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In November 2011 we carried out a full investigation into care provided by United Lincolnshire Hospitals NHS Trust. Read the press release and the investigation report here:
CQC investigation finds improvements at Pilgrim Hospital but further progress still needed to protect patients

In April 2013, we published an update report showing a number of improvements made at Pilgrim Hospital since our investigation. You can download this report below.

Inspection Summary


Overall summary & rating

Inadequate

Updated 11 April 2017

We carried out a focused inspection to United Lincolshire Hospitals NHS Trust so we could follow up on improvements that had been made since our last inspection. This was our third inspection to the trust since the introduction of our new inspection methodology. The announced inspection took place between the 10-14, 18-19 and 26-27 October 2016. We also carried out unannounced inspections to Pilgrim Hospital on 24, 25 and 27 October 2016. We carried out a further unannounced inspection on 19 December 2016 in respone to information we had received from members of the public/relatives of patients.

Overall, we rated Pilgrim Hospital as inadequate. The medical service and the outpatients and diagnostic imaging service were rated as inadequate, urgent and emergency services and maternity and gynaecology services were rated as requires improvement and surgery, critical care and services for children and young people were rated as good.

Our key findings were:

Safe

  • The approach to reviewing and investigating incidents in some services was insufficient and too slow and led to unacceptable delays. However, there was a positive approach to reporting and learning from incidents in the critical care unit.
  • We were not always assured incidents were reported appropriately, investigated, that lessons were learnt and shared in a timely way. However, some staff told us they had received feedback following raised incidents and could give examples of where learning from incidents had taken place.
  • Where patients had met the criteria for treatment of sepsis, staff were not always responding appropriately in administering treatment in the recommended time frame and in line with the “sepsis six” care bundle.

  • We were not assured patients were receiving their medication as prescribed.

  • Individual care records were not always written and managed in a way that kept people safe. Some records were incomplete and not up-dated to reflect patients care needs.

  • Fluid balance charts in some areas were not always updated appropriately to minimise risks to patients.
  • Staff training compliance for safeguarding adults and children did not meet the trusts mandatory target of 95% completion. We were therefore not assured all staff would be able to respond appropriately.
  • Not all areas met the trust target of 95% for a majority of their mandatory training and compliance was variable across the hospital.

  • Nurse and medical staffing levels and skill mix were not always appropriate to keep patients protected from avoidable harm at all times. However, there were the appropriate numbers of staff on duty in the critical care unit.

  • The hospital participated in the national safety thermometer scheme but it was not always displayed in the ward areas.

  • The poor condition of and unavailability of health records was having a negative impact on all clinic areas, resulting in appointment delays, additional anxieties and work for clinic staff and causing difficulties and delays in medical information being located.

  • The hospital did not secure records in a way, which protected patient confidentiality. We saw numerous occasions where staff left confidential records in public areas. The environment was hazardous for administrative staff in areas where boxes of medical records had been inappropriately stored.

  • Data from the trust showed 18,636 patients had been missing on the electronic patient administration system. Of these, 1,119 patients required a further appointment meaning they had been missing from the waiting list. There was an ongoing process to continue to identify further patients missing from waiting lists. This presented a risk to patients’ ongoing treatment and care.

Effective

  • The trust’s ‘rolling 12 month’ Hospital Standardised Mortality Ratio (HSMR) for April 2015 to March 2016 was 101.5.
  • The latest published Summary Hospital-level Mortality Indicator (SHMI) for July 2015 to June 2016 was 1.101 which was as expected.
  • Outcomes for patients were sometimes below expectations when compared with similar services at a national level.
  • Generally, care and treatment was planned and delivered in line with current evidence based guidance but there were times when care and treatment didn’t followed evidence based guidance.
  • Patient outcomes were variable compared to similar services and some standards were not measured or audited.
  • Not all staff had the right qualifications, skills, knowledge and experience to do their job. Not all staff had the training or completed competences recommended by the trust to care for patients with a tracheostomy or to care for patients receiving non-invasive ventilation.

  • There was no policy for restraining patients but we found evidence that patients had received tranquilisation drugs in order to sedate them.
  • Generally there was good multidisciplinary working across the service. This included support from community staff who attended meetings to discuss patient care.
  • There was a colour coded system to signify assistance required for patients to maintain dietary and fluid requirements.
  • Endoscopy services at this hospital were Joint Advisory Group (JAG) accredited.
  • A dementia care practitioner was available to support patients living with dementia.

