During this inspection we visited the maternity services, a surgical ward, a medical ward, the emergency assessment unit and reviewed the pharmacy services. We spoke to 33 people using the service and six relatives of people using the service.

In general people were very satisfied with the care and treatment they had received and in most cases were very complimentary about the attention and attitude of staff towards them.

On the Emergency Assessment Unit (EAU) we found areas of concern about staffing, care and how people's dignity was maintained that were not consistent with our findings in the other areas visited. We were told by the director of nursing and the chief executive that the days of our visit were the two busiest days for admissions in the last 12 months. We also found that there was ongoing investment in this area to ensure that people were cared for in a timely and appropriate way. These included increasing hours in the evenings and weekends that skilled staff were available.

We were unable to effectively audit and track some serious incidents concerning patient safety at the trust. This meant that the quality monitoring for the safety of people using the service was not reliable, so there were concerns about whether appropriate action, in relation to the incidents, had been taken by the trust.

People with whom we spoke reported that they were listened to and respected by staff and most spoke highly about the information available. They felt that staff were well trained to provide care and treatment. They told us that they enjoyed the food offered by the service and that they were offered choice about what they ate. However, some people said they were not asked whether or not they wished to wash their hands before they ate. They said they were happy with the standard of cleanliness of the hospital.

There were mixed experiences in respect of patients being asked how they wanted to be treated. Patients generally felt that care is given in a respectful way, but said they sometimes had to wait a long time when they called for assistance.

Patients felt they had not been given enough information about their care and treatment options and the risks and benefits of the treatment; or the facilities available to them. The majority of patients with whom we spoke had not been asked for any feedback on their care.

Patients were generally pleased with the choice and quality of meals available, including vegetarian options. Patients were generally comfortable in asking for food if they were still hungry and that food was available if they had to miss a meal.

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

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

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

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

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

• Surgical Procedures

• Diagnostic and Screening

• Treatment of disease, disorder or injury

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

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

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

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

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

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

Our key findings were as follows:

We saw several areas of outstanding practice including:

• The service’s dedicated childrens transition team was the only one in the region and other trusts sought advice from them. The transition team worked with other teams to meet the more complex individual needs of patients at the age of transitioning to other services. For example, they ran a joint clinic with the epilepsy specialist nurse three to four times a year.
• The neonatal unit (NNU) was piloting a ‘discharge passport’ to empower parent involvement in ensuring a timely discharge for babies.

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

Importantly, the trust must:

• The trust must ensure that nursing and medical staff complete all safeguarding and mandatory training including basic life support.
• The trust must ensure that all equipment is maintained and fit for purpose.
• The trust must ensure that initial assessments within the emergency department are undertaken and documented to maintain an accurate clinical record based on clinical judgement, and that initial assessments in the emergency department are documented.
• The trust must ensure access to a designated mental health assessment room.
• The trust must take action to ensure that patients are clinically risk assessed as safe to wait for out patient appointments.
• The trust must ensure that medical records contain completed risk assessments relevant to patient care.
• Ensure that patient’s records are appropriately stored in accordance with legislation at all times
• The trust must ensure that staff administering contrast for diagnostic imaging investigations use a patient group direction or have it prescribed.
• Ensure that do not attempt cardiopulmonary resuscitation (DNACPR) decisions are undertaken in accordance with national guidance and best practice.
• The trust must ensure that the design and layout of the paediatric emergency department enables effective oversight of paediatric waiting areas to ensure patient safety.
• The trust must ensure that there is an effective governance and risk management framework in place to identify and assess all risks relevant to the emergency department.
• The trust must ensure that patient’s dignity is protected in changing cubicles in In Beta X-ray.
• The Trust must ensure that the doors for Beta X-ray are fully fitted and a risk assessment is in place to ensure patients are not a risk of unnecessary exposure of ionising radiation.
• The trust must ensure there is an effective process in place for timely review of policies and procedures and that these comply with national guidance and best practice.

Action the hospital SHOULD take to improve

• The trust should improve its overall performance in the management of referral to treatment times.
• The trust should ensure that clinics are not cancelled without exploring every option in order to contribute to reduced waiting times.
• The trust should ensure the clinics start on time.
• The trust should ensure that all staff are aware of translation services for non-English speakers.
• The trust should ensure that clinical audit is undertaken and where data is not submitted, that it is followed up.
• The trust should ensure that all staff have received an appraisal and frequent supervision.
• The trust should review admission times and fasting periods for patients awaiting surgery to meet the nutritional and hydration needs of the patient.
• The trust should ensure managers and senior staff have the relevant level of skill and experience to perform their roles.
• The trust should ensure that staffing levels reflect the needs of patients at all times.
• The trust should ensure that it reviews its existing staff practice in relation to MCA and DoLS specifically in relation to the cohorting of patients in supervised bays.
• The trust should ensure that domestic staff follow infection control procedures, wear correct uniform, identification and personal protective equipment at all times.
• The trust should improve its overall performance in the management of patient falls.
• Continue to work to improve delayed discharges and discharges that occur between the hours of 10pm and 7am.
• Continue to work to improve attendance and documentation of meeting minutes at mortality and morbidity meetings.
• To ensure that patients diaries are being completed in line with guidance, and that these diaries are used throughout the patient journey.
• To improve the recording of actions following governance meetings and ensure that these are followed up and that evidence of learning or changes in practice are recorded.
• Ensure there are appropriate formal systems to share actions and learning from incidents consistently among all staff in the service.
• Update the policy for safeguarding children in line with best practice and national guidance, for example to ensure all child protection cases are overseen by a paediatrician.

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

Professor Edward Baker

Chief Inspector of Hospitals