Mid Essex Hospital Services NHS Trust employs nearly 5,000 members of staff and provides local elective and emergency services to 380,000 people living in and around the districts of Chelmsford, Maldon and Braintree (including Witham).The trust provides from five sites in and around Chelmsford, Maldon and Braintree. The main site is Broomfield Hospital in Chelmsford.

Broomfield Hospital is an acute 635 bedded hospital. Broomfield hospital also provides a country-wide plastics, head and neck and gastrointestinal (GI) surgical centre to a population of 3.4 million and an internationally recognised burns service at the St Andrews Centre that serves a population of 9.8 million.

We completed a focussed inspection on the 30th January 2017 following a Statutory Notification, to ensure that the trust had implemented the action plan to mitigate the risk of a serious incident reoccurring in the peadiatric Emergency Department. The peadiatric ED department had been reconfigured in 2016 to sit within the Womens and Childrens Directorate as part of the trusts action plan.

This was undertaken by two CQC inspectors and one specialist advisor. Only peadiatric services in the Emergency department (ED) at Broomfield Hospital were inspected. We have not rated this service as it was a focused inspection to review the actions taken by the trust in respect of this incident.

The inspection team made an evidence judgement on one domain to ascertain if services were safe.

We found:

• There was good evidence of lesson learned from incidents that had taken place and where changes had been made in practice and embeded.Due to the reconfiguration of the peadiatric ED department to the womens and childrens directorate, risks and incidents were discussed at a number of meetings and shared across the whole peadiatric pathway.
• There was a dedicated safeguarding peadiatric lead. Safeguarding Level three training had been expanded to include all Health Care Assistants in the ED department, and 100% of staff had completed Level 1 and Level 2 safeguarding childrens training.
• The Children’s Early Warning Tool (CEWT) training and sepsis training had been embedded in paediatric basic life support and paediatric immediate life support (PILS), which was part of the mandatory training programme, meaning that all staff (not just in paediatric ED), had been trained in the management of the unwell child.
• The Children’s Early Warning Tool (CEWT) was in line with national guidance and in line with the observations parameters outlined in the children’s and young people observation policy.
• There was a clear escalation pathway at the back of all observation charts, which included the use of the “SBAR” tool (situation, background, assessment and recommendation) to assist staff when escalating concerns.
• Sepsis workshops had been rolled out to all medical and nursing staff to develop competencies in recognising and responding to children with sepsis. This included the importance of concerns raised by parents about their child’s condition.
• Nurse vacancies had been recruited to although there was still a reliance on agency and bank staff to maintain staffing levels. Due to the reconfiguration of the peadiatric ED department to the womens and childrens directorate, staffing was reviewed daily, or as required by the peadiatric matron and clinical lead to ensure that staffing across with whole peadiatric pathway was safe.
• There was no specialist paediatric ED consultant, however the trust was trying to recruit to this post. Between April 2015 and March 2016, the emergency department saw over 16,000 patients that were less than 17 years of age. The Royal College for Emergency Medicine (RCEM) recommends that in emergency departments seeing more than 16,000 children per year there should be at least one paediatric emergency consultant. The trust does have a consultant with an interest in paediatrics, but overall the trust did not meet this standard.
• There was ongoing recruitment to have a second peadiatric registrar to support the ED registrar 24 hours per day. Although these posts were not fully recruited to, any vacant shifts were put out for locum cover. However, during the period 2 January 2017- 29 January 2017 14 shifts for the second paediatric register had remained unfilled
• Data on major incident training provided by the trust showed that 12 of the 14 nursing staff in the paediatric emergency department had completed this.

We noted that there were good areas of practice and also areas where the trust should continue to make improvements.

The trust should:

• Continue to recruit the specialist paediatric ED Consultant post to be in line with the Royal College for Emergency Medicine guidance.
• Continue to recruit to peadiatric Registrar vacancies to allow 24/7 additional support to the ED registrar.
• To ensure that the completion of the “safe to discharge” check is completed in all patient records by the medical teams.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Broomfield Hospital is part of the Mid Essex Hospital Services NHS Trust (MEHT). Broomfield Hospital is an acute district general hospital and it is the only hospital location within Mid Essex Hospital Services NHS Trust to provide accident and emergency (A&E) services. Broomfield Hospital also provides a county-wide plastics, head and neck and upper gastrointestinal (GI) surgical centre to a population of 3.4 million, and an internationally-recognised burns service in the St Andrew's Centre within Broomfield Hospital that serves a population of 9.8 million.