  • The maternity service used a maternity dashboard but they did not use this to set local goals for each of the parameters monitored, as well as upper and lower thresholds

Caring

  • Generally patients and relatives spoke positively about the care they received. Staff treated patients with kindness and compassion and provided emotional support. Staff were friendly and professional in their interactions with patients and relatives and patients felt involved in their care and informed about the care they received.
  • However, we observed some instances within the medical service of the hospital where patients were not treated with compassion, dignity and respect. We also received concerns from members of the public/relatives about the care being delivered.
  • We observed some instances where patients basic care needs were not always met.

Responsive

  • 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 had 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.
  • 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.
  • 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.

  • Maternal choice for a midwife led unit delivery was limited and there were no designated bereavement areas for families who had lost a baby.

Well led

  • Not all staff were aware of the vision and strategy for the trust and some staff felt uncertain about the future of the hospital.
  • There was not always an effective governance framework which supported the delivery of safe, good quality care.
  • Risks were not always dealt with appropriately or in a timely way.
  • We received mixed feedback from staff about morale and feeling they could raise concerns and were listened to. Some staff reported morale as good in their clinical area, where as others were less engaged with the hospital and did not feel as comfortable to raise concerns.
  • We were not assured that all of the local leaders had the necessary knowledge and capability to lead effectively because in some areas they were out of touch with the clinical care being delivered on the front line. In some areas, there was a lack of clarity about how staff were held to account.

We saw several areas of outstanding practice including:

  • The emergency department was trialling the introduction of a hot meal for those patients who were able to eat at lunchtime.
  • The department inputted hourly data into an emergency department (ED) 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 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 carers badge encouraged carer involvement, particularly for patients with additional needs. Being signed up to the carers badge also gave carers free parking whilst they were in attendance at the hospital.
  • In response to an identified need for early patient rehabilitation, a physiotherapy assistant had been employed to work within the critical care unit. Under the direction of a chartered physiotherapist, the assistant carried out a program of exercises with individual patients to support the rehabilitation process. This included a variety of exercises including the use of cycle peddles to aid the maintenance of muscle tone. Staff spoke positively about this service and of the benefits to patient recovery.
  • Staff on the children’s ward had learnt sign language to enhance their communication skills with children who had hearing difficulties.
  • The trust had direct access to electronic information held by community services, including GPs. This meant that hospital staff could access up-to-date information about patients, for example, details of their current medicine.

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

Importantly, the trust must:

  • The trust must ensure systems and processes are effective in identifying and treating those patients at risk of sepsis.
  • The trust must ensure that there are processes in place to ensure that patients whose condition deteriorates are escalated appropriately.

