East Sussex Healthcare NHS Trust

East Sussex Healthcare NHS Trust (ESHT) provides acute hospital and community health services for people living in East Sussex and the surrounding areas. The trust serves a population of 525,000 people and is one of the largest organisations in the county. Acute hospital services are provided from Conquest Hospital in Hastings and Eastbourne District General Hospital, both of which have Emergency Departments. Acute children’s services and maternity services are provided at the Conquest Hospital and a midwifery-led birthing service and short-stay children’s assessment units are also provided at Eastbourne District General Hospital.

The trust also provides a minor injury unit service from Crowborough War Memorial Hospital, Lewes Victoria Hospital and Uckfield Community Hospital. A midwifery-led birthing service along with outpatient, rehabilitation and intermediate care services are provided at Crowborough War Memorial Hospital. At both Bexhill Hospital and Uckfield Community Hospital the trust provides outpatients, day surgery, rehabilitation and intermediate care services. Outpatient services and inpatient intermediate care services are provided at Lewes Victoria Hospital and Rye, Winchelsea and District Memorial Hospital. At Firwood House the trust jointly provides, with adult social care, inpatient intermediate care services.

Trust community staff also provide care in patients’ own homes and from a number of clinics and health centres, GP surgeries and schools.

The trust employs almost 7,000 staff and has 706 inpatient beds across its acute and community sites. The trust serves the population of East Sussex which numbers 525,000.

We carried out this unannounced focussed inspection in March 2015. We analysed data we already held about the trust to inform our inspection planning. Teams, which included CQC inspectors and clinical experts, visited the two acute hospitals along with the Crowborough Birthing Centre and reviewed four of the eight core services that we usually inspect as part of our comprehensive inspection methodology. Services reviewed were maternity services, outpatient services, surgery and accident and emergency care; we reviewed these particular core services as in our comprehensive inspection in September 2014, we had identified serious concerns about the care and treatment provided. We spoke with staff of all grades, individually and in groups, who worked in these services. Staff from across the trust attended our drop in sessions on both sites.

In September 2014 we identified concerns about the provision of pharmacy services. We looked at this in our unannounced visits by a CQC pharmacist. A large number of people from the local community and staff had contacted CQC after the previous inspection report was published to tell us it was an accurate reflection of the way the trust provided services.

It is important to note that in the past two years the trust had been through a period of significant change with reconfiguration of some key services across both acute sites. The trust had followed guidance on both consultation and reconfiguration set out by the Secretary of State for Health. The consultation process was led by the local Clinical Commission Groups and has been assessed by an audit of its corporate governance. The assessment of this process by an internal audit company provided assurance to the board and stakeholders that “Corporate governance, in relation to the maternity project specifically, considered to be executed to a high standard and in compliance with the selection of Good Governance Institute outcomes examined”. It also set out that “Structures and decision-making processes clearly set out and followed”. We were aware that the reconfiguration was not universally accepted as a positive change by some members of the public and some staff. Despite the process, many people we spoke to said that they felt their concerns had not been listed to, and they had not been well engaged.

We met with the trust and Trust Development Authority (TDA) representatives on  23 March 2015 to hear about the action they had taken since the comprehensive inspection in September 2014. Details of the action plan were shared with us, with a copy of the draft plan being provided to us on 26 March 2015. Since then the trust has amended and finalised the action plan, making it more robust and focussed.

During this unannounced follow up inspection and in the preceding comprehensive inspection we reviewed clinical services as they are currently configured. Our remit does not include commenting on local decisions about the configuration of services. We have, where pertinent, considered the safety and effectiveness of the services post reconfiguration and whether the trust is responsive to individual and local needs.

Our key findings from the unannounced follow up inspection were as follows:

• The trust board continues to state they recognise that staff engagement is an area of concern but the evidence we found suggests there is a void between the Board perception and the reality of working at the trust. At senior management and executive level the trust managers spoke entirely positively and said the majority of staff were ‘on board’, blaming just a few dissenters for the negative comments that we received.

• We found the widespread disconnect between the trust board and its staff persisted. This is reflected in the national NHS Staff survey.

• The most recent NHS staff survey showed the trust performing badly in most areas. It was below average for 23 of the 29 measures, and in the bottom 20% (worst) for 18 measures.

• Overall the trust was amongst the bottom 20% of all trusts in England for staff engagement. Only 18% of staff reported good communications between managers and staff against a national average of 30%.

• The trust was also in the bottom quintile for staff reporting that they had the ability to contribute towards improvement at work.

• The trust told us they were disappointed by the results; but we saw no direct programme to address this or to change the position.There remained a poor relationship between the board and some key community stakeholders. We found the board lacked a credible strategy for effective engagement to improve relationships.

• We saw a culture where staff remained afraid to speak out or to share their concerns openly. We heard from several sources about detriment staff had suffered when they raised concerns about patient safety.

• Staff remained concerned when they contacted us of the risk of doing so.

• We saw that there remained little public engagement in the wider benefits of the reconfiguration. The trust had followed its original strategy. We saw this had failed to engage significant elements of the community. We saw no new plan to address this issue.

• We saw that local managers had taken some steps that had resulted in an improved patient experience in the outpatient areas but there remained long delays in the referral to treatment time. The trust had taken steps towards improvement but these were yet to demonstrate a sustainable improvement.

