened in 1984, and Essex County Hospital, which was established in 1820. In addition, the trust also provides some services, such as outpatient and maternity services, at the community hospitals in Clacton and Harwich – run by Anglian Community Enterprise (ACE) – and Halstead Hospital, which is run by Central Essex Community Services (CECS). The trust also runs a limited range of community services.

For the purposes of the comprehensive inspection, we focused on the Colchester General Hospital and Essex County Hospital, given the majority of services are delivered from these sites.

The Care Quality Commission (CQC) carried out a comprehensive inspection between the 6 and 8 May 2014. The inspection was undertaken as part of the review undertaken by Sir Bruce Keogh. The Keogh Mortality Review looked in detail at those trusts whose Standardised Hospital Mortality Indicator (SHMI) suggested possible concerns around quality of care. The CQC was asked to inspect all of the Keogh trusts in order to make a judgment on the quality of care being provided by these organisations.

The comprehensive inspection involved an on-site review of:

  • Accident and emergency (A&E)
  • Medical care
  • Surgery
  • Critical care
  • Maternity
  • Children and young peoples services
  • End of life care
  • Outpatient services.

The on-site element of the inspection involved a team of experts by experience (service users), clinical associates (experienced healthcare professionals) and CQC inspectors. The team is divided into subteams, each of which looked at one the service lines described above. The subteams were led by an experienced inspector, supported by clinical experts.

Prior to the CQC on-site inspection, the CQC considered a range of quality indicators captured through our intelligent monitoring processes. In addition, we sought the views of a range partners and stakeholders. A key element of this is the public listening events and focus groups with healthcare professionals.

The inspection team make an evidenced judgment on five domains to ascertain if services are:

  • Safe
  • Effective
  • Caring
  • Responsive
  • Well-led.

The comprehensive inspections result in a trust being assigned a rating of ‘outstanding’, ‘good’, ‘requires Improvement’ or ‘inadequate’. Each section of the service receives an individual rating, which, in turn, informs an overall trust rating. The inspection found that overall the trust has a rating of requires improvement.

Our key findings were as follows:

  • The leadership of the trust had undergone significant change, resulting in a lack of stability and clear direction at board-level.
  • Patients and relatives spoke very highly of services.
  • Caring and compassion was evident in all clinical areas.
  • Nurse staffing levels, particularly in medical elderly wards, were lower than safe staffing guidance recommended.
  • There were good standards of cleanliness and good systems and processes for infection prevention and control were in place.
  • The trust benefited from a very committed and loyal workforce.

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

Importantly, the trust must:

  • Take action to recruit a substantive and credible board of directors.
  • Put in place a clear strategy for leadership development at all levels.
  • Incorporate the patient voice in a systematic way into the workings of the board.
  • Undertake an independent review of the management of elective waiting lists in all areas
  • Improve the systems and processes for the storage and management of all medicines, including controlled drugs. Assure itself that ‘five steps to safer surgery’ (the NHS Patient Safety First campaign adaptation of the World Health Organization – WHO – surgical safety checklist) procedures were undertaken consistently and compliance audited.

Essex County

  • Review the decontamination procedures within the orthodontic clinic to ensure that these comply with the required national standards.
  • Ensure that the use of the World Health Organisation (WHO) checklist is fully embedded in surgical practice, including the ‘sign out’ and debrief.
  • Ensure that all staff have appropriate supervision and appraisal.
  • Ensure that staff have access to training and development opportunities to ensure that they maintain the necessary skill for their role, this is to include management, leadership and professional development training.
  • Ensure that there is a robust incident and accident reporting system in place and that lessons learnt from investigations of reports are shared with staff to improve patient safety and experience.
  • Ensure that there are appropriate waste disposal procedures in place and these are implemented, particularly in the outpatients department.
  • Ensure that all cleaning products are stored in accordance with manufacturing guidance and complies with legislative requirements.
  • Ensure that all sterile equipment and products are appropriately stored to ensure that there sterility is maintained, including an adherence to expiry dates.
  • Review the numbers and skill mix in the outpatients department to ensure that there are sufficient qualified and skilled staff to meet patient needs.
  • Review the cancellation of outpatient appointments and take the necessary steps to ensure that issues identified are addressed and cancellations are kept to a minimum.
  • Review waiting times in outpatients’ clinics and take the necessary steps to ensure that issues identified are addressed.
  • Review access into clinics to ensure that they are suitable for people with mobility problems.
  • Ensure that information on how to complain is accessible to patients in all patient areas within the hospital.
  • Review the involvement of staff in trust-wide issues to ensure that staff are fully conversant with the trust vision, strategies and objectives and can contribute to the development of services.
  • Review the information provided to staff regarding future development of services and how staff can be involved and engaged in this process.