  • The trust must take action to ensure safety systems, processes and standard operating procedures are in place to ensure there is an on-call gastrointestinal bleed rota to protect patients from avoidable harm.
  • The trust must ensure that all staff have an appraisal and are up to date with mandatory training, and ensure staff in the emergency department have received appropriate safeguarding training.
  • The trust must ensure staff have the appropriate qualifications, competence, skills and experience, in excess of paediatric life support, to care for and treat children safely in the emergency department.
  • The trust must ensure there is an adequate standard of cleaning in the emergency department.
  • The trust must ensure staff comply with hand decontamination in the emergency department.
  • The trust must ensure that patient records in the emergency department are complete; specifically that risk assessments, pain scores and peripheral cannula care are documented.
  • The trust must ensure patient records are kept securely in the ambulatory emergency care unit (AEC).
  • The trust must ensure governance and risk management arrangements are robust and are suitable to protect patients from avoidable harm.
  • The trust must take action to ensure there is a robust process in place to report incidents appropriately and investigate incidents in a timely manner and staff receive feedback, lessons are learnt and shared learning occurs.
  • The trust must take action to ensure systems and processes are effective staff respond appropriately in administering treatment in the recommended time frame in accordance to the sepsis six bundle of care.
  • The trust must take action to ensure systems, processes are in place to reduce the significant number of omitted medication doses, and any omissions recorded in accordance with trust policy.
  • The trust must take action to ensure ligature risk assessments are undertaken in all required areas.
  • The trust must take action to ensure ligature cutters are accessible and available when needed to meet the needs of people using the service.
  • The trust must take action to ensure there are sufficient numbers of suitably qualified competent, skilled and experienced staff to meet the identified needs of patients.
  • The trust must take action to ensure the Care Quality Commission (CQC) is informed about any DoLS applications made in line with Regulation 18 of the Health and Social Care Act 2008 (Registrations) Regulations 2014.
  • The trust must include evidence of outcomes and learning from complaints within communication with staff.
  • The trust must take action to ensure that people are told when something goes wrong.
  • The trust must take action to ensure that emergency equipment in the antenatal day unit is checked when the unit is in use.
  • The trust must take actions to ensure that staff within gynaecology have greater involvement in the reporting and monitoring of incidents. This would include sharing learning from historical incidents.
  • The trust must take action to ensure staff in maternity are appropriately trained and supported to provide recovery care for patients post operatively.
  • The trust must take action to ensure that all staff receive basic life support and infection prevention and control training.
  • The trust must take action to ensure all staff working in the termination of pregnancy service receive formal counselling training.
  • The trust must take actions to ensure that all paperwork is correctly completed to ensure Human Tissue Authority guidance is followed in the disposal of fetal remains.
  • The trust must take actions to ensure that when gynaecology patients are admitted the inpatient records are found as soon as possible. Where temporary patient notes are created, these must be combined with inpatient records as quickly as possible.
  • The trust must take actions to ensure that the area designated as the labour ward recovery area is ready for use with privacy maintained at all times.
  • The trust must complete a ligature risk assessment of the Children’s ward where CAMHS patients are admitted.
  • The trust must ensure paediatric medical staffing is compliant with the Royal College of Paediatrics and Child Health (RCPCH) standards.
  • The trust must ensure nurse staffing on the children’s ward is in accordance with Royal College of Nursing (RCN) (2013) staffing guidance.
  • The trust must ensure there is at least one nurse per shift in all clinical areas trained in either advanced paediatric life support (APLS) or European paediatric life support (EPLS) as identified in the RCN (2013) staffing guidance.
  • The trust must ensure staff adhere to the trust’s screening guidelines for screening for sepsis.
  • The trust must ensure the management of health records enables the safe care and treatment of patients, compliance with information governance requirements and ensures patient confidentiality is maintained. This includes the availability, the condition and storage of medical records.
  • The trust must ensure that equipment is appropriately maintained. 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 do not suffer unnecessary delays and are placed on the waiting list.
  • The trust must ensure patients have complete and recorded outcomes to ensure there are documented decisions and actions in relation to their treatment and care.

In addition the trust should:

  • The trust should ensure there are robust systems in place to ensure all incidents are reported, investigations occur in a timely manner, staff receive feedback and processes are in place to ensure learning occurs.
  • The trust should ensure that governance procedures are robust, risks are clearly identified and that there is a comprehensive assurance system.
  • The trust should ensure ligature cutters are immediately available in the ED.

