Assurance review to Colchester Hospital University NHS Foundation Trust

Assurance review to Colchester Hospital University NHS Foundation Trust Prepared by NHS England, Midlands and East region, on behalf of Monitor February 2014 Version v 5 FINAL 1

Contents 1. Introduction 2. Purpose of the review 3. Methods of investigation 4. Summary findings 5. Key findings against the trust action plan 6. Conclusion Appendices Appendix 1: Terms of reference for the review Appendix 2: Panel membership Appendix 3: Assurance visit agenda Appendix 4: Focus Groups Appendix 5: Ward visits Appendix 6: Interviews Appendix 7: List of documents reviewed 2

Introduction Colchester Hospital University NHS Foundation Trust was one of 14 NHS hospitals inspected as part of the Sir Bruce Keogh review of the quality of care and treatment in June 2013. As part of that review, a multi-agency risk summit was held to agree an action plan. It was agreed at the risk summit that a follow-up visit would be held later in the year to review progress. The Trust was put into special measures in November 2013, following concerns with regards to the quality of care for cancer patients. An Improvement Director, Mark Davies, was subsequently appointed by Monitor in December 2013. At the time of the visit there had been significant changes to the Executive team, many of whom were recently appointed and had just started in post in early 2014. Purpose of the assurance review Responsibility for monitoring progress against the agreed action plan rests with Monitor as the regulator of NHS Foundation Trusts. Monitor subsequently requested support from NHS England to undertake the follow up review of the action plan on their behalf. The review terms of reference agreed between Monitor and NHS England are attached at appendix 1. NHS England s support has comprised of: A desktop review of the documentary evidence supplied by the trust in support of its progress against the agreed Keogh action plan A one day announced site visit, undertaken by a multi-agency panel of experts, to look at whether care and treatment on site at the hospital was in line with the documentary evidence received, and to ascertain to what extent the agreed actions had been implemented and effective. This included meetings with members of the trust executive and non-executive board, talking to patients, carers and staff, and undertaking ward and departmental visits Preliminary feedback to be provided to the Trust at the end of the review, and shared with Monitor and CQC Panel to escalate any concerns whilst on site to the CQC, Monitor, CCG, and trust for action A formal report on the panel s findings The assurance review panel was chaired by Dr David Levy, Regional Medical Director for NHS England (Midlands & East). The panel included a number of the original Keogh Review panellists, including the lay representative, and representatives from North East Essex Clinical Commissioning Group and NHS England s Area Team for Essex. This one day assurance visit was intended solely to review progress against the action plan and was not intended to identify any new areas of concern or make recommendations about the removal of special measures in place. 3

Methods of investigation A one day desk top review was undertaken by NHS England and a one day announced visit followed this at Colchester Hospital University NHS Foundation Trust on Friday 7 th February 2014, with a site visit to Essex County Hospital on the afternoon of the 6 th February at the request of Trust staff. The panel visiting the trust consisted largely of the members of the Keogh review panel, allowing comparisons to be made over time. As per the Keogh review visit, the panel used a variety of methods including interviews, focus groups, ward observations and review of documentation. This has enabled the panel to consider evidence from multiple sources in making their judgments. Summary findings Following review of evidence from available sources, the panel agreed whether they are assured, partly assured or not assured that the trust has implemented the actions agreed following the Keogh quality of care and treatment review. Where it was agreed that the trust had fully implemented an action and the outcomes of that action were apparent, an outcome of assured was recorded. Where there was evidence of progress with implementation, but implementation was not complete, the outcomes were not yet evident or it was too early to tell if the changes were embedded and sustainable, the panel recorded an outcome of partly assured. Where there was limited or no evidence that implementation had started, or significant concerns remained, the panel was able to record an outcome of not assured. An outcome has been recorded for each group of actions set out in the reports of the Keogh rapid responsive review and risk summit. In summary, 33 groups of actions were assessed, with one group of actions recorded as assured and 26 as partly assured. Six areas were recorded as not assured. The full outcomes are contained later in the report, but the outcomes in summary are listed below: 1. Development of a quality focus not assured 2. Clinical leadership structure partly assured 3. Committee structure and reporting partly assured 4. Communication between Board and Ward level and escalation of risks and issues partly assured 5. Role of Governors partly assured 6. Absence of clear prioritisation and pace of change not assured 7. Performance reporting partly assured 8. Ward level performance reporting - partly assured 9. Deteriorating patients - partly assured 4