We inspected the services within the urgent and emergency services (Emergency Department (ED), Emergency Assessment Unit (EAU), Emergency Short Stay wards (ESS and the ambulatory care services) at this hospital on 13 April 2015 in response to concerns of stakeholders and information of concern received into the CQC. Concerns were raised by stakeholders around the flow of patients through the A&E department, whether timely care was being provided and whether patients received sufficient pain relief. Concerns were also raised about ambulance handover delays which resulted in patients waiting for long periods of time prior to being taken into the hospital.

This was our third inspection of the Urgent and Emergency Services due to concerns raised with us. In August 2014 our inspection raised concerns over patient safety, security for patients, especially those with mental illness and paediatric patients, incident reporting and staffing levels and training. At our comprehensive inspection in November 2014 we saw that these issues had failed to be addressed. In February 2015 we returned to the EAU as we were alerted to qualified nurses who were working without registration. Following this issue being raised by us to the trust, action was taken to ensure that only registered nurses were directing patient care in this area. We returned in March 2015 to ensure that actions taken remained in place within the EAU. The service was rated as inadequate following these inspections. We returned in April 2015 due to concerns being raised with us in respect of the care provided within the service. Overall the rating for Urgent and Emergency Services remains as ‘Inadequate’ following this inspection. The domain ratings remained the same with safety, responsiveness and well-led being rated as ‘Inadequate’ and caring being rated as ‘Good’. However the effectiveness of the service has been downgraded from ‘Requires improvement’ to ‘Inadequate’ due in part to a deterioration of the care provided for patients with pressure ulcers.

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 of partners and stakeholders.

This was a focused inspection undertaken by five inspectors from CQC three of whom were qualified nurses, one paramedic and one governance and risk specialist. Only the services within urgent and emergency services (Emergency Department (ED), Emergency Assessment Unit (EAU) and Emergency Short Stay wards (ESS) at Broomfield Hospital were inspected.

Our key findings were:

• The trust has not sufficiently implemented the recommendations and requirements following our five inspections to this service and patients continue to experience a poor level of care and treatment.
• The flow of the emergency department, staff vacancy, skill mix and triage still had an impact on the care patients received which in some cases was poor. Care in the emergency department did not always adhere to NICE guidelines, particularly around head injuries and sepsis.
• The staffing within the EAU and ESS were appropriately trained, qualified and registered for the care they were delivering.
• The care of patients with mental health concerns fell below the expected standard of care in the emergency department.
• Improvements were required in terms of the reporting and learning from incidents.
• There were staffing shortages for nurses throughout the emergency floor and there were notable medical staff shortages within the emergency department.
• Governance structures at departmental level across the emergency department were not robust and were in significant need of improvement.
• Good governance arrangements were not in place as there was a lack of understanding of the risks and issues within the emergency department by the senior management and executive team.
• Assurances on governance and risk arrangements for the services were provided by the departmental leaders to the trust, with the trust believing the services protected patients from abuse and avoidable harm. however the executive team could not produce the evidence to support the safety of services.
• The multiple changes in leadership locally had impacted on the running and morale of the services.
• The culture within the department was poor, there was fear of the management team blaming staff locally for failure to deliver targets and reports or pressure to undertake work practices that were not safe for patients.

We observed areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

• Ensure medicines are administered in a timely way, especially for patients receiving intravenous antibiotics and time critical medicines.
• Ensure care documentation including care plans and risk assessments are undertaken in a timely way, accurately, are fully completed and reviewed when required.
• Improve staff training and awareness on mental health so that the provision of care for patients in urgent and emergency services with mental health conditions improves.
• Ensure patients with mental health concerns are risk assessed on arrival at the emergency department and that patients with mental health concerns are appropriately observed and monitored.
• Review staffing levels on the reception desk in the emergency department.
• Ensure that resuscitation trolleys are regularly checked and stocked.
• Improve staff knowledge and understanding of what constitutes a safeguarding referral for adults.
• Ensure that all safeguarding referrals for adults in the emergency department are completed and actioned in a timely way.
• Improve hand washing techniques and infection control practices and techniques in the emergency department.

