Basildon and Thurrock University Hospitals NHS Foundation Trust serves a population of around 415,000 in south west Essex covering Basildon and Thurrock, together with parts of Brentwood and Castle Point. The trust also provides services across south Essex. The trust provides an extensive range of acute medical services at Basildon University Hospital, which includes The Essex Cardiothoracic Centre and Orsett Hospital as well as x-ray and blood testing facilities at the St Andrew's Centre in Billericay. The trust employs more than 4,000 staff and has more than 10,000 public members. The trust became one of the first 10 NHS foundation trusts in April 2004.

The trust was placed into special measures following reviews by Sir Bruce Keogh June 2013 following concerns around quality of care and high mortality. The Care Quality Commission undertook a comprehensive inspection of the trust in March 2014 and rated the trust as Good. Following this inspection the Commission recommended to Monitor that the trust could come out of special measures.

We undertook a responsive inspection to the critical care unit in March 2015 in response to concerns relating to safety with staffing shortages within the critical care outreach team, areas for improvement within the effectiveness of the service, responsiveness on patient pathways and the pace at which change had been implemented. Subsequently the rating for this service overall changed from ‘Good’ to ‘Requires Improvement’.

We returned to inspect on 16th February 2016 and inspected all the key questions in the critical care service with a view to providing a new rating. We did not undertake a full comprehensive inspection of the trust, this inspection focused solely on the general critical care unit. We found that the service had made significant improvement in the delivery of the service which we have detailed through this report, and we have changed the rating of the service to ‘Good’.

The change to the ratings of the critical care service has also changed the overall trust rating for the key question of ‘is the service safe?’ to Good overall.

Our key findings were as follows:

• There were significant improvements made to how safe, effective, responsive and well led the service was since our last inspection in March 2015.

• Staffing levels for nursing, medical and therapies staff had improved and were at a safe level.

• The mortality ratio for the unit has reduced significantly since our last inspection where it was 1.8 and is now 1.0 on the ICNARC SMR and 0.83 on the APACHE model.

• The critical care unit acquired infection in the blood rates per 100 admissions was consistently in line with or better than the England average of four.

• The critical care unit does not currently meet the core standard of 50% of registered nurses having a recognised critical care course with 27% of nursing staff who had completed their certificate in critical care, however a number of staff were currently on the course and the rates by the end of the year were expected to reach over 50%.

• We observed good use of mental capacity assessments and deprivation of liberty safeguards during the inspection.

• The completion of DNACPR forms has significantly improved since the previous inspection with a greater awareness of what is required of the medical staff with regards to DNACPR.

• There had been notable improvements in the leadership of the critical care and outreach service.

• Morale and culture within the critical care and outreach service had improved significantly since our previous inspection.

Following our inspection the trust should:

• Improve the mandatory training rates for the critical care outreach team.

• Ensure all staff receive updated equipment competency training.

• Reduce the delayed discharges over four hours from the critical care unit to the main wards.

• Reduce the number of transfers out of hours between 10pm and 7am.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Following review of two serious incidents which occurred in October 2012 and the information we gained at this unannounced inspection, we had significant concerns regarding the current medical and nursing leadership within the children’s department to support junior staff, and protect children who may be at risk of inappropriate or unsafe care and treatment. We also had concerns around the quality of medicines management within the trust.

Whilst families we spoke to were complimentary regarding the service given by the trust, we found systematic failings in monitoring practices, risk management practices and learning lessons to ensure safe practice and continuous improvement in children’s services. Whilst the Care Quality Commission (CQC) acknowledges the immediate actions taken to minimise risks to children being cared for by the provider, the provider has instigated ongoing investigations regarding the two serious incidents. If necessary, CQC will not hesitate to take further enforcement actions to ensure the safety of children.

We did not speak to people regarding this standard as this was a review of a warning notice around incident reporting, quality monitoring and assessment practices.

People we spoke with told us that they were happy with the care and treatment they received. We spoke with the parents of four children who were attending the Accident and Emergency department. They told us that they were happy with the care and treatment their children received. One person told us: “We were seen almost immediately. I cannot fault the nurses or doctors here.” Another person said: ”It can be very busy here at times but we are always seen as soon as possible.”

We spoke with ten people in different areas of the hospital, who told us that they had been thoroughly involved in decision making about their care and treatment. They told us that the nursing and care staff in particular were very good at explaining their care and treatment options to them. People also told us that staff treated them with respect and dignity and they found staff to be kind and caring.

People we spoke with were knowledgeable about different elements of their care, such as the medication they were taking, physiotherapy and occupational therapy interventions. They told us that staff responded to their care needs in a timely manner. Comments included “The staff have been excellent” and “they cared for me well.”

