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Grantham and District Hospital Good

Inspection Summary


Overall summary & rating

Good

Updated 27 March 2015

The inspection of Grantham and District Hospital was carried out on 30 April 2014 as part of the wider inspection of United Lincolnshire Hospitals NHS Trust. The trust was chosen for inspection because it was an example of a high-risk trust. In 2013, the Keogh Mortality Review found significant concerns, and the trust was placed in ‘special measures’ as a result. We returned in February 2015 and inspected only those key questions where the service had been rated as requiring improvement or inadequate. We did not undertake a full comprehensive inspection on 2 February 2105.

In 2014 the hospital was rated as ‘requires improvement’ overall. Core services for accident and emergency (A&E) and medical care were found overall to require improvement. When we returned in 2015, we saw that significant improvements had been implemented, and that all services were rated as good.

Our key findings were as follows:

  • There was significant improvement in clinical staff engagement, with senior clinicians sitting on the Clinical Executive Committee making decisions, and reporting directly to the trust board.
  • There was an increase in the numbers of consultants and paediatric staff in A&E.
  • Completion of patient records in surgery had improved.
  • The service to paediatric patients attending the A&E department had improved, through recruitment of nursing staff and training of existing staff.
  • The time taken for patients to be handed over from ambulance crews to the A&E department was in excess of targets set.
  • The hospital had improved signage to meet the needs of the large Eastern European population in the county.
  • There was an adequate supply of electronic profiling beds and other equipment in the Critical Care Unit.
  • Staff throughout the hospital were observed to be kind, caring and compassionate.
  • The hospital was clean, and hand-washing facilities and alcohol gel were available in all areas. Staff used gloves and aprons when providing care to patients. The infection control team were holding a hand-washing awareness session in the corridors. The infection control team were very enthusiastic.
  • Patients were supported to have appropriate nutrition and hydration in most areas of the hospital.

We saw several areas of good practice including:

  • The A&E department had a robust system for reporting incidents, known as IR1s. These were discussed and staff had changed their practices as a result of them.
  • There was a designated and suitably decorated cubicle for children in A&E.
  • Patients stated that they were cared for with compassion, and were very supportive of staff.
  • Staff were using an assessment tool for pain, specifically designed for patients with dementia, where this was applicable.

However, there were also areas of poorer practice where the trust needs to make improvements:

The trust should:

  • Review arrangements for the provision of medications and transport on discharge.

Following this focused inspection and in light of the significant improvements made by the trust I have recommended that the trust is removed from special measures.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Good

Updated 27 March 2015

Effective

Good

Updated 27 March 2015

Caring

Good

Updated 27 March 2015

Responsive

Good

Updated 27 March 2015

Well-led

Good

Updated 27 March 2015

Checks on specific services

Maternity and gynaecology

Updated 10 July 2014

This service does not have facilities for babies to be born at this hospital. However, the trust was still advertising a birthing facility that had closed in February 2014.  This was following a review of the service and public consultation by commissioners. We spoke with 17 members of staff, including midwives, student midwives, maternity support workers and administration staff. We also spoke with three women who used the service and three family members.

We were not assured learning from incidents and complaints were being cascaded to staff. Some staff were unaware of the monthly quality report, which detailed all relevant quality issues for the service.

Not all equipment was fit for purpose or repaired in a timely manner.

There were no specialist midwives for bereavement, substance misuse or safeguarding. When questioned, staff explained to us these specialist posts were needed to meet the needs of the women using the service. There was inequality in the ultrasound scanning facilities offered to women. The head of midwifery post had been vacant for three months. Staff were unaware that a plan had been put into place to ensure the head of midwifery post was temporarily covered until a replacement head of midwifery employed. The majority of staff told us they felt isolated from the trust and felt decisions were made without consultation.

Medical care (including older people’s care)

Good

Updated 27 March 2015

In 2014 we found that there was a good culture of reporting incidents and accidents amongst staff, and appropriate action was taken with learning being disseminated. Staff did not receive feedback from incidents they reported, so lessons were not being learnt from these. We found staff were given feedback on important issues raised during our visit in February 2015. Lessons were learned which had been disseminated across the sites. Cleanliness had recently improved, beds had been upgraded, and infusion pumps were readily available. Although some aspects of the environment required improvement, plans were in place to undertake this work. Numbers of qualified nurses were still below that required by the trust, although the trust were recruiting; agency and bank staff were used when required and available. Patients received effective care and treatment that met their needs. In 2014 care bundles had been developed, but these had only recently been implemented and required embedding in practice. However, in 2015 the use of care bundles was embedded in practice, and senior medical reviews were undertaken regularly. Staff were caring and compassionate. They interacted with patients in a respectful manner. Patients’ privacy and dignity was maintained. In 2015 we found that transport arrangements for patients awaiting discharge were variable, and a pharmacy service was not available on Saturday and Sunday afternoons. The service was well-led by senior nursing staff. Staff reported feeling supported by managers. There was a lack of shared learning across sites.