In addition the trust should:

• Improve the incident reporting culture for staff to increase the number of incidents reported overall.
• Ensure that recruitment plans, to increase the amount of permanent nurses, are agreed and actioned to ensure that the high usage of agency and bank staff is reduced.
• Review mechanisms for using feedback from patients, so that there are opportunities for reviewing and improving service quality.
• Improve patient confidentiality in the ambulance entrance particularly when staff are discussing patient care.
• Ensure that staff are provided with feedback and informed of learning from incidents.
• Ensure the corridor within the emergency department which leads from the ambulance doors and the resuscitation area is kept clear of obstructions at all times.
• Improve shift and nursing handovers in the emergency department to ensure all staff are informed of the required information.
• Safely plan and increase consultant cover in the emergency department from 11 to 16 hours per day as recommended by The Royal College of Emergency Medicine.
• Improve patient care within the emergency department for conditions such as sepsis and head injuries in line with Royal College of Emergency Medicine guidelines.
• Improve implementation of the escalation protocol in the emergency department.
• Improve ambulance handover times within the emergency department.
• Improve local staff engagement within the ED and between the EAU and ED.
• Improve the working relationship between the ambulance service and the emergency department.

On the basis of the ratings, I have requested for the regulator of non-foundation trusts, the Trust Development Authority (TDA), to review our concerns and implement buddy and support systems for the trust to immediately drive improvement in quality, safety and governance across urgent and emergency services and at trustwide leadership level. We have also served a warning notice to this trust and requested for significant improvements to be made to the quality of healthcare provided to patients. The trust has agreed and continue to voluntarily submit information to the Care Quality Commission to demonstrate the safety of patients, as well as how effective systems and process are within urgent and emergency services.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Mid Essex Hospital Services NHS Trust employs nearly 5,000 members of staff and provides local elective and emergency services to 380,000 people living in and around the districts of Chelmsford, Maldon and Braintree (including Witham). The trust provides services from five sites in and around Chelmsford, Maldon and Braintree. The main site is Broomfield Hospital in Chelmsford which has been redeveloped as part of a £148 million Private Finance Initiative (PFI).

Broomfield Hospital is an acute 551 bedded hospital which has an additional 18 contingency beds not inclusive of obstetrics. It is the only hospital location to provide Accident and Emergency (A&E) services. Broomfield Hospital also provides a county-wide plastics, head and neck and upper gastrointestinal (GI) surgical centre to a population of 3.4 million and an internationally recognised burns service at the St Andrew's Centre that serves a population of 9.8 million.

We inspected this hospital on 19 August 2014 in response to concerns of stakeholders and information of concern received into the CQC. Concerns were raised by stakeholders around the number of serious incidents being reported, learning from incidents, staffing levels and leadership within the A&E Department. There were also concerns around the number of incidents being reported around persons deemed ‘at risk’ of absconding from the department. Concerns around the assessment and treatment of care provided to people with mental health conditions were also shared with us prior to our inspection.  

This was a responsive review undertaken by five inspectors from CQC and two specialist advisors. We were also supported by an Expert by Experience. Only the services within the A&E department at Broomfield Hospital were inspected. We have identified that the service was not compliant with some regulations following this inspection. We have not rated the service as this was a focused inspection however a further comprehensive inspection will be undertaken in November 2014 to determine ratings of all services within the trust.

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.

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

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

Whilst we noted some good practice there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

• Continue to increase the number of permanent trained nurses, paediatric nurses and consultants within the A&E department.
• Embed skill mix assessments for nursing staff to ensure that skill mix is appropriate and ensures the safety of patients in A&E.
• Review the consultant rota to ensure that the minimum numbers of consultants are scheduled on the rota in line with The College of Emergency Medicine guidance.
• Review and improve the management and directorate structure within A&E
• Improve the care provision for mental health patients within A&E.
• Review the use of the room where mental health patients are placed for assessment.
• Ensure that the emergency alarm in the additional majors bays sounds in the correct department.
• Improve the environment in the A&E department, including paediatric A&E, waiting areas and the majors area, to ensure the safety and treatment of patients.
• Improve governance processes and embed an open culture of reporting, sharing and learning from incidents and complaints to improve the care and experience provided to patients.
• Increase attendance at safeguarding training for all staff and improve safeguarding awareness.
• Ensure that staff receive training to support patients with mental health needs.
• Improve numbers of staff attending conflict resolution training and provide breakaway training.