10. End of Life provision across the health community partly assured 11. Surgical site infections - partly assured 12. Sepsis - partly assured 13. Escalation procedures - partly assured 14. Patient flow and management between A&E and EAU not assured 15. Mortality review partly assured 16. Clinical coding - partly assured 17. Visibility of Executive team - partly assured 18. Effectiveness of Clinical leaders and management at divisional level - partly assured 19. Leadership from senior doctors - partly assured 20. Complaints process - partly assured 21. Patient experience themes - partly assured 22. Engagement with trust staff - partly assured 23. Radiology escorts assured 24. Staffing levels and skill mix partly assured 25. Support for junior doctors not assured 26. Sickness absence and vacancies partly assured 27. Hospital porters partly assured 28. Quality of handovers partly assured 29. Reporting of serious incidents - partly assured 30. Dissemination of lessons learned - partly assured 31. Clinical supervision not assured 32. Staff appraisals and development partly assured 33. Compliance with mandatory training not assured 5

Key findings of the assurance review Keogh review action Outcome: Assured Partly assured Not assured Comments including any outstanding issue(s) KLOE 1. Can trust staff clearly articulate governance process for escalation of issues and risks and assurance over quality of care? 1. Quality Focus still being developed 1.1 Trust needs to consider how it will develop a clearer focus on quality, based on transparent performance information and a tone from the top. This should include implementation of planned improvements and recommended actions from the Keogh panel report. 1.2 The Trust must increase the pace of planned change to develop a safe and mature organisation that provides high quality care. 1.3 Trust needs to develop a clear and comprehensive Quality Strategy and ensure it is consistently applied throughout the organisation. This needs to include areas of priority with defined action plans in place 1.4 The role of the Quality Hub and staffing needs to be reviewed, including: Serious Incidents Complaints Integrated quality measures including Datix, SI s and lessons learned Not assured Not assured 1.1 and 1.2. The panel saw evidence of progress in the development of a quality focus and the implementation of actions from the Keogh review. However, the panel felt more pace was needed, the changes made needed to be embedded, and further improvements still need to be made. The move from quarterly to monthly Quality and Patient Safety Committee meetings was noted as a positive improvement. The depth and substance of the Quality and Patient Safety Committee papers as sent to Trust Board meetings was also noted as having improved in the last few months. Panel members saw ward level quality scorecards on the wards visited, and ward staff were able to describe how this is used at monthly ward meetings. The panel also saw examples of newsletters produced for staff communications as a result of ward level data. 1.3 Not assured. Whilst the panel appreciate that a Quality Strategy has been produced, containing some priority areas for action, the panel felt strongly that this needs to be significantly improved to be more comprehensive and to outline a longer term quality vision with clear measureable priorities. It is recommended that this is urgently refreshed by the Medical Directorate team who lead on quality strategy. Although the quality strategy was weak the panel were pleased to hear staff speak that patient safety was their top quality priority. 1.4 Not assured. The panel noted that there is widespread confusion 6

KLOE 1. 2. Clinical leadership 2.1 The Trust should review the management structure in place to ensure it is robust enough to support consistent leadership and management at divisional level. This should show a single reporting line for both divisional managers reporting into divisional directors. 2.2. The Trust needs to review the organisational structure and consider the benefits of including nursing representation at senior level, to ensure clinical leadership and accountability for patient safety throughout the Trust. 2.3 The Trust should review the reporting lines for clinical and associate directors and consider if current arrangements allow the Executive team to achieve a joined up approach to management. amongst staff at all levels regarding the role of Quality Hub and how this can help staff. There was poor understanding on the wards in particular as to the role and function of the Quality Hub. Further development to include complaints would make it more useful for staff. 2.1. The Trust has reviewed the management structure and the divisional clinical directors were noted as now appointed, nursing and operations leads yet to be appointed. 2.2. The Trust outlined plans to break down training into bite size chunks for training in risk management, project management and similar. The panel felt that a structure outlining this would be beneficial. The panel also recommended participation in CQC visits for senior clinical leaders and managers. 2.3. Reporting lines in the clinical reporting structure were noted as clear and the panel were partly assured on quality reporting lines, but noted there was confusion amongst staff at all levels as to who at Board level is responsible for quality. The appointment of a Deputy Divisional Clinical Director for cancer was noted. Trust to produce a strategic plan to develop a clinically led and managerially supported strategic organisation to re-visit existing divisional strategy, including consideration of nurse leadership at senior level Trust to appoint a Deputy Divisional Clinical It was noted that the Trust had met with the Leadership Academy to discuss support needs. Good progress overall was noted, however until all recruitment and training/development is completed and the new structure embedded the panel could not be completely assured. 7

