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Lincoln County Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 11 April 2017

The United Lincolnshire Hospitals NHS Trust has three main hospitals and provides a range of hospital-based medical, surgical, paediatric, obstetric and gynaecological services to the 700,000 people of Lincolnshire. The trust employs 7,500 staff.

We inspected Lincoln County Hospital between the 10-14, 18-19 and 26-27 October 2016. We also carried out unannounced inspections on 24, 25 and 27 October 2016.

We included the following locations as part of the inspection:

  • Lincoln County Hospital
  • Pilgrim Hospital
  • Grantham Hospital

We did not inspect County Hospital Louth, John Coupland Hospital in Gainsborough, Skegness and District General Hospital or the Johnson Community Hospital in Spalding.

We rated Lincoln County Hospital as requires improvement overall. Surgery and services for children and young people were rated as good, urgent and emergency care, medical care and maternity and gynaecology were rated as requires improvement.

Our key findings were as follows:

Safe

  • There were not always effective systems in place to ensure ambulance handover times took place in line with the Department of Health target of 15 minutes, with no patients waiting more than 30 minutes and that the initial assessment of patients should take place within 15 minutes of presentation to the department.
  • Where patients had met the trust criteria for sepsis screening, not all patients were screened appropriately; this put patients at risk of harm because they did not receive the correct treatment in a timely manner and in line with national and local guidelines.
  • Staff did not routinely raise patient safety incidents for those patients who had not been appropriately screened or treated for sepsis.
  • In some areas, staff did not always recognise concerns, incidents or near misses. Where incidents had been raised some staff reported little or no feedback and could not give examples of where learning from incidents had taken place.
  • Safety systems, processes and standard operating procedures were not always fit for purpose. We saw out of date resuscitation equipment and insufficient evidence to suggest resuscitation equipment had been checked in line with trust policy. Arrangements were not always in place to ensure the safe storage of medicines and arrangements for the disposal and storage of used sharps meant there was a risk of harm to staff, patients or members of the public.
  • Records to demonstrate hourly rounding (checks on patients) were not always completed.
  • There was no abduction of children policy available for any of the inpatient areas of the service.
  • Health records were not always available for outpatient appointments.
  • As of the week of our inspection, there were 8,108 patient appointment outcomes, which staff had not completed and closed on the electronic record system. Data supplied by the trust showed the current position was worse than the previous year. This presented a risk to patients in their ongoing treatment and care. Following our inspection the trust had forecast that the numbers of incomplete outcomes would fall by half in early 2017.
  • Nurse staffing on the neonatal unit was in line with the British Association of Perinatal Medicine (BAPM) standards.
  • Patients were protected from abuse; staff had an understanding of how to protect patients from abuse. Staff could describe what safeguarding was and the process to refer concerns.
  • Staff used paediatric early warning scores (PEWS) and neonatal early warning scores (NEWS) to appropriately identify a deteriorating patient.

Effective

  • The trust’s Hospital Standardised Mortality Ratio (HSMR) for March 2016 was 97.62. HSMRs are intended as an overall measure of deaths in hospital. High ratios of greater than 100 may suggest potential problems with quality of care.

  • The latest published Summary Hospital level Mortality Indicator (SHMI) for January 2015 to December 2015 was 110.99 and within hospital SHMI deaths was a reported 105.4 for the same period. The Summary Hospital-level Mortality Indicator (SHMI) is the ratio between the actual number of patients who die following hospitalisation at the trust and the number that would be expected to die based on average England figures, given the characteristics of the patients treated there.

  • Patient’s care and treatment was mostly planned and delivered in line with current evidence based guidance, standards, best practice and legislation. We saw good use of patient pathways aligned to the National Institute for Health and Care Excellence (NICE) quality standards. However, staff did not consistently adhere to local guidelines for sepsis screening.
  • Where outcomes for patients were below expectations when compared with similar services we saw action plans had been put in place.
  • Nursing staff were not always managed or developed effectively. Not all nursing staff had received an annual appraisal and appraisal completion rates had significantly declined since the previous year.
  • Endoscopy services at this hospital were Joint Advisory Group (JAG) accredited.
  • There was an effective multidisciplinary team (MDT) approach to planning and delivering patient care and treatment; with involvement from general nurses, medical staff, allied health professionals (AHPs) and specialist nurses. All staff we spoke with told us there were good lines of communication and working relationships between the different disciplines.
  • Staff had some understanding of the Mental Capacity Act (MCA) 2005 and consent. We saw consent to care and treatment was mostly obtained in line with legislation and guidance, including the MCA and patients were supported to make decisions.