In addition the trust should:

• Take prompt action to ensure that the children’s A&E department is in line with national guidance.
• Review working with the psychiatric liaison services, CAMHS and the local mental health trust to improve the care provided to patients within the department.
• Improve multi-agency working with external agencies including the local ambulance trust and police force around mental health provision.
• Ensure that all staff work together effectively to enhance the experience of the patients, ensuring effective communication at all levels.
• Ensure that risks are assessed and managed within the department.
• Hold meetings in the department to discuss incidents or other governance concerns to staff at all levels.
• Improve the completion of documentation, risk assessments and allergy status for patients within A&E.
• Improve communications from Board to the A&E department.
• Take prompt action to ensure that staff speak to and refer to patients in a dignified and compassionate way.

During this inspection we found that the essential standards of quality and safety were not being met in some areas. As a result of our findings we met with the Chief Executive and Chief Nurse of the Trust on 28 August 2014 to discuss our concerns. We were informed that the trust would address the concerns identified; we were also shown areas that were in the process of being improved since our visit. Therefore we have issued the trust with compliance actions.

We have asked the provider to send CQC a report that says what action they are going to take to meet these essential standards. We will follow up to ensure appropriate action to address the concerns has been taken in November 2014.

Professor Sir Mike Richards

Chief Inspector of Hospitals

On this occasion we did not speak with anyone who used the service about the way their medicines were managed. People were protected against the risks associated with medicines because the provider had improved arrangements in place for the storage and recording of medicines.

We visited Broomfield Hospital in July 2012. We found that the trust was not compliant with Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 in that they were not accurately assessing peoples' needs and planning care to meet people's individual needs and ensure they were receiving the support they required.

We found that the trust remained non-compliant in that people still did not have accurate or timely assessments of their needs in place, the planning and delivery of care was not robust and did not always ensure the welfare and safety of the people using the service. We also found that the trust was not adhering to recognised guidance issued by the appropriate professional and expert bodies.

We spoke to people using the service. They told us that they were happy with the food provided and the choice available. Comments included "I get enough to eat", "The food here at Broomfield is very good" and "The food is much better than the last time I was in hospital." We found that people were provided with sufficient amounts of nutritious food

and were provided with support to enable them to eat and drink. However we found that people did not always have a prompt and accurate assessment of their actual or potential risk of malnutrition and dehydration.

We found that the provider did not have proper arrangements in place for the safe storage and security of some medicines and the safe administration of medication.

We did not speak to people using services on this occasion as this visit primarily focused upon record keeping.

Patients we spoke told us that they were satisfied with the care and treatment they received during their hospital stay. Patients on Felsted ward told us that staff were attentive and caring. One patient told us ‘’Staff are busy and they work very hard. I always get the help I need. The doctors and nurses are wonderful. I cannot fault the care here.’’

Patients we spoke with on Phoenix ward told us that the care was excellent. Two parents we spoke with told us that they felt confident that their children received the very best care. One patient told us ‘’The doctors, nurses and all the staff here are patient and understanding. They really take into account our fears and keep us up to date with any changes in treatment.’’ Another patient said ‘’I think the care is exceptional. There is always someone available to speak with and answer any questions I have.’’

Two patients we spoke with on Rayne ward told us that they were happy with the care they had received. One patient commented that on occasions the treatment had not been explained to them initially by the doctor. They told us that when they asked the nursing staff that they were given a full explanation of the treatment.

Patients on Danbury and Billericay wards told us that staff were polite, pleasant and helpful. They also told us that procedures were explained to them in a way that they could understand. Some patients told us that staff gave advice in a calm and reassuring way and presented them with treatment options, making them feel included in decisions about their care.

The majority of patients we spoke with told us that they were happy with the quality and choice of food available to them during their visit to Broomfield Hospital. One patient commented that, in their opinion, there were not enough vegetables served. Two patients on Felsted ward to us that there was a very good choice of hot and cold meals available. One patient on Rayne ward said that food was ‘’ok’’. Another patient told us ‘’The food is very good, much better than I expected it would be.’’ We were told, by two patients we asked, that they were provided with sufficient drinks. We were told water jugs by their bedside were replenished frequently and they were offered regular hot drinks.