Director for Cancer Trust to clarify reporting lines Trust to undertake a risk assessment of structures and divisional single point of accountability and staffing Trust to discuss with Leadership Academy the support required for clinical leadership and Board development. KLOE 1. 3. Committee structure and reporting A systematic approach to reporting should be developed, in response to confusion over the Trust s committee structure and where accountability for patient safety sits: 3.1 The Trust should review committee structure to ensure clear lines of reporting and accountability for patient safety. KLOE 1. 4. Communication between ward and Board level escalation of issues and risks Processes for escalation of issues and feedback of outcomes to ward level as articulated by the Board were not consistently understood by ward staff interviewed: A broad external review of governance has been undertaken; and the panel noted the committees and reporting lines in place. However these appear to be overburdened and are not functioning to their full potential. For example, Quality and Patient Safety committee papers are too long and have a very ambitious agenda. The panel also noted that the Trust do not appear to fully utilise the skills and experience of the Clinical Governance Manager. Progress was noted but changes need to be embedded over time, and further improvements still need to be made. 4.1. The Trust has made progress in ensuring robust mechanisms are in place. Ward staff were able to describe arrangements for escalation of risks and issues, however implementation of these systems is patchy. 4.1 The Trust should ensure there are robust mechanisms embedded within the divisional structure that allow front line staff to escalate risks and concerns about the quality of patient care in a 4.2. Quality reports have improved but staff feedback suggests staff are not listened to, and that data is not analysed and acted on. Many staff commented on the lack of feedback received following upwards reporting. The Trust response to the friends and 8

consistent manner. 4.2 Trust Board should ensure there is a systematic approach in place for the collection, reporting and acting upon information on the quality of service. This should include patient and clinician insights and include staff feedback and engagement in learning and service improvement. 4.3 Trust Board and management (wider than the Chief Executive) should consider how to strengthen their visibility, accessibility and listening mechanisms with frontline staff. This could include visiting areas of the hospital including at nights/weekends, to understand concerns and should include feedback to wards on observations. 4.4 The Trust should review the role of the Quality Hub see 1.4 KLOE 1. 5. Role of governors 5.1 The Trust should consider governors attending Board committees so that they can undertake their role more effectively. Not assured family test was not comprehensive and reassuring and lacked insight. The Trust complaints team noted some improvement have been made but flagged that complaints were often not being coded under the correct category which does not help support learning from complaints. The cancer department commented to panel that they felt unsupported. The Director of Nursing also commented that nursing staff had been disempowered, but the trust was working to strengthen the nursing voice. 4.3 Not assured. Please note the new Executive team had recently started in post. The presence of the Trust Chief Executive in A&E on a daily basis was noted, but they were not noted as similarly present on the wards. The Director of Nursing and Non-Executive Directors (NEDs) were noted as visible on the wards by staff at the main Colchester Hospital site, however staff at Essex County Hospital complained that they had not seen NEDs or the Director of Nursing. The panel welcomes the plans expressed by the Director of Nursing to undertake weekly visits to the Essex County Hospital site. Trust staff also commented on the lack of feedback on observations and lack of feedback on actions being taken in response. See comments for 1.4 A governor induction and training programme is in place. Governors now sit on all committees, and attend these, however currently this appears to be in the role of observer rather than as a full participant. The panel were advised that this is because of the pending governor change over and that once new governors have been elected the incoming governors will be supported to undertake a more active role in engaging with committees. It is expected that this will be part of any plan for the new intake in April. 9

KLOE 2 How does the Trust use quality and performance information to support good governance? 6. Absence of clear prioritisation and pace of change 6.1 Following the update of the Quality Strategy, the Not assured Board should approve a single prioritised action plan for the Trust showing clearly the priorities by time period. This should be clearly communicated to staff and progress against plan monitored. KLOE 2. 7. Performance reporting 7.1 The Trust should review the information received by the Board and Executive committees to ensure members receive the correct information at a sufficient level of depth to scrutinise and challenge performance. The panel noted that the Trust has developed a Quality Strategy which does contain priority action areas, but it was also noted this lacks ambition, timescales and agreed action owners, and is not sufficiently comprehensive. Staff also appeared unaware of the Quality Strategy despite efforts having been made by the trust to communicate this. The panel felt strongly that the Quality Strategy urgently needs to be re-written and re-launched, despite this having been signed off by the Trust Board, before the panel could be fully assured. The Trust did acknowledge that this is work in progress. The panel wish to note that despite this they felt that staff do focus on patient safety. The panel expressed concern that performance reports include data but contain no interpretation and explanation of what the data means, and thus felt that NEDs could not be sufficiently informed or assured as a result. It was also noted that NEDs appear to be very operationally involved, and therefore unable to take a step back to critically evaluate performance as expected. However it was acknowledged by panel that this could be addressed by making improvements to performance reports and also that this may have been a necessary short term response to numerous recent Executive team changes. The issue with the depth and detail of performance reports was acknowledged in interviews with the Executive team who commented to the panel that reports are not sufficiently granular and detailed. Some senior staff advised that they use ward level quality scorecards instead as a performance guide. The panel noted improvements in the new quality dashboard, but were overall not able to record an 10