• Patients were not being seen for follow-up appointments within the timescale requested by their clinician.

• The call centre for outpatient appointments was not effective. Patients were often unable to make contact with the staff.

• Clinics were sometimes cancelled, and patients had not been informed, or informed at very short notice. There was a lack of appropriate staff to ring patients; who arrived for their appointment and found the clinic was not being held.

• Within the trust, we did not see a cycle of improvement and learning based on the outcome of either risk or incidents.

• Staff remained unconvinced of the benefit of incident reporting, and were therefore not reporting incidents or near misses to the trust. the trust was not able to benefit from any learning from these. this position had not improved.

• The risk register was not capturing risks in a robust way.

• We saw a redesign of the governance structure, but were unable to yet see any significant benefits or improvements from this.

• We saw low staffing levels that impacted on the trusts ability to deliver efficient and effective care.

• In maternity we saw some small improvements had been made to the governance systems but the major improvements needed to bring about sustainable improvements, such as staffing as yet remained unchanged.

• We saw that surgical services and outpatients’ services did not report incidents in a way that would lead to the trust improving services from that learning. We saw that in maternity and surgery there had been improvements in incident reporting but learning was still limited and lessons learned were not embedded.

• We had concerns about the accuracy and robustness of data provided to external stakeholders and the board.

• Training for safeguarding for medical and nursing staff fell well below acceptable levels.

• In a number of areas we remained concerned about medicines management and pharmacy services.

• Checks on controlled drugs were inconsistent in ED, and remained sporadic in surgery, despite a drug register in one area noting an incidence of drugs missing.

• The trust was breaching the provision of single sex accommodation requirements frequently and regularly but not identifying or reporting these. Women and men were both accommodated overnight in the clinical decisions unit and had to walk past people of the opposite sex to use the lavatories and washing facilities.

• There was little consideration for affording privacy to people attending the OPD and radiology where patients changing and waiting facilities were unsuitable and where weighing and other procedures were carried out in corridors.

• The trust healthcare records and records tracking systems remained inadequate.

• The trust was failing to meet the requirements of the National Schedule for Cleanliness in the NHS. Scores from cleanliness audits provided by the trust did not match the aggregated scored from the cleanliness audits we were provided with.

• Staff we spoke with were unaware of their responsibilities regarding the Duty of Candour. Staff we spoke to had not received training on the statutory Duty of Candour (a legal duty to be open and honest with patients or their families when things go wrong that can cause harm) and were therefore unable to describe the processes the trust had in place.

• The trust does receive a higher than average number of complaints for its size although numbers of complaints have fallen over the last two years.  We found a complaints system that gave both poor support for people who wished to raise a concern, and concerns on how the trust handled complaints.

We identified some good practice including

• The telephone triage system provided a high standard of information, guidance and support to women, without them necessarily needing to come into hospital.

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

Importantly, the trust must:

• Give full consideration to whether there have been any breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Regulation 5 (3)(d) Fit and proper persons: directors

• The board needs to give serious consideration to how it is going to rebuild effective relationships with its staff, the public and other key stakeholders. This was a requirement following our inspection in September 2014 but we are not yet assured from the action plan and speaking with the lead executive officer that this had begun to be addressed.

• The board needs to create an organisational culture which is grounded in openness, where people feel able to speak out without fear of reprisal. This was a requirement following our inspection in September 2014 but we are not yet assured that this work was underway.

• Undertake a root and branch review across the organisation to address the perceptions of a bullying culture, as required in our previous inspection report.

• Review and improve the trust’s pharmacy service and management of medicines.

• Review the reconfiguration of outpatients’ services to ensure that it meets the needs of those patients using the service.

• Review the waiting time for outpatients’ appointments such that they meet the governments RTT waiting times, and that this is sustainable. 

• Ensure that health records are available and that patient data is confidentially managed.

• Review staff deployment in maternity services to ensure that they are sufficient for service provision such that the organisation meets the recommendations made by the Royal Colleges. This was a requirement following our inspection on September 2014 but we are not yet assured from the action plan and data provided by the trust that this has been fully addressed.

• Reduce the proportion of OPD clinics that are cancelled at short notice and develop systems to ensure that where this is unavoidable, that patients are informed in a timely manner.

• Develop achievable succession planning to minimise the impact of staff movements.

• Improve the governance of incident reporting systems to ensure that the number of incidents reported via the electronic system reflects all the incidents that happen.

• Ensure sustained compliance with the National Schedule for Cleanliness.

Additionally the trust should

• Ensure that fridges used for the storage of medicines are kept locked and are not accessible to people and that medicines are secured in lockable units.

• Develop sustainable systems to ensure equipment checks are carried out as required by trust policy and national guidance.

• Develop sustainable systems to ensure that VTE assessments and management are conducted in accordance with the guidance from the Royal Colleges.

Subsequent to this inspection visit a warning notice served under Section 29a of the Health and Social Care Act 2008. This warning notice informed the trust that the Care Quality Commission had formed the view that the quality of health care provided by East Sussex Healthcare NHS Trust requires significant improvement:

On the basis of this inspection, I have recommended that the trust be placed into special measures.

Professor Sir Mike Richards

Chief Inspector of Hospitals