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Lister Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 5 April 2016

Lister hospital is part of East and North Hertfordshire NHS Trust and it is a 720-bed district general hospital in Stevenage. It offers general and specialist hospital services for people across much of Hertfordshire and south Bedfordshire and provides a full range of medical and surgical specialities. General wards are supported by critical care (intensive care and high dependency) and coronary care units, as well as pathology, radiology and other diagnostic services. There are specialist sub-regional services in urology and renal dialysis.

We carried out this inspection as part of our comprehensive inspection programme, which took place during 20 to 23 October 2015. We undertook two unannounced inspections to this hospital on 31 October, and 11 November 2015.

We held listening events in Stevenage and Welwyn Garden City before the inspection, where people shared their views and experiences of services provided by East and North Herts NHS Trust. Some people also shared their experiences by email or telephone. We talked with patients and staff from all the departments and clinic areas. We also reviewed the trust’s performance data and looked at individual care records.

We inspected eight core services, and rated three as good overall being surgery, critical care and outpatients. Four core services were rated as requiring improvement being medical care, maternity and gynaecology, children, young people and families and end of life care. Urgent and emergency services was rated as inadequate.

We rated the Lister Hospital as good for one of the five key questions which we always rate, which was whether the service was caring. We rated the hospital as requiring improvement for safety, effectiveness, responsiveness and for being well led. Overall, we rated the hospital as requiring improvement.

Our key findings were as follows:

  • Staff interactions with patients were positive and showed compassion and empathy.

  • Feedback from patients was generally very positive.

  • The children's emergency department, if rated separately, from the adult department, would have been rated as good.

  • Most environments we observed were visibly clean and most staff followed infection control procedures.

  • Safeguarding systems were in place to ensure vulnerable adults and children were protected from abuse

  • Nurse staffing levels were variable during the days of the inspection, although in almost all areas, patients’ needs were being met.

  • Medical staffing was generally appropriate and there was good emergency cover.

  • Working towards providing a seven day service was evident in most areas.

  • Patients’ needs were generally assessed and their care and treatment was delivered following local and national guidance for best practice.

  • Outcomes for patients were often better than average.

  • Pain assessment and management was effective in most areas.

  • Most patients’ nutritional needs were assessed effectively and met.

  • Most staff had appropriate training to ensure they had the necessary skills and competence to look after patients.

  • Patients generally had access to services seven days a week, and were cared for by a multidisciplinary team working in a co-ordinated way.

  • Staff were suitably qualified and skilled to carry out their roles effectively and in line with best practice.

  • Services were generally responsive to the needs of patients who used the services.

  • Critical care services were organised to respond to patients’ needs. The service had been designed and planned to meet people’s needs. There were suitable facilities for delivering critical care services particularly in the newer refurbished areas.

  • We found surgical services were responsive to people’s needs and outcomes for patients were good.

  • In maternity, the service had some good examples of services which provided excellent care beyond that of a typical district general hospital, for example, the foetal medicine service.

  • The play specialist team provided exceptional care and support for children and young people.

  • The children's bereavement services provided empathetic and compassionate care to families.

  • In the end of life care service, feedback from patients and those who were close to them was very positive.

  • In outpatients, waiting times were within acceptable timescales and clinic cancellations were around 2%.

  • There were effective systems for identifying and managing the risks associated with Outpatient appointments at the team, directorate or organisation levels.

  • Generally, there were effective procedures in place for managing complaints.

  • There was a strong culture of local team working across most areas we visited.

We saw several areas of outstanding practice including:

  • The trust’s diabetes team won a prestigious national “Quality in Care Diabetes” award in the best inpatient care initiative category.

  • The trust had developed an outreach team to deliver seven day, proactive ward rounds specifically targeting high-risk patients. This included the delivery of a comprehensive set of interventions which included smoking cessation and structured education programmes.

  • We saw patients with learning disabilities and their relatives receiving high levels of outstanding care.

  • The ophthalmology department had implemented a minor injuries service. Patients could be referred directly from accident and emergency, their GP or opticians to be seen on the same day.

  • The Lister Robotic Urological Fellowship is an accredited and recognised robotic urological training fellowship programme in the UK by the Royal College of Surgeons of England and British Association of Urological Surgeons. This technique is thought to have significantly reduced positive margin rate during robotic prostatectomy and improved patient functional outcome.

  • We saw some examples of excellence within the maternity service. The foetal medicine service run by three consultants as well as a specialist sonographer and screening coordinator is one example; the unit offers some services above the requirements of a typical district general hospital such as invasive procedures and diagnostic tests. The unit has its own counselling room away from the main clinic and continues to offer counselling postnatally.

  • Another example being urogynaecology services, the Lister is expected to become an accredited provider for tertiary care in Hertfordshire.

  • The service also offered management of hyperemesis on the day ward in maternity to minimise admission.