Caring

  • Generally, feedback from patients who used the service and those close to them was mostly positive about the way they had been treated.

  • We observed nursing and medical staff treating patients with dignity, respect and kindness. Staff spent time talking to patients and showed compassion when patients needed help. However, at times, staff focused on the task instead of the patients as individuals. Staff were providing one to one support for some patients as they had been assessed as being at increased risk. However, when providing one to one support, staff did not always engage with patients meaningfully.

  • Results of the CQC A&E Survey (2014) showed the trust performing ‘about the same’ as other trusts.

  • The NHS Friends and Family Test (FFT) results were worse than the England average.

Responsive

  • There were systems in place to support vulnerable patients and those patients who were medically fit for discharge, with good access to learning disability specialist nurses and the assertive in-reach team (AIR).

  • Some patients were not able to access services for assessment, diagnosis or treatment when they needed to.
  • Patients had been unable to access services in a timely way for an initial assessment, diagnosis or treatment including when cancer was suspected. During 2016 the trust has failed to meet the majority of the national standards for the cancer referral to treatment targets. This included the referral standard for patients suspected of cancer who needed to be seen with two weeks. This standard had not been consistently met during 2016.
  • The trust had failed to meet the national standard for the referral to treatment time for incomplete pathways for the previous three consecutive months.
  • There were significant delays in patients receiving their follow up outpatient appointment across several specialities with 3,772 appointments being overdue by more than six weeks. These did not include the patients identified as missing from the waiting lists.
  • Stroke services provided timely access to initial assessment, diagnosis or urgent treatment of those patients who may be experiencing a stroke.

  • Delays in obtaining to take out (TTO) prescriptions had been identified as delaying discharges and staff attributed this in part to a sporadic pharmacy service to the wards. In addition, pharmacy staff did not routinely access the electronic discharge documents and this resulted in discrepancies not being identified until medicines had been dispensed.

  • There was insufficient consideration paid to meeting the information and communication needs of patients. The service had not taken steps to meet the requirements of the accessible information standard. However, staff could access interpreting services for patients who did not speak or understand English. The service was provided externally and included the provision of British Sign Language.

Well led

  • Generally staff knew there were a vision and strategy in place for the trust.

  • There was not always an effective governance framework which supported the delivery of safe, good quality care.
  • We found some risks regarding the provision of services for patients had not been identified by senior nurses and service leads.
  • We were not assured incidents were reported and acted upon appropriately. Staff did not routinely raise patient safety incidents for those patients who had not been appropriately screened or treated for sepsis. This meant there were missed opportunities to address poor compliance in order to minimise the risk of patients being exposed to avoidable harm, when they met the trust criteria for sepsis screening.
  • Staff satisfaction and morale varied across the hospital with some staff groups feeling more engaged than others.
  • We found most staff were dedicated and committed to delivering high quality, safe care.

We saw several areas of outstanding practice including:

  • The emergency department (ED) inputted hourly data into a specific risk tool which had been created, to give an internal escalation level within ED separate to the site operational escalation level. This tool gave an “at a glance” look at the number of patients in ED, time to triage and first assessment, number of patients in resus, number of ambulance crews waiting and the longest ambulance crew wait. This gave a focus across the trust on where pressure was building and there were local actions for easing pressure.
  • The ED had designed and were using a discharge tool ‘TRACKS’ (T-transport, R-relatives/ residential home, A-attire, C-cannula, K-keys, S-safe) to facilitate the safe discharge of older and/or vulnerable patients.
  • The trust had introduced a carer’s badge, which enabled any family members and trusted friends to be involved in the care of their loved ones. The carer's badge encouraged carer involvement, particularly for patients with additional needs. Being signed up to the carer's badge also gave carers free parking whilst they were in attendance at the hospital.
  • Ashby Ward had just introduced visits from pets called a therapy (PAT) dog. PAT is a charity and volunteers from PAT, along with their own pets, visit care organisations to enable patients to interact with them.
  • On the care of the elderly wards a red, amber, green system was used to identify patients who required more assistance than others. Red signified those patients who required the most help, whilst green identified those patients who required the least. This system was also applied to each patient’s menu card to signify the amount of support a patient required with eating. Patients with a green sticker were given their meals first. Staff who took meals to patients with a red sticker then stayed to support the patient to eat their meal.
  • Staff on Nocton Ward had introduced sibling activity bags for any siblings of the infants admitted on the ward. This demonstrated a positive approach to involving the whole of the family in the service experience.