  • 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 implement the difficult airway trolley in the emergency department at the earliest opportunity.
  • The trust should ensure the proper and safe management of medicines, including storage at the correct temperature in the emergency department.
  • The trust should ensure it continues to work to response to the increased capacity and improve flow through the emergency department in order to ensure patients are seen by a registered healthcare practitioner in 15 minutes, do not have to wait longer than four hours and that ambulance handovers happen within 15 minutes.
  • The trust should ensure there is 16 hours of consultant presence each day.
  • The trust should ensure there is a suitable room in ED to treat those patient with mental health needs.
  • The trust should consider if mental capacity assessments and best interest decisions for patients attending the emergency department are recorded in line with the Mental Capacity Act.
  • 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 consider how the emergency department can comply with the accessible standard for information and also how facilities for the hard of hearing can be improved at the reception area of the emergency department.
  • The trust should consider how the environment in the emergency department could be more dementia friendly.
  • The trust should ensure mandatory training is completed in line with trust policy.
  • The trust should ensure safeguarding adults and children’s training is completed in line with trust policy.
  • The trust should ensure standards of hygiene and cleanliness at all times to prevent and protect people from healthcare-associated infection.
  • The trust should ensure that timely care planning takes place to ensure the health, safety and welfare of the service users.
  • The trust should ensure observation charts for monitoring fluid balance of patients are completed to ensure the health, safety and welfare of the service users.
  • The trust should ensure systems, processes, standard operating procedures are in place to ensure documentation, and checklists for the safe delivery of care for patients with a tracheostomy are completed and displayed in accordance with trust policy.
  • The trust should ensure evidence based guidance is followed. The trust did not follow national guidance for the administration of rapid tranquilisation medication.
  • The trust should ensure staff training on Consent, Mental Capacity Act and Deprivation of Liberty Safeguards is completed in line with trust policy.
  • The trust should ensure staff appraisal rates are completed in line with trust policy.
  • The trust should ensure patient records are kept securely.
  • The trust should ensure all fridge temperatures for the storage of medication are recorded in line with trust policy.
  • The trust should ensure staff training on Consent, Mental Capacity Act and Deprivation of Liberty Safeguards is completed in line with the trust target of 95%.
  • The trust should ensure do not attempt cardio pulmonary resuscitation (DNACPR) orders are completed and mental capacity assessment for those deemed to lack capacity are completed in line with trust policy and national guidance.
  • The trust must ensure pain assessments tool are completed for patients in line with evidence based guidance and staff are clear about the specialist pain team referral pathway.
  • The trust should ensure systems are robust to identify vulnerable patient groups including, but not exclusive to, patients living with dementia and patients with learning disabilities.
  • The trust should ensure there are robust systems in place to manage quality and safety issues in the absence of the Quality and Safety Officer (QSO) for the medicine directorate.
  • The trust should ensure patient records are kept securely.
  • The trust should ensure all fridge temperatures for the storage of medication are recorded in line with trust policy.
  • The trust should ensure that staff vacancies are recruited into to meet the patient acuity within this service.
  • The trust should ensure that the emergency call bells on the risk register since 2014 are installed.
  • The trust should ensure they review the consultant rota to ensure that the rota is sustainable, and that consultants receive 11 hours rest in line with the European working time directive.
  • The trust should ensure there is an allocated physiotherapist to surgical ward areas.
  • The trust should ensure that a Psychologist or Counsellor are available to support vascular amputation patients.
  • The trust should ensure that the measures are addressed for the National Emergency Laparotomy Audit.
  • The trust should ensure that the safety thermometer is displayed in all areas.
  • The trust should ensure that all staff receive a yearly appraisal.
  • The trust should ensure they address concerns regarding the clinical waste arrangements with disposal trolley bins permanently outside the theatre corridor.
  • The critical care unit should display safety thermometer outcomes within the department so that staff and visitors are informed of safety outcomes for the unit.
  • The critical care unit should establish a recorded program of equipment maintenance and capital replacement in line with standards for equipment in critical care.
  • Critical care should consider improving links with speech and language therapists to ensure patients are able to swallow effectively following tracheostomy or long term intubation.
  • The critical care department should consider increasing the number of staff able to access the post registration award in critical care nursing.
  • The senior management team should consider incorporating CCOT into the critical care team to facilitate continuity of care between critical care and the wards.
  • Critical care should consider integrating a named medical consultant when caring for emergency medical patients, to ensure continual and consistent treatment for these patients on discharge from the unit.
  • Critical care should review the service in line with intensive care standards.
  • Critical care should consider collecting data to reflect their delayed discharges by speciality and reason to support this topic on the risk register.
  • The trust should take actions to ensure that NICE guidance is followed in the provision of care for patients with hypertensive disorders in pregnancy.
  • 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 if recent NICE guidance is not followed then the current guidance includes an addendum to explain the current decision. (CG 190)
  • The trust should audit the length of time patients attending for emergency gynaecology appointments are expected to wait.
  • The trust should take action to improve the provision of multidisciplinary training.
  • The trust should ensure that within maternity service users feedback is captured.
  • The trust should ensure that action plans are made following audits, and a reaudit is performed, such as following the regular CTG audits.
  • The trust should consider delivering more transition clinics for other long-term conditions other than diabetes and cystic fibrosis.
  • The trust should ensure they devise an abduction policy for the neonatal unit and children’s ward, and test the policy regularly.
  • The trust should ensure all staff follow best practice documentation guidance to ensure all entries into clinical notes is of a satisfactory level and in line with professional standards.
  • The trust should ensure staff working in the children and young people’s service receive formal clinical supervision.
  • The trust should ensure outpatient and diagnostic services are delivered in line with national targets.
  • The trust should ensure staff report incidents in line with trust policy.
  • The trust should ensure staff are reminded of the procedures regarding fridge temperatures falling outside expected range.
  • 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.
  • The trust should ensure all staff are supported and are not subject to any behaviour falling outside the trust code of conduct.
  • The trust should ensure all staff know their responsibilities and expectations regarding screen breaks.
  • The trust should continue to review the progress and effectiveness of the outpatient transformation programme and work undertaken to reduce diagnostic backlogs.
  • The trust should ensure staff documented ultrasound probe cleaning.