8. Ward level performance reporting 8.1 Ward level information published on notice boards should be displayed in a consistent and standardised way and include steps taken to improve where performance is below expectation. outcome of assured given the issues noted. The panel noted that quality scorecards were not displayed in the wards visited, and when talking to staff panel members were advised that staff have been told to remove these from the wards. The use of Friends and Family test and patient safety crosses including information on falls and other quality areas on the wards visited was noted. However it was felt that they were not patient friendly or easy to interpret. It was also noted, however, that these contain no information on outcomes or details of actions taken in response to red areas of underperformance and hence the panel was only partly assured in respect of this action. KLOE 3 What governance arrangements does the Trust have to monitor and address clinical and operational performance data? 9. Deteriorating Patients 9.1 The Exec team should engage with clinical leadership and frontline staff to understand the reasons for inconsistent escalation of deteriorating patients. Trust to re-launch sepsis care bundles and escalation policy and seek assurance both are fully embedded at the Trust. 9.2 Immediate action should be taken to address issues identified relating to deteriorating patients. A clear action plan should be developed and regularly monitored by the Board in order to seek assurance that issues are being addressed. 9.3. The Trust wide roll out of the national early warning system (NEWS) should be expedited, with a Assured 9.1. The sepsis bundle has been rolled out, but is not in use throughout all areas of the hospital which is recognised by the Trust. 9.2. The panel saw examples of serious incidents in relation to deteriorating patients where the Board has looked at the information but did not appear to have taken overt action in response. Issues with the care of medical patients during out of hours were highlighted to the panel during ward visits and staff meetings. The whiteboards viewed included the NEWS score which was helpful. However, on one ward, the patient name had not been updated following a bed move and the ratings were thus for a different patient. The panel expressed concern at the inadequate level of outreach care available it was noted that this is provided by a single outreach nurse only. The panel saw good example of the use of deteriorating patient stickers on D Arcy Ward. 9.3 Assured. The panel observed that NEWS has been rolled out, 11

clear training programme for staff, a policy in relation to EWS and escalation, and regular audit of the tool and triggers undertaken. KLOE 3 10. End of Life provision across the health community 10.1 Trust should continue to work with the CCG and Assured community health providers to develop end of life care pathways with partners. training completed, and audit undertaken. 10.1 The panel were assured having reviewed the jointly developed End of Life care strategy, which has recently been signed off by key partners. 10.2 A strategy should be developed through joint engagement with the CCG to review wider health system engagement to make better use of hospital beds, including out of hospital care, preventative strategies and community care, to improve end of life provision for patients. KLOE 3 11. Surgical site infections 11.1 The Trust should continue to meet with the consultant body to monitor plans to reduce the rates of surgical site infection. 11.2 The Trust should continue to monitor the use of surgical safety checklists to ensure they are filled in correctly and consistently by consultants and their teams across all Trust settings where required. 11.3 Trust should review the use of prophylactic antibiotics by surgical teams. 10.2. The panel noted that the strategy is a good robust document but that this needs time to be fully embedded before the panel could be completely assured. 11.1. The panel noted that there has been an external review of surgical site infections, and whilst rates have reduced, there remains variation in practices across the Trust. The panel also noted that there was no evidence of actions having been taken in response to the external review commissioned. 11.2. It was noted that the Trust is not achieving 100% use of checklists or 100% correct completion of checklist. On talking with staff the lack of compliance was described as being an oversight in competing the documentation rather than active resistance to use the checklists. The panel felt from talking to the Medical Director that there is the beginning of a positive cultural and behavioural change amongst consultants which was re-assuring, although noted the lack of evidence of actions being taken in respect of non-compliance. 12

KLOE 3 12. Sepsis 12.1 The Trust should ensure that the management of sepsis using a care bundle approach is embedded throughout the Trust and is regularly reviewed to make sure it is consistent KLOE 3 13. Escalation procedures 13.1 The Trust should consult with front line staff to understand why the policy for escalation is not being used consistently and why, where staff have raised concerns previously, no action has been taken in response. 13.2 The Trust should review their protocols and plans and ensure they are followed when there is a need to open additional beds at times of increased activity. These should include forward planning for staffing of wards as well as equipping them. 13.3 The Executive team should clearly understand the lines of accountability for the quality of care on Not assured 11.3. Whilst the use of prophylactic antibiotics by surgical teams has been reviewed there had been no change in practice as a result. The panel would like to see protocols for prophylactic antibiotics usage being implemented, and would also recommend an external/ccg led review. The sepsis bundle has been rolled out, but is not in use throughout all areas of the Trust and further work needs to be undertaken to ensure this is consistently applied and embedded across the Trust. The panel noted that medical staff rarely complete their parts of the sepsis bundle paperwork. In particular it was noted that nurses will instigate elements of the bundle, e.g. giving oxygen, but that the elements requiring actions by medics were not being filled in. Some overall resistance to the use of care bundles was described by the Medical Director. 13.1 and 13.2 -. In focus groups it was noted that many staff did not feel improvements in relation to the use of contingency beds had been made. For example staff frequently described running between wards to find beds. Ward sisters were able to describe a safe process with permanent staff, when only one escalation area is open, although it was recognised that this was less safe when two escalation areas were open. This corresponded with comments made by the Director of Nursing. It was noted that the trust escalation policy still relies on the use of non-clinical nurses (e.g. research nurses) in clinical areas which is not acceptable. Staff also gave examples of heath care assistants being pulled away from their usual duties to work in escalation areas. In summary the panel was concerned at the lack of appropriate and 13