Urgent and emergency services (A&E)

Good

Updated 11 April 2017

Overall, we rated urgent and emergency services as good.

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

Care and treatment provided by the department was in line with current evidence based guidance, standards and best practice. The department assessed patients throughout their care pathway in line with ‘National Institute of Health and Care Excellence’ (NICE) quality standards and College of Emergency Medicine (CEM) guidelines.

The department collected information about patients’ care, treatment and outcomes; the department used these to improve patient care.

Staff treated patients with dignity, respect and kindness during all interactions we observed.

Staff helped people and those close to them cope emotionally with their care and treatment.

Staff respected patients’ rights to make choices about their care.

Waiting times and delays were minimal and managed appropriately. Care and treatment was coordinated with other services and providers.

There were systems in place to support vulnerable patients.

There was an effective governance framework in place. The department monitored quality, risks and performance issues through monthly clinical governance meetings and there was a good feedback loop.

We saw an effective system in place to ensure patients received appropriate initial assessment by appropriately qualified clinical staff within 15 minutes of arrival to ED in line with best practice.

Emergency preparedness plans were in place and staff knew of these.

Staff gave sufficient priority to safeguarding vulnerable adults and children.

However;

There was not a robust system in place for checking availability of life saving equipment.

We found staff had not checked resuscitation equipment in line with trust policy. Several single-use items in the paediatric resuscitation trolley were out of date.

There were not sufficient numbers of children’s nurses in the department and four out a possible 20 (20%) adult nurses had completed paediatric competencies.

There were insufficient numbers of nurses and doctors trained in paediatric resuscitation.

Nurses and doctors told us the department was not big enough for the number of patients now accessing the department. We saw doctors bringing patients into the department to cubicles, which were already in use. There was no dedicated receiving area for patients arriving by ambulance.

Staff allocated ambulance stretchers to the corridor until a cubicle was available. There was a risk to safety as it would be difficult to evacuate the area in an emergency or to assess and treat a patient who became unwell.

Patients could not always access the right care at the right time due to the department’s overnight closure, especially those with urgent care needs.

There was a mixed morale amongst staff in the department, some staff described the overnight closure as worrying and wondered if the department would ever re-open overnight. Some said they liked it as staffing levels had improved during the day. Consultants said morale was low; they felt they were unable to provide the service they wanted to the local population of Grantham.

Surgery

Good

Updated 27 March 2015

In 2014 the service was good, but improvements were required in the safety of the service. This related to the records of specific areas of care (catheter care and cannulas), which were not completed in all cases. However, in 2015 we found that this had improved, with audits showing that 100% of records were completed. We rated this domain as good in 2015.

Care was effective in the service, with good outcomes reported for patients, and practice was in line with national guidance. Staff were caring and compassionate in their support for patients. Privacy and dignity was maintained. There were very good results from the NHS Friends and Family Test for Ward 2.

In 2014 the service was not always responsive to patients’ needs. The trust was not meeting referral to treatment times for the surgical specialities operating at Grantham and District Hospital. We found a similar picture in 2015. In 2014 there were intermittent problems with the lifts servicing the ward, which meant that patients were sometimes cared for in the day surgery unit. However, in 2015 we found that this problem had been resolved. The unit was responsive to individual patient needs and translation services were available, if required.

The service was well-led. Managers had a clear strategy for the service, and staff reported feeling supported. Staff felt the senior management of the trust was more visible within the hospital over the last year.

Intensive/critical care

Good

Updated 27 March 2015

The unit provided safe and effective care, with a good safety record and outcomes for people. There were suitable numbers of staff to meet people’s needs, and they had received training, which prepared them for working within the specialist environment. Staff were caring and compassionate, maintaining people’s dignity and privacy. There were positive interaction between staff and patients, and their relatives.

While there was good access to the service, in 2014 we noted that the use of manual beds rather than electric profiling beds required improvement in order to meet people’s needs. However, in 2015 we noted that the unit had been supplied with electric profiling beds, two of which could weigh patients whilst they were on the bed.

The service was well-led. Staff reported feeling supported by managers in the department, and that senior leaders in the organisation were more visible and accessible. While performance on the staff survey in 2013 had been poor for many questions, all staff we spoke with told us that things had improved in the last year.

End of life care

Good

Updated 27 March 2015

Outpatients

Good

Updated 27 March 2015