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

Inadequate

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

Inadequate

Updated 11 April 2017

Checks on specific services

Maternity and gynaecology

Requires improvement

Updated 11 April 2017

We rated this service overall as requires improvement.

Many of the audits did not provide plans for presentation of findings to colleagues or current timelines.

Staff had not received recovery update training.

The unit struggled to gain feedback from the non-English speaking population.

Maternal choice for a midwife led unit delivery was limited.

There were no designated bereavement areas for families who had lost a baby.

The gynaecology ward often included non-gynaecology patients.

The labour ward recovery area was not set up for use or in a private room.

Data collection was not robust due to discrepancies in collection.

Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. Lessons were learned and communicated to staff.

Clinical areas were visibly clean and attempts were made to improve the working environment.

Safeguarding support for staff had increased with the introduction of specialist midwives.

Women’s care and treatment was planned and delivered in line with current evidence based guidance.

Staff gained consent prior to all care and treatment, including for disposal of fetal remains.

Staff received appraisals and were supported in training with practice development staff.

Staff responded compassionately and families were treated with kindness and respect.

Women were aware of how to complain and their complaints were taken seriously.

The women’s and children’s service was driven by quality. Despite an unknown future short term changes were performed to improve services for women.

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

Medical care (including older people’s care)

Inadequate

Updated 11 April 2017

Urgent and emergency services (A&E)

Requires improvement

Updated 11 April 2017

  

We rated urgent and emergency services as requires improvement overall. We rated safe as inadequate, effective, responsive and well led as requires improvement and caring as good.

Systems, processes were not always reliable or appropriate to protect patients from avoidable harm. Staff did not consistently follow guidance to ensure patients were screened for sepsis or received sepsis treatment in a timely manner. Not all patients were seen in 15 minutes by a registered healthcare professional. Staff did not consistently complete risk assessments for patients.There was no on call gastrointestinal bleeding (GI) rota to provide treatment anytime of the day or night.

Whilst there was an incident reporting process in place, we were not assured that all incidents were reported, incidents were investigated in a timely manner or lessons were learnt and shared with all members of staff.

Not all areas were visibly clean and cleaning audits achieved less than trust targets. Not all staff decontaminated their hands and staff did not routinely submit hand hygiene audits. The trust were addressing hand hygiene audit submissions.

The size of the department meant patients were sometimes cared for in the central area as not enough cubicles were available. No risk assessment of the environment to identify ligature points and minimise risks to patients had been undertaken.

There were no ligature cutters or difficult airway trolley available. Emergency equipment was not checked in line with trust policy.

There was no pharmacy support for staff and we found out of date medicines. Medicines fridge temperatures were not checked in line with trust policy and the medicine fridge in the emergency department (ED) was not working correctly.

In ambulatory care unit (AEC) records were not stored securely and there were delays in returning records to the medical records department.

Consultant presence in the ED was less than the recommended 16 hours a day. Medical and nursing staffing was reliant on locum, agency and bank staff. However, the trust was actively addressing this.

Staff did not consistently follow some guidelines, for example, sepsis screening and care. Staff did not consistently document patient pain assessments.

Processes were not in place to ensure that all staff received appraisals. Safeguarding and mandatory training was below trust targets. The trust were unable to provide assurance that registered nurses had undertaken specific competencies in order to care for children.

The NHS Friends and Family Test (FFT) results were slightly worse than the England average and patient privacy was compromised at times in the second triage room.

Governance, risk management and quality measurement processes were not robust. Governance meetings were in their infancy. There were no robust mechanisms for feeding back results of audit or results of the safety quality dashboard (SQD). Morbidity and mortality meetings were not held consistently. There was inconsistency between the risks that had been identified on the risk register and what staff said the risks were.

Staff were not always involved in changes to the provision of services.

Patients and relatives spoke positively about the care they received. Staff treated patients with kindness and compassion and provided emotional support. Staff were friendly and professional in their interactions with patients and relatives and patients felt involved in their care and informed about the care they received.

The service had accessed NHS Interim Management and Support (IMS) in order to review ways of working within the emergency department (ED) and improve the quality and efficiency of patient care.

Staff administered medicines in a timely manner and advance nurse practitioners had undertaken further training to be able to prescribe medicines. Staff ensured patients’ nutrition and hydration needs were met, and patients were offered hot meals. Staff had good understanding of consent procedures.