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

Importantly, the trust must:

  • The trust must take action to ensure staff in the emergency department are appropriately trained and supported to provide the care and support needed by patients at risk of self-harm.
  • The trust must take action to ensure all staff working in the emergency department receive appropriate supervision, appraisal and training to enable them to fulfil the requirements of their role.
  • The trust must take action to ensure systems and processes are effective in identifying where safety is being compromised and in responding appropriately and without delay. Specifically, systems and processes to identify and respond to the assessment and treatment of sepsis in the emergency department.
  • The trust must take action to ensure staff have the appropriate qualifications, competence, skills and experience, in addition to paediatric life support, to care for and treat children safely in the emergency department.
  • The trust must continue to ensure systems and processes are effective and that staff respond appropriately in recognising and treating patients in line with the trust’s sepsis six care bundle.
  • The trust must take action to ensure ligature risk assessments are undertaken and that ligature cutters are available in all required areas.
  • The trust must take action to ensure staff in maternity are appropriately trained and supported to provide recovery care for patient’s post operatively.
  • The trust must take action to ensure all staff working in the termination of pregnancy service receive formal counselling training.
  • The trust must take action to ensure that the handover process on Nettleham Ward does not compromise patient’s’s privacy.
  • The trust must take action to ensure that sensitive patient groups are not mixed within gynaecology and maternity outpatient areas.
  • The trust must ensure the environment within Clinic 6 is reviewed and actions taken to prevent or control the potential risk to patients from infections. The trust must comply with the Health and Social Care Act 2008, Code of Practice on the prevention and control of infections and related guidance.
  • The trust must ensure that the drinking water dispensers are cleaned and maintained in accordance the manufacturer’s instructions including completion of scheduled electrical safety testing, a water hygiene maintenance programme and cleaning schedule.
  • The trust must ensure that equipment is appropriately maintained. It must ensure any checks carried out by staff are recorded and done with sufficient frequency and with sufficient knowledge to minimise the risk of potential harm to patients.
  • The trust must ensure that patients who are referred to the trust have their referrals reviewed in a timely manner to assess the degree of urgency of the referral.
  • The trust must ensure that the patients who require follow up appointments are placed on the waiting list.

In addition the trust should:

  • The trust should ensure there are effective and consistent systems for learning from incidents to be shared across the emergency department.
  • The trust should ensure the governance framework in the emergency department clearly identifies risks, responsibilities and actions required to ensure all staff raise patient safety incidents appropriately.
  • The trust should ensure that the resuscitation trolleys and their equipment are checked, properly maintained and fit for purpose in the emergency department.
  • The trust should ensure there are adequate processes in place to ensure handovers between the ambulance and the emergency department take place within 15 minutes with no patients waiting more than 30 minutes.
  • The trust should ensure there are adequate processes in place to ensure patients who self-present to the emergency department receive an initial clinical assessment by a registered healthcare practitioner within 15 minutes of the time of arrival.
  • The trust should ensure that there is 16 hours of consultant presence available each day in the emergency department.
  • The trust should ensure there are appropriate procedures in place for identifying seriously ill patients who self-present at the reception of the emergency department.
  • The trust should ensure procedures are followed regarding the safe management of sharps boxes.
  • The trust should ensure all staff have completed mandatory and role specific training.
  • The trust should ensure the environment for children’s provision in the emergency department meets the 2012 Intercollegiate Committee Standards for Children and Young People in Emergency Care Settings.
  • The trust should ensure staff are appropriately trained and supported to meet the requirements related to duty of candour.
  • The trust should ensure an annual audit is carried out in line with the recommendations of The Royal College of Emergency Medicine (RCEM) guidelines; Management of Pain in Children (revised July 2013).
  • The trust should ensure they take steps to address the accessible information standard in the reception area of the emergency department at Lincoln County Hospital.
  • The trust should ensure mandatory training is completed in line with trust policy.
  • The trust should ensure all staff are aware of the arrangements in place to respond to major incidents.
  • The trust should ensure hourly rounding charts and charts used for monitoring fluid balance of patients are completed to ensure the health, safety and welfare of the service users.
  • The trust should ensure medications are always handled safely, in line with legislation, the trust’s policies and best practice guidelines.
  • The trust should ensure venous thromboembolism treatment is prescribed in a timely manner and re-assessed after 24 hours.
  • The trust should ensure there are measures in place to ensure patient medical notes are stored securely.
  • The trust should ensure continued engagement within the Oromaxillo facial service in order to further develop the service.
  • The trust should consider 24 hour reception cover on the surgical emergency assessment unit.
  • The trust should consider a discharge co-ordinator post within ward areas.
  • The trust should consider how the role of the domestic assistants support the ward team in relation to food serving and cleaning.
  • The trust should ensure that grading of incidents is consistent and follows trust guidance.
  • The trust should ensure that the new IT system supports accurate documentation of safety thermometer data.
  • The trust should ensure that notes for patients undergoing caesarean section are consistent including standardised documents.
  • The trust should ensure that safeguarding supervision is provided regularly for all staff.
  • The trust should ensure that accurate up to date maternal weights are performed on admission in order to prescribe weight dependant medication.
  • The trust should ensure that the resuscitation trolleys on Bardney Ward are checked, and appropriate documentation completed.
  • The trust should ensure that if recent NICE guidance is not followed then the current guidance includes an addendum to explain the decision (CG 190).
  • The trust should ensure staff development programmes are supported and staff are encouraged to attend learning opportunities.
  • The trust should audit the length of time patients attending for emergency gynaecology appointments are expected to wait.
  • The trust should ensure that within maternity service users feedback is captured.
  • The trust should ensure that they audit the number of patients whose elective caesarean sections are delayed to the next day.
  • The trust should ensure that action plans are made following audits, and a re-audit is performed, such as following the regular CTG audits.
  • The trust should ensure outpatient and diagnostic services are delivered in line with national targets.
  • The trust should ensure that incidents are correctly graded and there are effective systems in place to ensure learning from incidents takes place.
  • The trust should ensure that there are sufficient documented procedures and records in place to provide assurance that ultrasound probes are decontaminated after use in line with the manufacturer’s recommendations and in compliance with the Health and Social Care Act 2008, Code of Practice on the prevention and control of infections and related guidance.
  • The trust should ensure that there is sufficient signage throughout the outpatient department to direct patients/visitors to the hand hygiene facilities that are provided to minimise the risk of spreading infection.
  • The trust should ensure that the condition of health records enables the safe care and treatment of patients, compliance with information governance requirements and ensures patient confidentiality is maintained.
  • The trust should ensure all staff working in the outpatient and diagnostic departments attend the trust's mandatory training programme as required by their role and professional responsibilities.
  • The trust should consider reviewing the method by which MRI reports are transferred onto the Radiology Information System to ensure the risk of error during the transfer of data is minimised or removed.
  • The trust should ensure that there are sufficient systems in place and utilised to minimise the risk of potential harm to patients. Sufficient time must be available to ensure comprehensive patient identity and procedure checks are completed prior to all diagnostic procedures being commenced.
  • The trust should ensure that staff working in the radiology department have sufficient knowledge of the national diagnostic reference levels to be able to apply them appropriately when required.
  • The trust should take action to ensure all staff working in the outpatient and diagnostic services receive an annual appraisal to ensure they are able to fulfil the requirements of their role.
  • The trust should consider whether the action taken to reduce the back log of clinic letters waiting to be sent to GPs and patients following their appointment was effectively resolving the backlog of letters.

On the basis of this inspection, I have recommended that the trust be placed into special measures.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 11 April 2017

Effective

Requires improvement

Updated 11 April 2017

Caring

Good

Updated 11 April 2017

Responsive

Requires improvement

Updated 11 April 2017

Well-led

Requires improvement

Updated 11 April 2017

Checks on specific services

Maternity and gynaecology

Requires improvement

Updated 11 April 2017

We rated this service as requires improvement because:

The grading of incidents was not always consistent. Collection of data was also inconsistent across the service.

Staff did not demonstrate learning from audits such as CTG audits or post-partum haemorrhage audits.

The maternity dashboard data was not utilised fully. The data lacked red amber and green rating, which meant that staff could not assess the data against trust targets.

Staff did not receive regular recovery training.

Only 51% of health care assistants had received training in basic life support.

Patient confidentiality could be compromised by the location of staff handover on Nettleham Ward.