Should do:

  • Review the waste disposal bins in toilets designated for people with disabilities.
  • Review issues identified and associated with transport problems when accessing outpatient appointments.

Colchester

  • Ensure that there is a robust incident and accident reporting system in place; including reporting staff shortages and that lessons learnt from investigations of reports are shared with staff to improve patient safety and experience.
  • Ensure that all equipment has safety and service checks in accordance with policy and manufacturer’s instructions and that the identified frequency is adhered to, including emergency equipment requiring daily checks, portable appliance testing and regular maintenance.
  • Ensure that all patients’ records are kept up to date and appropriately maintained to ensure that patients receive appropriate and timely treatment.
  • Review the process for referring safeguarding concerns to the local authority to ensure that these are undertaken appropriately for the safety and wellbeing of patients.
  • Ensure that there are sufficient numbers of qualified, skilled and experienced staff at all times, particularly in A&E, medical wards and children’s services including the high dependency unit.
  • Review handover arrangements to ensure that they are effective and the necessary information is passed to the next responsible staff team so that patients receive appropriate treatment in a timely manner.
  • Ensure that staff complete their mandatory training and have access to necessary training, especially safeguarding and resuscitation, and development to ensure they maintain the appropriate skills for their role.
  • Ensure that patients are assessed by appropriately trained and experienced staff within the A&E department.
  • Review the recording of necessary information such as arrival and discharge times in the A&E department to ensure that the information on performance is robust and correct.
  • Review the patient flow from the A&E department to ensure that patients are assessed to meet their needs and there are no unnecessary delays.
  • Review the complaints process to ensure that appropriate lessons can be learned and improvements made in service delivery.
  • Ensure all staff adhere to the infection prevention and control of infection policy and procedures, particularly with regard to hand washing and cleaning procedures on the maternity unit.
  • Ensure that all sterile fluids and medicines are stored in accordance with manufacturers and legislative guidance and that expiry dates are adhered to.
  • Review the arrangements for dealing with controlled drugs to ensure that they comply with national standards and legislation and that these are implemented and adhered to by staff.
  • Ensure that patients’ records are appropriately stored in accordance with legislation at all times.
  • Ensure that a patient’s mental capacity is assessed appropriately and that records are up dated and maintained in accordance with national guidance and recommendations.
  • Ensure that the assessment for a do not attempt cardio-pulmonary resuscitation complies with best practice and national guidance, involves the patients or their representatives and that these discussions are recorded, including when discussions have been deemed inappropriate.
  • Review the arrangements for internal transfer of patients in the night and ensure that this is kept to a minimum, particularly for frail and elderly patients.
  • Review the involvement of staff in trust-wide issues to ensure that staff are fully conversant with the trust vision, strategies and objectives and can contribute to the development of services.
  • Review the cancellation of outpatient appointments and take the necessary steps to ensure that issues identified are addressed and cancellations are kept to a minimum.
  • Review waiting times in outpatients’ clinics and take the necessary steps to ensure that issues identified are addressed.

Should do:

  • Review the blood testing processes in the A&E department to ensure that they are efficient and timely.
  • Review information given to patients on why they are waiting in the A&E department to allay anxieties.
  • Review the information following clinical audits and ensure that any actions and learning are shared with staff.
  • Review the training available to staff on caring for people living with dementia or with a learning disability and provide training to ensure that staff have the appropriate skills for their role.
  • Review staff communication and engagement to ensure that they are aware of the trust strategies and vision, including new initiatives such as the clinical care strategy for end of life care.

We would normally take enforcement action in these instances, however, as the trust is already in special measures we have informed Monitor of these breaches, who will make sure they are appropriately addressed and that progress is monitored through the special measures action plan.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Use of resources

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

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up. Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.