There was an electronic tool, which calculated the level of risk in ED this was used to monitor and escalate the level of risk. Staff had twice daily safety huddles and were seen to respond quickly and efficiently to emergency situations.

Generally, care and treatment was planned and delivered in line with current evidence based guidance, and the service participated in some national audits.

Staff worked collaboratively with each other and with other teams within the hospital to provide care that was coordinated and appropriate. The culture was friendly and supportive, staff worked as a team and local leaders were visible and approachable.

Staff were aware of the trust’s vison and consistently demonstrated the values of the organisation.

Surgery

Good

Updated 11 April 2017

Overall we rated surgical services as good.

Staff recognised concerns, incidents or near misses and gave us example of when they may report these.

Staff said they received feedback following raised incidents and could give examples of where learning from incidents had taken place.

Equipment checked was within its service date and new equipment was evident across the service.

Most clinical areas were visibly clean, uncluttered and well organised.

We observed staff providing kind and compassionate care to patients and their relatives in all areas we visited.

Friends and Family Test data (FFT) showed an average of 86% of patients on surgical wards said that they would recommend the service.

Staff within this service showed a commitment to improving services and felt well supported by senior staff.

Senior staff were well respected and valued by staff who described them as dedicated and hardworking.

However;

Staff knew how to report incidents and what should be reported but incidents remained open on the system.

The trust results in the National Emergency Laparotomy Audit showed out of 11 measures only two areas were compliant with eight measures amber and one red.

Patient records were stored in unlocked trollies, staff told us that new locked trollies were being delivered to those wards that currently did not have them but had not arrived during this inspection.

There was no formal psychologist or counselling support for vascular patients following amputation.

Medical outliers were admitted to the surgical wards, which resulted in cancelled operations which was outside the control of this service.

Risks were not always dealt with appropriately or in a timely way. For example, the absence of emergency call bells on the surgical wards had been on the risk register since 2014 but minutes at the governance performance meeting in May 2016 showed that the risk remained unresolved.

Intensive/critical care

Good

Updated 11 April 2017

Overall, critical care service was rated good for safe, effective, caring, responsive and well led.

The critical care unit appeared visibly clean and promoted patient safety through established infection control processes, with no reported incidents of meticillin-resistant staphylococcus aureus (MRSA) or clostridium difficile (C.Difficile). Local audits showed staff consistently used good hand hygiene practices and were bare below the elbow in line with best practice.

There were adequate medical and nursing staff to meet the recommended staff to patient ratio, as defined in the core standards for intensive care units.

The department planned and provided care according to national and local guidelines and was an active member of the Mid Trent critical care network, where common working policies were developed and agreed.

We observed staff providing compassionate care and maintaining patient privacy and dignity at all times.

The unit was responsive to local demand by using beds flexibly according to the level of care required. The unit worked collaboratively with the colorectal cancer service to provide facilities and care for the post-operative patients at level one (enhanced ward level care).

Patients were supported on discharge by the critical care outreach team .Those receiving level three (Intensive care) had the opportunity to attend a post critical care clinic for longer-term support.

The service was led by experienced senior manager with the skills and capability to lead the service effectively .Staff told us they felt supported to carry out their roles within the unit.

However the critical care unit informed the inspection team that delayed patient discharges was a problem for the unit and this was on the departments risk register. However, the unit did not keep a comprehensive record of delayed discharges.

The critical care unit did not have the recommend number of nurses with a post registration qualification in critical care nursing as defined in the core standards for intensive care units.

Services for children & young people

Good

Updated 11 April 2017

Overall, we rated this service as good overall but safety required improvement.

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 team 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.

Despite the implementation of a sepsis management pathway by the trust in 2014, we found this had not been embedded. Children and young people were not screened for sepsis when observations had identified them as at risk of sepsis.

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 were no assured that staff would know what actions to take in the eventuality of a missing child.

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.

Staff demonstrated a good knowledge about incident reporting and evidence of learning from incidents. The numbers of incidents were low compared to other sites within ULHT and there had been no never events or serious events in the last 12 months.

There was evidence of good risk assessments for children and young people admitted to the service at this hospital, this included infection control; bed rails assessment and skin integrity assessments. There was evidence of reviewing the risk assessments within the appropriate timescales. Regular pain assessments were undertaken adapted to the age group of the child being assessed.

