Source · CQC inspection
Broomfield Hospital
Provider Mid Essex Hospital Services NHS Trust
Type NHS Healthcare Organisation
Region East
Last inspected 20 Dec 2019
Overall rating: Requires Improvement View full CQC report
Domain ratings
Safe
Requires Improvement
Effective
Good
Caring
Good
Responsive
Requires Improvement
Well-led
Good
Earlier inspection findings
Must-do actions (6)
Must-do action 1 of 6
Must do
Safe
The trust must continue to monitor NEWS2 scoring to ensure that patients are monitored in line with national guidance.
Must-do action 2 of 6
Must do
Safe
The trust must ensure sepsis documentation is compliant with national guidance.
Must-do action 3 of 6
Must do
Safe
The trust must ensure there are sufficient numbers of suitably qualified, competent, skilled and experienced staff.
Must-do action 4 of 6
Must do
Safe
The trust must assess, monitor and mitigate the risks relating to the health, safety and welfare of service users.
Must-do action 5 of 6
Must do
Safe
The trust must maintain securely an accurate, complete and contemporaneous record in respect of each patient.
Must-do action 6 of 6
Must do
Safe
The trust must ensure that all relevant staff are up to date with safeguarding children level three training.
Should-do actions (29)
Should-do action 1 of 29
Should do
Responsive
The trust should ensure people can always access the service when they need it and waiting times for treatment are in line with the England average for all specialities.
Should-do action 2 of 29
Should do
Responsive
The trust should ensure complaints are investigated and closed within the timeframes set out in the trust’s policy.
Should-do action 3 of 29
Should do
Safe
The trust should ensure that recruitment of staff continues to meet the needs of the department.
Should-do action 4 of 29
Should do
Safe
The trust should work to improve documentation such as comfort rounding and nutritional assessments in patient records.
Should-do action 5 of 29
Should do
Safe
The trust should continue to improve mandatory training rates for medical staff and ensure the trust target is met.
Should-do action 6 of 29
Should do
Safe
The trust should ensure that cleaning records throughout the department are completed on a daily basis.
Should-do action 7 of 29
Should do
Effective
The trust should ensure patients’ fluid and nutrition charts are completed where needed.
Should-do action 8 of 29
Should do
Effective
The trust should work to improve performance in national clinical audits to meet national standards.
Should-do action 9 of 29
Should do
Well-led
The trust should ensure staff appraisal rates meet the trust target.
Should-do action 10 of 29
Should do
Responsive
The trust should work to establish clear pathways of care from emergency department to other areas of the hospital.
Should-do action 11 of 29
Should do
Responsive
The trust should consider how to improve the average time patients wait for treatment in the emergency department and the overall time patients are in the department before they are discharged or accepted into the hospital as an inpatient.
Should-do action 12 of 29
Should do
Caring
The trust should review its existing staff handover process to ensure it promotes patient privacy, individuality and comfort.
Should-do action 13 of 29
Should do
Safe
The trust should ensure that equipment is checked on a regular basis in line with service policy.
Should-do action 14 of 29
Should do
Well-led
The trust should ensure that action plans are regularly reviewed and updated to facilitate improvements in a timely manner.
Should-do action 15 of 29
Should do
Safe
The trust should consider reviewing medical staffing arrangements to ensure they are in line with national recommendations.
Should-do action 16 of 29
Should do
Safe
The trust should ensure all eligible staff undertake annual competency assessment in cardiotocography (CTG) interpretation and auscultation in line with national recommendations.
Should-do action 17 of 29
Should do
Safe
The trust should ensure all staff know what to do if a baby was abducted from the maternity unit.
Should-do action 18 of 29
Should do
Safe
The trust should ensure prescription charts are completed with women’s weight and allergy status.
Should-do action 19 of 29
Should do
Safe
The trust should ensure staff have completed all mandatory and safeguarding training courses required for their role.
Should-do action 20 of 29
Should do
Well-led
The trust should consider reviewing the appraisal process to ensure all staff find it useful.
Should-do action 21 of 29
Should do
Safe
The trust should improve the compliance of medical staff for safeguarding training
Should-do action 22 of 29
Should do
Safe
The trust should review medical staffing levels to ensure numbers meet the needs of patients and the service.
Should-do action 23 of 29
Should do
Well-led
The trust should ensure that all medical and administration staff complete the appraisal process every year.
Should-do action 24 of 29
Should do
Responsive
The trust should ensure that patient waiting times are in line with national referral to treatment times.
Should-do action 25 of 29
Should do
Well-led
The trust should ensure data collection is reliable and integrated.
Should-do action 26 of 29
Should do
Well-led
The trust should ensure all nursing staff receive an annual appraisal.
Should-do action 27 of 29
Should do
Safe
The trust should ensure the design, maintenance and use of facilities, premises and equipment are appropriate for the acuity within the service.
Should-do action 28 of 29
Should do
Responsive
The trust should ensure people can always access the service when they need it and waiting times for treatment are in line with the England average for all specialities.
Should-do action 29 of 29
Should do
Responsive
The trust should ensure complaints are investigated and closed within the timeframes set out in the trust’s policy.