There was no midwife led unit, reducing patient’s choice for a home from home environment. Sensitive patient groups were mixed within the gynae-oncology clinic and antenatal clinic.

The lack of a dedicated elective caesarean section operating teams meant that in the event of an emergency patient’s surgery would be delayed.

Governance structures functioned effectively and interacted appropriately. Teamwork throughout the hospital was apparent and staff felt they were listened to.

A strong business unit team had increased the visibility of the patient’s and children business unit in the last 18 months.

When something went wrong staff told us people received a sincere apology. Openness and transparency was encouraged. Staff were aware of their responsibilities for reporting incidents, and learning was shared.

Medicines were stored safely with clean secure preparation areas. Clinical areas were clean and staff had made efforts to improve the environment for patients.

Patients care and treatment was planned and delivered in line with current evidence-based guidance. Normal birth rates and still birth rates were better than the national average. A seven day antenatal maternity day assessment service was available for patients with concerns or high risk pregnancies.

Staff were caring and compassionate in the care they provided. The service had increased the number of trust wide specialist midwives. Some of these such as the bereavement midwife had not started.

Patients and families knew how to raise a concern and were treated compassionately when they did.

Medical care (including older people’s care)

Requires improvement

Updated 11 April 2017

Urgent and emergency services (A&E)

Requires improvement

Updated 11 April 2017

  

We rated safe as inadequate, effective, responsive and well-led as requires improvement and caring as good because:

We were not assured incidents were reported and acted upon appropriately. Staff did not routinely raise patient safety incidents for those patients who had not been appropriately screened or treated for sepsis. This meant there were missed opportunities to address poor compliance in order to minimise the risk of patients being exposed to avoidable harm, when they met the trust criteria for sepsis screening. Where incidents had been raised some staff reported little or no feedback and could not give examples of where learning from incidents had taken place. Following our inspection the trust told us staff had been trained in risk reporting but they did not always recognise concerns, incidents or near misses. Staff reported little feedback from incidents but the trust told us they had several systems for sharing lessons learnt. We did not see this on inspection.

Staff did not consistently adhere to local guidelines for sepsis screening and the trust had a higher than expected hospital standardised mortality ratio (HSMR) in the area of sepsis. Where patients had met the trust criteria for sepsis screening, not all patients were screened appropriately; this put patients at risk of harm because they did not receive the correct treatment in a timely manner.

There was not an effective governance framework in place to support the delivery of safe, good quality care. Significant risks regarding the provision of services for patients had not been identified by senior nurses and service leads. Risks identified during the inspection such as insufficient numbers of paediatric nurses working in the department and the environment for children and young people had not been assessed or placed on the department risk register.

The environment and staffing arrangements in the emergency department (ED) did not meet Intercollegiate Committee Standards for Children and Young People in Emergency Care Settings (2012). In the children's waiting area there was no audio-visual separation from the adults’ waiting area and limited numbers of age-appropriate games. Not all nursing staff had been trained to care for children. However, there were cubicles both in the resuscitation and major’s area of the department dedicated to the care of children and young people.

Safety systems, processes and standard operating procedures were not always fit for purpose. We saw out of date resuscitation equipment and insufficient evidence to suggest resuscitation equipment had been checked in line with trust policy. Arrangements in place to ensure the safe storage of medicines and disposal and storage of used sharps had not been adhered to. This meant there was a risk of harm to staff, patients or members of the public.

Nursing staff were not always managed or developed effectively through the appraisal process. Not all staff had received up to date mandatory training and staff had not received training regarding their responsibilities in line with legislation and guidance, including the Mental Health Act (1983). There was no policy or procedure for the administration of the Mental Health Act (1983; amended 2007) or the assessment, management and care of adult patients who attended the emergency department (ED) due to self-harming or suicidal behaviours.

Royal College of Emergency Medicine (RCEM) audit results showed outcomes for patients were sometimes below expectations and the ED performance for ambulance handover times, the number of patients being treated, admitted or discharged in under four hours, the initial assessment of patients taking place within 15 minutes of presentation to the department and trolley waits were worse than national standards and Department of Health targets.

Medical staffing levels and skill mix were not appropriate to keep patients protected from avoidable harm at all times. There were low levels of staff satisfaction in addition to high levels of stress and work overload.

There was insufficient consideration paid to meeting the needs of those patients who were hard of hearing and staff we spoke with were not aware of a dementia care pathway and ‘action cards’ available for those patients living with dementia.