Patients we spoke with told us that the hospital was clean. One person on Braxted ward told us ‘’It is very clean here, toilets and bathrooms are clean.’’ Two people on Felsted told us ‘’There are cleaners here most days. It is always very clean here." Patients we spoke with on Billericay ward and Danbury ward also said they felt the environment was clean. One person said that they felt the ancillary staff were thorough and unobtrusive.

Patients we spoke with told us that they received their medicines at the expected times during their stay in hospital. Two patients we spoke with on Rayne ward told us that where new medicines had been prescribed for them that the reasons for their use had been explained to them. Patients told us that they were given sufficient information about their medicines when they were discharged home.

Two patients we spoke with on Billericay ward told us that staff always responded promptly when they requested assistance. One patient told us that they felt there were enough staff available. They commented, however, that over the previous bank holiday weekend they felt that the ward was short staffed.

One patient on Danbury ward told us that staff usually assisted them when needed. They told us that on one occasion staff had ‘forgotten about them’ and they were left in the bathroom for 40 minutes without assistance.

Patients we spoke with on Rayne and Felsted wards told us that staff were usually available when needed. One patient told us ‘’I rarely have to wait and if I do it is usually because someone needs more urgent help. That’s only to be expected.’ ’Patients told us that they felt medical and nursing staff worked well as a team and that this gave the confidence in their care and treatment.

Patients we spoke with told us that they were happy with the care they received from staff. Patients on Felsted and Rayne wards told us that they felt staff were skilled and knowledgeable.

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

People with whom we spoke told us that they were overall very satisfied with the treatment and service they received at Broomfield Hospital. People told us that staff treated them with dignity and respect. Most people commented that the treatment they received was 'very good' or 'excellent'

Some people told us that treatment was not always explained to them and that there was a lack of written information available about treatment options. We were told that overall staff were very helpful. A number of people commented that they felt there was a shortage of staff at times. They told us that on occasions staff appeared to be 'very rushed' and that staff shortages meant that they did not always receive assistance with personal care or assistance at meal times as needed.

People told us that the hospital was very clean. They told us that staff washed their hands before and after assisting them. All of the people with whom we spoke said that they had not noticed any shortage of equipment in the hospital and, in their experiences, it had been available whenever it was required. They felt that staff appeared to be trained and competent its use.

People with whom we spoke told us that they were unaware of the procedure for making a complaint and that they had not received any written information about how to complain. Most people told us that they were very satisfied overall with their hospital experience, however the majority of people said that they had not been asked to give their views or for any feedback on their stay.

This section was not completed for this inspection. More information about what we found during the inspection is available in the report below.

This section was not completed for this inspection. More information about what we found during the inspection is available in the report below.

We did not inspect all services at this inspection but we combined previous inspection ratings for those not inspected to give an overall rating for the hospital. We inspected urgent and emergency care, medical care, surgery, children and young people’s services, outpatients and diagnostic imaging.

Our rating of services went down. We rated it them as requires improvement because:

• We rated safe, effective, responsive and well-led as requires improvement and caring was rated as good.
• Our rating for safe remained the same. Staffing remained a challenge for the trust and the processes to ensure that temporary staff were competent for roles was not consistently applied. There were inconsistent practices in medicines management and record keeping.
• Our rating for effective went down to requires improvement. Local and national audits were not being utilised to drive improvements and improve patient outcomes, there was a lack of training for staff in the Mental Capacity Act, 2005.
• Our rating for caring remained the same. However, we found in some areas of medical care services, that staffing challenges limited staff’s capacity to always deliver compassionate care.
• Our rating for responsive went down to requires improvement. There were significant issues with access and flow throughout the hospital. Patients could not always access care and treatment in a timely manner.
• Our rating for well-led went down to requires improvement. There were no clear strategies for individual services. Staff were unclear of how they could contribute to the development and delivery of long-term objectives. The trust was going through a period of transition and infrastructures were being developed and were yet to be implemented.

However

• The trust had developed plans with external stakeholders for future provision of services in line with national objectives to achieve sustainable quality care.