Not all patients were made aware of the complaints system. We asked six patients who were using services in the department of geriatric medicine what they would do if they had a complaint or concern about the services they were receiving. None of them knew about the hospital’s complaints procedure and only one knew about the patient advice and liaison service (PALS) where they could get assistance.

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.

The overall feedback from people in the Accident & Emergency (A&E) department was positive. Whilst some had been waiting a couple of hours to be seen, they recognised the need of staff to prioritise the more urgent cases. They told us that staff were professional and caring, although information about what was happening and how long they may have to wait was not always good.

Other comments people made to us included that the department was clean, the waiting area could be larger, vending machines should be made available, information provision could be better and the seating could be more comfortable.

Overall, people with whom we spoke were satisfied with the care provided across the trust. People, told us that they were well informed regarding their care and treatment. They said they felt involved in the decision making and were made aware of any risks associated with their treatment.

Carers we spoke with were satisfied with the information provided and felt well informed of the care being provided to their relatives. They said that staff were helpful and willing to answer questions. A number of people on the wards we visited told us that there were not always enough staff available to assist them at times.

People said that the staff were knowledgeable, and that they felt safe in their hands. One person told us ‘’I feel safe here. Staff are caring and gentle I have no concerns at all.’’

People told us that since their admission to hospital they had been treated with respect and dignity. Written information is not always freely available and some people said that the doctors and triage staff do not always provide them with adequate information.

People were positive about the care and welfare provision and the staff across the trust. They described the staff as caring and helpful and that there were sufficient numbers of staff on duty and in general they responded to requests for help.

People with whom we spoke were complimentary about the quality and choice of meals provided and told us they had no real complaints. They also said that the cleaning standards within the hospital were good. They said there were cleaners around a lot of the time who were working hard to keep the areas clean.

People said that the staff knew what they were doing and were helpful. People told us they would complain if they were not satisfied with the service. Two relatives confirmed that they were unaware of how to raise concerns or make a complaint but had heard of Patient Advice and Liaison Service (PALS).

Overall, the people with whom we spoke told us they found their experience at Basildon Hospital to be positive and were happy with the care, treatment and support provided.

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.

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

Basildon and Thurrock University Hospitals NHS Foundation Trust serves a population of around 405,000 in south west Essex covering Basildon and Thurrock, together with parts of Brentwood and Castle Point. The trust also provides services across south Essex. The trust provides an extensive range of acute medical services at Basildon University Hospital, which includes The Essex Cardiothoracic Centre and Orsett Hospital as well as x-ray and blood testing facilities at the St Andrew's Centre in Billericay. The trust employs more than 4,000 staff and has more than 10,000 public members. The trust became one of the first 10 NHS foundation trusts in April 2004.

The trust was placed into special measures following reviews by Sir Bruce Keogh June 2013 following concerns around quality of care and high mortality. The Care Quality Commission undertook a comprehensive inspection of the trust in March 2014 and rated the trust as Good. Following this inspection the Commission recommended to Monitor that the trust could come out of special measures.

We returned to inspect on 17th and 18th March 2015 and inspected those key questions where the service had been rated as requiring improvement which are reported in a separate report. We did not undertake a full comprehensive inspection. We undertook an inspection of the critical care service during this inspection due to concerns received about the leadership and responsiveness of the service.

In 2014 we inspected the critical care unit at Basildon University Hospitals NHS Foundation Trust and found significant improvements to the care delivered to the population. At this time we rated the unit as Good.  When we returned in 2015 we found this service had concerns relating safety with staffing shortages within the critical care outreach team, areas for improvement within the effectiveness of the service, responsiveness on patient pathways and the pace at which change had been implemented. The rating for this service overall has changed from ‘Good’ to ‘Requires Improvement’.

Our key findings were as follows:

• The critical care outreach team had been depleted through maternity leave and resignation and the trust had commissioned a review prior to our inspection.

• There were also significant delays on occasions in discharging patients from critical care unit which impacted on the responsiveness of the service. The trust had commissioned a report into delayed transfers of care within the hospital.

• The pace of change within the critical care, although improving, required further work to ensure that patients received a timely service.
• Patient outcomes as recorded by the Intensive Care National Audit and Research Centre were poor in four out of the seven areas reviewed.
• The strategy for the critical care unit was discussed by the senior management group during our inspection.

We identified the following areas of poor practice where the trust needs to make improvements:

The trust should:

• Continue to work and improve on the skill mix and staffing levels throughout the hospital particularly in the critical care service.
• Review staffing and management structures for the critical care outreach service to ensure that an appropriate number of outreach staff are on duty for each shift.

Professor Sir Mike Richards

Chief Inspector of Hospitals