The care provided to patients in urgent and emergency services was good. Patients were supported, treated with dignity and respect and were involved as partners in their care. It was easy for patients to complain or raise a concern. Posters and leaflets were available in the ED and these allowed members of the public to identify how they could raise a concern or make a formal complaint.

Patient’s care and treatment was mostly planned and delivered in line with current evidence based guidance, standards, best practice and legislation. We saw good use of patient pathways aligned to the National Institute for Health and Care Excellence (NICE) quality standards. Individual care records were written and managed in a way that kept people safe. Records were accurate, complete, legible and stored securely.

The service had been proactive in addressing significant concerns we had identified during our inspection concerning ligature points in the department and the department’s ability to respond to an emergency or major incident. Responses were timely and appropriate and actions had been put in place to assess and manage risks to patients.

There was effective multidisciplinary working with staff, teams and services working together to deliver effective care and treatment. Staff were qualified and had the skills they needed to carry out their roles effectively including being appropriately trained and proactive in their approach to safeguarding. Medical and nursing staff were dedicated and committed to delivering high quality, safe care. At times of extreme pressure we saw staff united in managing the flow of attendances through the department.

Services were planned with commissioners, other providers and relevant stakeholders and delivered in a way that met the needs of the local population with an assessment and ambulatory care unit (AAC) located next to the ED that provided urgent, same day treatment for patients, so that they did not have to be admitted to hospital if there was no requirement for this.

Surgery

Good

Updated 11 April 2017

We rated this service as good because:

Staff understood their responsibilities to raise concerns and report incidents and near misses.

Lessons were learned and communicated widely to support improvement. For example, thorough checking of surgical hip or lens implants before use.

Risks to patients were assessed, monitored and managed on a day-to-day basis. These included signs of deteriorating health and medical emergencies.

Monitoring and audit of safety systems was robust. There was an effective audit for the World Health Organisation (WHO) five steps to safer surgery checklists.

There were systems, processes and standard operating procedures in infection prevention control, records, and maintenance of equipment, which were mostly reliable and appropriate to keep patients safe.

Patients were protected from abuse; staff had an understanding of how to protect patients from abuse.

Care and treatment was planned and delivered in line with current evidence based guidance, standards, best practice and legislation and patients received effective care and treatment.

We saw where patients symptoms of pain were mostly managed in both ward and department areas with good comfort outcomes.

We observed staff positively interacting with patients and patients were treated with kindness, dignity, respect and compassion while they received care and treatment. Feedback from patients was positive about the care and treatment they had received.

Surgical care services were responsive to patient’s needs; patients could access services in a way and at a time that suited them and there was a proactive approach to understanding and meeting the needs of individual patients and their families.

The leadership, governance and culture in surgical care services supported the delivery of high quality person-centred care; governance and risk management arrangements were mostly effective and as such able to protect patients from avoidable harm.

There were periods of inappropriate skill mix when staffing the escalation beds in the surgical assessment lounge.

There was a lack of consistency in staff understanding of the Mental Capacity Act (2005), the use of mental capacity assessments and Deprivation of Liberty Safeguards (DoLs).

Medical staff in the head and neck clinical directorate were not always compliant with the trust appraisal process.

Intensive/critical care

Good

Updated 27 March 2015

Services for children & young people

Good

Updated 11 April 2017

We rated this service as good because:

There was a good understanding of the incident reporting system with most incidents reported being of the no harm to low harm category. The service had not reported any never events in the 12 months prior to the inspection.

There were good infection prevention and control measures within the service and this was reflected in the zero cases of healthcare acquired infections.

The use of the paediatric early warning score (PEWS) and neonatal early warning score (NEWS) was embedded within the service and aided timely recognition of the deteriorating patient.

The service delivered care according to local and national policies which were evidence based, and also contributed to national audits to benchmark care against other providers.

We observed many positive examples of compassionate and dignified care being provided to all patients. Feedback from parents, carers and the children themselves was complimentary about the care they had received and felt the level of information provided was adequate. They were also complimentary about the involvement of siblings in the patient experience and how staff extended the compassionate care to them.

The service was responsive and met the needs of the children and young people accessing the service. The hospital had engaged with local parent groups about service planning and delivery and also provided facilities for parents to stay with their child whilst admitted.

The service was well-led at local ward/unit level and staff told us and we found the leadership above this level was also good.