There were no reported cases of MRSA bacteraemia or Clostridium difficile for the service in the last 12 months.

The service delivered care according to local and national policies which were evidence based. They had received accreditation for the evidence-based care, which was being delivered.

We observed staff providing care, which was compassionate and engaged at a level, which was age appropriate. Children and their parents were involved in their care and told us they were given adequate amounts of information about their care and treatment.

The service was responsive to the needs of those accessing the services. The individual needs of children and young people were being met and staff had attended courses to enable them to communicate with those that had hearing impairments.

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.

End of life care

Good

Updated 27 March 2015

The service was safe. There was a good culture of reporting and learning from incidents. Records were in place, documenting patients’ wishes regarding resuscitation that were appropriate. Some records did not always document the involvement of relatives in the decision-making process.

The service was effective, working to the Gold Standard Framework. Patients’ pain relief was prescribed and administered in a timely manner. The trust had taken part in the National Care of the Dying Audit, the results of which were awaited at the time of our inspection.

The service was caring. Patients received care from staff that was attentive and sensitive to their needs. Patients and the families we spoke with were positive about the care they received. Patients’ privacy and dignity was maintained.

The service was responsive to patients’ individual needs. In 2014 staff told us that end of life care services were planned on the principle of person-centred care. This meant that patients’ wishes were at the centre of decisions made about their care. However, in 2014, only 17.5% of patients who died in the hospital were seen by the palliative care team. Staff reported a high demand for support from the palliative care team, which they were not able to provide. We were told that the trust was going to address this through the recruitment of an additional palliative care nurse. In 2015, we found that the trust had implemented link nurses on each ward, who identified patients at the end of their life.

The service was well-led. We found that staff shared the visions and values of the trust; namely, that the patients were at the centre of decisions made about how the service was run. The views of patients and staff were being proactively sought to drive up standards in the service.

Outpatients

Inadequate

Updated 11 April 2017

We rated this service as inadequate because:

Outpatient services did not manage and maintain medical records in a way, which enabled the safe care and treatment of patients, complied with information governance requirements, or ensured patient confidentiality. This included the availability, the condition and storage of medical records.

Data showed continuous poor performance against national cancer targets. We saw significant numbers of patients overdue for appointments including new and follow up appointments. In some cases, the 2016 position was worse than the previous year. The trust performance against referral to treatment times had declined between June 2016 and September 2016.

Data showed 8,108 incomplete patient appointment outcomes, which staff did not record on the electronic record system. Data supplied by the trust showed the current position was worse than the previous year.

There had been significant delays in the reporting of diagnostic imaging results due to technical difficulties. This affected patients receiving timely access to care and treatment.

Not all staff reported incidents in line with trust policy. Therefore, not reporting incidents presented a risk to patients because it meant departments could not put mitigating in place to prevent an incident from happening again.

There were delays in staff typing and sending clinic letters to GPs and patients. We saw significant numbers of letters waiting to be typed.

Not all staff received appraisals in a timely manner. Some staff we spoke with said their appraisals were not meaningful and did not provide opportunities to develop. In particular, administrative staff did not benefit from regular or meaningful appraisals.

Progress against some poor performance and identified risks was slow. We saw issues identified since our last inspection had not been address 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.

We had concerns in relation to the culture in some outpatient departments. Some staff said they had experience bullying and intimidating behaviour particularly from managers. The majority of administrative staff we spoke with said managers did not support or listen to them. There were shortages in administrative staffing.

However we also found:

Staff delivered patient care in line with evidenced based care and best practice guidelines. Staff had access to relevant trust policies and national guidelines to support them deliver patient care. Staff reported incidents in line with the Ionising Radiation (Medical Exposure) Regulations 2000 (IR(ME)R

There was effective multidisciplinary working with staff, teams and services working together to deliver care and treatment to meet the patient’s needs. Staff from different specialties and roles provided one-stop clinics in some departments.

Staff were caring, compassionate and involved patients in their care and treatment. We saw positive interactions between staff. Patients were positive about their care and treatment. Staff supported patients in the event of bad news.

Services met the needs of local people with some specialist services available for patients. Some clinics developed new ways of working to meet demand and address overdue appointments for example virtual clinics.

Staff had access to translation and interpretation services and where possible used their resources to enhance the patient’s care pathway.

We saw some examples of patient and staff involvement. We saw where changes had occurred because of patient and staff involvement.

We saw examples of departments innovating to improve care for patients.