escalation wards and ensure the governance structure and reporting of risks are appropriately managed. The escalation plan should be audited for compliance with review at Board level. KLOE 3 14. Patient Flow and management between A&E and EAU 14.1 The Trust should improve bed flows and patient Not assured management via: Reviewing systems to enable best use of beds at all times, minimising movements of inpatients overnight, and ensuring EAU patients are admitted to appropriate ward Progressing the move to 24/7 working with senior doctors available out of hours Reviewing the use of PAR score documentation and escalation process to provide assurance that Trust policy is consistently applied Reviewing size and use of the outreach team Continuing with recruitment plans to increase staffing levels in A&E and EAU visible cover and forward planning. 13.3 Not assured. No evidence of audit of compliance was demonstrated to panel and it was unsure if the issues and risks described by staff have been noted on any Trust risk register. A number of issues were identified by panel, resulting in an outcome of not assured. Junior doctors described frequent reliance on locums, particularly middle grades in A&E. In addition, not infrequently, it had proved impossible to fill locum posts despite an adequate period of notice, meaning that existing staff had to cover the workload. Junior doctors reported concern that they had, on occasion, been required to act up with which they were uncomfortable. They expressed concern that, in contrast to some other hospitals, there was no EAU team. The work was instead covered by specialty teams on a rota. This, on occasion, led to poor handover at the time the specialty teams switched, due to staff not being on duty. This was reported as resulting in incomplete assessments, and delays posing a clinical risk to patients in EAU. The panel did not hear examples of patients being moved inappropriately. 24/7 working out of hours the panel was advised that increased senior cover was modest. The panel also heard that whilst this had been identified as a priority focus for the Medical Director other pressing issues, particularly around the quality of care and treatment for cancer patients, meant that progressing 24/7 senior cover out of hours had been delayed. It was noted that nursing staff plans are being reviewed. Issues with outreach and critical care team members being pulled away from their other duties to help staff in A&E and EAU was noted, and the 14

KLOE 3 15. Mortality review 15.1 The Trust should ensure that actions required as a result of the executive mortality review group are systematically communicated to staff 15.2 Trust should consider if staff members from a range of seniority and departments can attend the mortality review meetings to make this as open a process as possible, and to share learning Assured panel has already expressed concern about the inadequate level of outreach care available due to the size of the team. Physiotherapy and occupational health staff stated to panel that they were under staffed and this has led to delays in assessing people and therefore affects discharge and rehabilitation. It was suggested that this affects 10 patients plus at any one time. The team advised that when the Trust moved to 7 day working they had proposed a different plan, which was supported by their associate director. However this was not adopted and their concerns were now being borne out. Staff confirmed they had raised the issue through their clinical directorate but did not feel they were being listened to. (At the time of the panel visit in February, 7 day working plans were out for consultation following a previous pilot) 15.1. Increased staff engagement and participation in mortality review meetings was described by the Medical Director, and A&E was highlighted as a particular area where attendees feedback to their colleagues on learning from the meeting. The Medical Director also described how actions and outputs from the review group go to the Quality and Patient Safety Committee for further discussion, where the nature of the issue (e.g. whether this is a data quality issue or clinical issue) is identified. It was felt that learning from these outcomes has helped to drive up standardisation around the use of care bundles, but at the same time the Medical Director acknowledged that this work had not progressed as far as he would have liked. 15.2 Assured. The Medical Director gave examples of representation at mortality review meetings, including from junior doctors, and nursing, and described regular attendance from a local GP who in 15