Nurse and medical staffing did not meet requirements of the Royal College of Nursing (RCN) and Royal College for Paediatric and Child Health (RCPCH). Nurse staffing on the children’s ward did not have an experienced member of staff on for each 24 hour period and did not provide at least one member of staff with advanced paediatric life support (APLS) or European paediatric life support (EPLS) qualification on each shift. There were insufficient members of the medical tram to provide paediatric consultant cover seven days per week. In addition consultant cover provided did not cover the busy 12 hour period up to 10pm.

There was a lack of awareness on the children’s ward in relation to ligature risks, for example we did not see a ligature risk assessment had been carried out and there were no ligature cutters immediately available in the ward area. There was no abduction policy; therefore we were not assured that all staff would know what actions to take in the eventuality of a missing child.

We could not be assured that sepsis management was embedded within the service and this was supported by information provided by the trust.

We could not be assured that staff followed the did not attend (DNA) policy for the children’s outpatient department, and there was no DNA monitoring of paediatric patients in departments where children attended.

End of life care

Good

Updated 27 March 2015

The specialist palliative care team provided positive information and advice to general ward staff on the care of the dying patient. However in 2014, the service was not well developed, and there was a disconnect between what managers wanted to happen and what some of the palliative care team were undertaking. Patients using the service had only praise for the staff and felt involved in their care. At our inspection in 2015, we found that this disconnect was no longer apparent, as staff within the specialist palliative care team now felt well supported by the trust. The team had begun to use patient demographics to drive service delivery and training, and implementation of palliative care link nurses was well underway.

In 2014 we stated that improvements to the service, in terms of ensuring that the overarching strategy was accomplished, addressing challenges within the completion of the 'do not attempt cardio-pulmonary resuscitation' (DNA CPR) form, and the training of nursing staff on general wards, were required to ensure a safe, effective and responsive service. However, at our inspection in 2015 we found that significant improvements to training and overarching strategy had been implemented. The completion of DNA CPR forms still requires further improvement to ensure that patients who may lack capacity are protected when these decisions are made about their care.

Outpatients

Requires improvement

Updated 11 April 2017

We rated well led as inadequate, safe and responsive as requires improvement and caring as good because:

The concerns we found during this inspection were the same as our findings in 2014 and 2015, this was despite actions plans to address the areas of concern following both of these inspections.

We saw significant numbers of patients overdue for appointments including new and follow up appointments. Performance against some cancer waiting targets was consistently below the national standards placing patients at risk of potential harm from delayed treatment. Where the trust made progress to address the backlog of waiting list appointments this negatively affected the trust meeting the referral to treatment standards for new patients across many specialities.

Data showed 8,108 patient appointment outcome records, which had not been completed and closed on the electronic record system. Data supplied by the trust showed the current position was worse than the previous year.

The trust had not maintained an accurate record of patients who required outpatient appointments. The trust was tracking thousands of computer records to establish the patients who should have received appointments.

There were delays of up to several months in the reporting of some diagnostic reports due to failures in the information technology systems used by the regional picture archiving and communication system (PACS).

Progress against some poor performance and identified risks was slow. We saw issues identified since our last inspection had not been addressed for example, overbooking of clinics. Reports showed there had been long standing issues for example, condition of health records, which the trust had not addressed.

There was a potential risk to patient safety because managers did not always share learning from incidents with all staff. Safety procedures and maintenance contracts were not always in place to ensure the environment and equipment were adequately assessed, risks identified and equipment maintained.

Nursing staff were not always managed effectively as not all staff had received up to date mandatory training. Medical staffing vacancies affected the trust’s ability to meet the demand for outpatient services.

The condition of patient health recording had a negative impact across all clinic areas and posed a potential risk to patient confidentiality. The lack of availability of records affected most clinic areas.

Staff provided patients with evidenced based care and treatment and followed national guidelines. Patients received care delivered by staff that were experienced, skilled and had knowledge to deliver care that met patient’s needs.

Staff in outpatient and diagnostic services provided a caring, professional and compassionate service. Staff ensured patients received the best possible care. Patients were happy with the care they received. Staff had been flexible and worked their weekends to provide additional clinics in many specialities to try to meet the demand for outpatient services.

Diagnostic radiology services delivered care and treatment in a safe environment. Systems were in place to protect patients from harm during radiological investigations and ensured compliance with the departments legal responsibilities.