15.3 Trust to consider how it can more systematically use the mortality information it has to improve care pathways and provide assurance to the Board that actions agreed from reviews are being addressed KLOE 3 16. Clinical coding 16.1 Trust to continue to develop the clinical coding team and develop relationships with clinical coding staff to reduce the coding error rate. KLOE 4 What does the Trust do to develop and strengthen clinical engagement and leadership? 17. Visibility of Executive team 17.1 The trust should consider the need to formalise ward observations to increase the visibility of the Executive team with frontline staff and how findings of these observations are reported back at ward level. KLOE 4. 18. Effectiveness of Clinical leaders and management at divisional level 18.1 The planned move to a clinically led organisation requires a strategy to achieve this, and should include a comprehensive development programme for those in or aspiring to be clinical leaders. This should apply to clinicians in the wider sense and not just medical staff. turn links with their primary care colleagues. The panel also reviewed supporting documents supplied. 15.3. Improvements in End of Life care pathways was noted, however in other areas such as heart failure and COPD there was no evidence of learning in order to improve care pathways. It was noted that the development of a joint strategy with the CCG would however partially address this. It was also noted that the Trust monitors SHMI and HSMR via the use of HEAD and Dr Foster intelligence, for example, and that mortality rates appear to be reducing. The quality of clinical coding was noted as having improved but it was also noted that engagement between the clinical coding team and other departments, particularly with surgical colleagues, was limited. Increased Executive team visibility was noted from interviews, discussions with staff, and focus group on the main Colchester Hospital site, however the panel also noted the lack of actions or typed up notes resulting from these visits and staff also reported a lack of feedback following visits. 18.1. There is a strategy in place for a clinically led organisation, and a development programme has been established for divisional directors. The Trust has also undertaken a top 35 talent review. However no evidence of the involvement of nursing staff or Allied Health Professionals in appropriate development programmes was seen by the panel, and hence the panel was only partly assured. 16

18.2 The Trust should seek feedback from staff at all levels on how to improve two way communications between front line staff and management. 18.3 Trust should review the assurance process in place for bullying and harassment. 18.4 The Trust should review any specific reports of bullying received in order to ensure that the response to this has been appropriate and a proper investigation undertaken. KLOE 4. 19. Leadership from senior doctors 19.1 The Trust should ensure that there is a clear strategy in place with timescales to implement the clinically led structure. 19.2 The Trust needs to understand from the nursing team why they perceive that senior consultants are not engaged or support them in a in a more consistent and effective manner (re. ALERT training programme). 19.3 The Trust should seek feedback from nursing staff and junior doctors on how senior medical staff can engage with and support them in a more effective manner. 18.2. Both the Director of HR and the Trust Chair referred to the development of a communications strategy for staff. However, staff reported to the panel the lack of feedback from management and advised that they were unclear about key trust initiatives such as the purpose of the re-launched Quality Hub. 18.3. Nursing staff and junior doctors reported being treated with respect, however feedback from other staff and the staff survey results (as reported to the Trust Board) suggest that issues with bullying and harassment continue to affect staff and that these are not isolated incidents. 18.4. The panel appreciates that the Trust has looked at staff survey results on bullying and harassment, for example, but did not see any evidence that the Trust has undertaken any proper investigation in response to reports of bullying. 19.1. A clinically-led strategy has been developed, and a number of divisional directors were noted as now appointed, but some gaps in recruiting to the new clinically led structure remains. Trust staff at all levels also appeared unclear on who leads in respect of Quality at Director level. 19.2 and 19.3. The Trust staff survey results suggest some collation of feedback from nursing staff, for example, although it was not clear what actions or outcomes have been taken as a result. Feedback from staff focus groups about senior medical support and engagement was positive, although the panel did not see much evidence of how the Trust has sought or used feedback from staff. 17

19.4 The Trust should be innovative in its engagement with the senior medical workforce, in order to enable divisional clinical leads and senior doctors to further develop to fulfil their roles, and for their roles and responsibilities to be clarified. KLOE 4. 20. Complaints process 20.1 The Acting DoN and PALs manager should review the handling of complaints and processes whereby complaints can be systematically feedback and used by staff teams to improve service delivery. This should include: Improving understanding of visibility of complaints methods with staff and patients The Trust continues to liaise with and meet patients to ensure concerns addressed. Review size and structure of the complaints team. Review the governance arrangements at directorate. level to improve ownership of complaints. Review the process and person responsible for ensuring a complaint is answered in a timely manner. Develop a mechanism for learning lessons from complaints and communicating these across the organisation to ensure key messages are cascaded. E.g. establishing a lessons learned panel with divisional leadership team membership 20.2 The trust should review the focus, culture and approach of PALs to be more patient experience 19.4.. The Trust has developed a staff communications strategy and the panel heard about development programmes being implemented or developed for clinical leads and other senior staff. However, as this work is at an early stage and is not yet fully embedded the panel could not be fully assured against this action. 20.1. The Complaints and PALs team have undertaken a lot of work and made improvements in processes and systems, however key members, including the team leader, continue to be interim and thus the sustainability of the team and the improvements made remains unclear. Permanent members of the team were not sure if interim staff would be able to continue in post, whether roles would be recruited to permanently, or whether resources would be lost longer term. Lack of resource to flesh out complaints responses at ward level was identified by the team as an issue, and medical leadership in respect of complaints was felt to be unclear. The current team are well led, with a clear view of the challenges and the required solutions, and are very committed to improving the service. 20.2. The enthusiasm and commitment of the PALs team was noted, and panel felt that a good plan around the role of PALs had been developed. However the plan is in the early stages of implementation and full reporting of themes and outcomes to both ward and board is not complete. 18

focused, impartial and approachable. KLOE 4. 21. Patient experience themes 21.1 The Trust should undertake real patient communication and engagement through: Reporting patient stories to the Board in a systematic way (not just numbers and trends) Communicating actions taken in response to patient feedback back to patients The Executive team should gain assurance that action plans in response to feedback are implemented. Actively seeking feedback from patients and relatives which is wider than just from the membership. The Trust Board should receive a summary of the substance of complaints, trends and themes as a minimum. This should be reviewed and an action plan agreed to respond to key themes. PALS information should be included in this. Trust should capture more real time patient experience data and report it in a systematic way from ward to Board and back to ward. The Trust should develop an action plan to address issues raised in the CQC patient survey. Board to seek assurance that where action is taken the impact is triangulated with patient experience themes. KLOE 6 22. Engagement with Trust staff 22.1 There appears to be an issue with the flow of information between staff and managers at the How does the Trust engage with its workforce and other stakeholders? Evidence of patient stories being taken to the Board was supplied, but the panel did not see evidence of a systematic plan for learning from these or learning from other sources of intelligence. There was no evidence of a patient engagement strategy or plan. The NED responsible for patient engagement stated that the communication lead was developing this. The panel was told that Health Watch are undertaking work at the hospital but this was not mentioned by the NED. While wards and areas in the hospital were undertaking individual initiatives there was no evidence to suggest that these were co-ordinated or joined up. The Patient Experience Working Group was also referenced in Quality Committee minutes to be undertaking work but this has yet to be fully developed. The involvement of Governors and the wider Foundation Trust membership could also be further developed and allied to enable more joint work with partner agencies across the health economy. 22.1. The panel saw some good examples of information and communication flow, but felt that mechanisms for 19

Trust that is not visible to the Trust Board. 22.2 The Trust should ensure it uses systematic processes such as Focus Groups to engage with and gather feedback from staff, including ways to gather feedback confidentially. 22.3 The Trust should consider how it uses the information collected to act on concerns raised by staff and how it feeds back actions taken as a result to all staff in a consistent manner. Assured KLOE 7 How is the Trust assured it has the necessary workforce to deliver safe care? 23. Radiology escorts 23.1 The Board should obtain urgent assurance that Assured the policy is being applied consistently. This should include working with the CQC to provide them with assurance that action has been taken and Trust staff are compliant with the policy. KLOE 7 24. Staffing levels and skill mix 24.1 The Board should urgently review staffing levels on the following wards to assure themselves that staffing levels are safe, especially out of hours: Brightlingsea D Arcy Fordham Nayland 24.2 Staffing reviews have taken place and additional Assured staff engagement are not yet fully rolled out. Staff also reported a general theme of lack of feedback in response to issues, queries, and concerns being raised. 22.2 Assured. The panel saw and heard about some good examples of honest and confidential staff feedback and as such felt sufficiently assured in this area. 22.3. Whilst the panel saw some good examples of staff engagement and mechanisms for collecting staff feedback, these are not yet fully rolled out, and as previously noted staff have reported not receiving feedback on action taken in response to issues which they have raised. The panel reviewed the escort policy and saw on site evidence of this being implemented and adhered to, including use of the 2 boxes on wards and in A&E. It is recommended that the Trust should audit compliance and include within this the impact on ward staffing in areas requiring the most escorted journeys. 24.1 Assured. A nursing skill mix has been undertaken, and completed for the wards identified, which the panel were assured on, although it was noted that this has not yet been approved at Board level. 24.2. This was noted as having been completed for some staff groups or departments, with recruitment underway or completed, but was noted as not having been completed consistently across all of the Trust. In particular the panel felt that the staffing review of EAU needed to be revisited. 20

nursing and medical staff recruited, however the panel felt that they did not see a comprehensive strategy for assessing and addressing staffing issues at the Trust. The Trust should develop a clear credible plan for staffing levels which sets out how it will ensure staffing levels and mix are safe. 24.3 The Board should assure itself that investment in additional medical and nursing staff is impacting in high risk areas. Information should be reported to the Board that clearly triangulates staffing levels qualified to unqualified nurse ratios, incident rates, (e.g. falls), so that the Board can measure the impact of additional investment in staffing levels and ensure staffing levels are consistently safe. KLOE 7 25. Support for junior doctors 25.1 The Trust should review the staffing levels and support for junior doctors, addressing concerns about bleeps, inappropriate delegation and escalation processes. Not assured Not assured 24.3 Not assured. The panel saw no evidence of triangulation or mechanisms in place to identify the impact of staffing changes. The panel felt that this should be the role of the Quality Hub. Junior doctors raised a number of patient safety concerns, including the quality of handovers, and moving of patients between EAU and wards leading to junior doctors seeing sick patients who had not previously been flagged. See comments for 14.1. Lack of registrar input, especially out of hours, was also identified as a cause for concern by juniors, as was reliance on locums where a locum was available to cover rotas. Junior doctors noted the requirement to contact the consultant on-call to discuss ITU admission (consultantto-consultant referral only) and commented on the delay this could pose, particularly when the outreach team had clearly indicated an ITU admission was needed. Given the issues raised the panel was not assured about support for junior doctors The hospital at night electronic bleep software system has been suggested to the Trust Medical Director as an appropriate 21

26. Sickness absence and vacancies 26.1 The Trust should review reporting for medical sickness. If sickness levels are inaccurate the Trust should investigate the reasons for this and develop clear actions to address the issues. KLOE 7 27. Availability of hospital porters 27.1 The Trust needs to ensure there are sufficient porters available to prevent code red calls being used inappropriately. Partly Assured KLOE 8 What assurance does the Trust have that the organisation is safe? 28. Quality of handovers 28.1 The Trust should ensure that all members of the handover team (medical) understand and follow standard operating procedures in place. The observed handover could have been improved by: More emphasis on physiology by patients with the highest PAR scores. Acutely sick patients being prioritised and highlighted during handover Clear allocation of tasks improvement that the Trust should implement. Medical sickness was identified as an issue, and medical absence in EAU appears to be a particular concern. However the Trust appeared to be unclear as to the reasons why medical staff are off sick so frequently or for as long as they are. The panel saw no evidence of the reasons for sickness being investigated and saw no evidence of actions being taken in response. However the importance of tackling this issue and sickness at divisional level has been reported to the Trust Board since December 2013 which was noted as a positive step, hence the outcome of partial assurance. The panel saw rotas in place but noted that this has only recently been implemented, and was done without consultation with key departments. The new Director of Operations also reported that this new system did not work in A&E. Ward sisters also reported to the panel that this did not work as it depletes ward staff who are left escorting patients for long periods whilst waiting for porters. As such the panel was only partly assured as to the success of this change. 28.1. The panel was assured in respect of day to night and night to day handovers, with the process being well described by junior doctors, with descriptions exactly matching the new protocol, for example. The panel was not assured about other staff handovers as no evidence was presented or information made available to them. Concerns were raised about ward handovers and medical handover see 14.1. Some issues with standard operating procedures for ambulatory care conditions were noted. Panel members commented that there 22

Greater detail in the description of patients, for example via the use of SBAR framework 28.2 Surgical and other speciality handover arrangements should be formalised and attended by senior nursing staff KLOE 8 29. Reporting of Serious incidents 29.1 The Trust should clarify the process for escalation of SI s and communicate this to all staff. 29.2 The Trust should ensure that the learning from incident reporting happens at all levels throughout the Trust. The Trust must assure itself that lessons learned from events, themes and cases are visibly used in Trust-wide events in a systematic manner to alert the relevant staff to the issue. 29.3 The Trust should make it easier for front line staff to escalate quality issues such as a trigger form (other than Datix for incident reporting) that requires a response back. KLOE 8 30. Dissemination of lessons learned 30.1 The Trust should consider further investment in learning from reviews and ensure lessons learned and key themes are disseminated throughout the organisation and progress against action plans Not assured no evidence submitted appears to be a lot of unnecessary admissions particularly of elderly patients, and some staff raised concerns that implementing ambulatory care pathways would result in the Trust losing money. 28.2 No evidence was submitted therefore panel could not be assured. 29.1. The panel felt that the process in place is adequate but needs embedding further. The policy is due to be renewed and should reflect the national serious incident policy. 29.2. Some good examples of learning was relayed to panel members on ward visits and during interviews and focus groups. Panel members also saw performance information and information from learning being communicated to some ward staff via newsletters, however learning from events and incident reporting was not consistent. 29.3. The complaints team reported making the Datix form use easier for staff to use, and other examples of reporting forms were supplied by the Trust for review. However staff on wards reported not getting feedback after completion of incident reporting forms. The Trust does not have any other reporting mechanism than Datix. Staff articulated that they use the Top 2 process to highlight concerns and issues. 30.1. Staff understanding is variable, and some staff reported receiving feedback which others did not receive. 30.2. The Trust produces regular quality hub briefings. 23