However, there were also areas of poor practice where the trust needs to make improvements. The trust took immediate actions to address areas of concern regarding the emergency department and a medical care ward.

  • Staff did not always report incidents appropriately, and learning from incidents was not always shared effectively.

  • Some of the staff we spoke with did not know what duty of candour meant for them in practice.

  • The triage system within the emergency department was not sufficient to protect patients from harm or allow staff to identify those with the highest acuity. Urgent action was taken to address this following it being brought to the trust’s attention.

  • The emergency department did not consistently meet the four hour target for referral, discharge or admission of patients in the emergency department.

  • Infection control practices were not always followed in the emergency department.

  • In the emergency department, patient records lacked sufficient detail to ensure all aspects of their care were clear.

  • Medicines were not always stored and handled safely.

  • The medical care services required improvement in some aspects of patient safety, such as nursing staffing levels, infection control procedures, medicine management and the documentation within patient records.

  • Some patients were cared for on medical speciality wards, where nursing staff did not always feel they had the appropriate skills to care for non specialist patients. Patients whose condition deteriorated were not always appropriately escalated. This was brought to the attention of the trust and we saw action was taken to ensure harm free care which included the review of all patient records.

  • We found poor medicines’ management within the medical service which was brought to the attention of the trust who took immediate action to address our concerns. This resulted in the review of all medicine management procedures within the service with timely action plans.

  • Issues relating to high vacancies, poor staffing levels and the lack of skills and competencies to care for poorly children, along with the high level of clinical activity on Bluebell Ward were not being addressed in a timely way to ensure children were protected from avoidable harm. Following our inspection, the trust took urgent actions to address this.

  • Mandatory training attendance in some areas was not sufficient to meet the trust’s target, and did not ensure that all staff were trained appropriately.

  • Leaders in some services were not always visible in the department and it was the perception of some staff that they did not feel adequately supported as a result of this.

  • Some nursing staff we spoke lacked an understanding of the Mental Capacity Act (MCA) and how to assess whether a patient had capacity to consent to or decline treatment.

  • Medical records were stored centrally off-site and were not always available for outpatient clinics.

  • The management of risks within some services needed to be more robust and addressed in a timelier manner.

  • Not all services had effective leadership and staff engagement in place.

Importantly, the trust must:

  • Ensure all required records are completed in accordance with trust policy, including assessments, nutritional and hydration charts and observation records.

  • Ensure there are effective governance systems in place to assess, monitor and mitigate the risks relating to the health, safety and welfare of patients including the timely investigation of incidents and sharing any lessons to be learned.

  • Ensure effective systems are in place to ensure that the triage process accurately measures patient need and priority in the emergency department.

  • Ensure that the triage process in maternity operates consistently and effectively in prioritising patients’ needs and that this is monitored.

  • Ensure that all staff in all services complete their mandatory training in line with trust requirements.

In addition the trust should:

  • Ensure that the temperature of all fridges are monitored and where temperatures are consistently outside of the agreed settings that this is escalated and action taken.

  • Ensure staffing levels and competency of staff in all services meet patients’ needs.

  • Ensure that only competent and qualified staff are conducting patient triage in line with guidance in the emergency department.

  • Ensure that risk assessments, including in relation to pressure ulcers and falls, are completed for all patients and regularly reassessed.

  • Regularly monitor and improve infection control practices and all staff follow trust procedures.

  • Ensure that patient information is kept confidential at all times.

  • Ensure that all patient records are accurate to ensure a full chronology of their care has been recorded.

  • Review clinical pathways to ensure they are up to date with relevant guidance.

  • Ensure there are effective mechanisms to feedback lessons learnt from complaints to prevent future similar incidents.

  • Review staff competencies in relation to

    Patient Group Directives (

    PDGs) to ensure staff are competent to administer medications under these.

  • Ensure that all staff understand the level of MCA, DoLS and best interests’ assessment required for their role and how this is delivered.

  • Ensure that defined cleaning schedules and standards are in place to comply with the Department of Health 2014 documents ‘Specification for the planning application, measurement and review cleanliness services in hospitals’.

  • Ensure that patients’ medical records are available at all clinics to prevent delays in appointment or appointments being rescheduled.

  • Review the process of bed allocation for surgical patients to prevent patients’ surgery being cancelled on the day of surgery due to lack of available beds.

  • Ensure that information leaflets and signs are available in other languages and in easy-to-read formats

  • Ensure learning from localised incidents and complaints is shared across all staff groups.

  • Ensure patients always have identity bands in place.

  • Ensure that agency staff receive a timely induction to areas they work.

  • Ensure CCU mortality and morbidity meetings minutes include action plans when needed.

  • Ensure all nursing staff receive annual appraisals in accordance with trust policy.

  • Reduce delays experienced by patients in transferring to a ward bed when they no longer require critical care.

  • Ensure that outpatient appointments for gynaecology and maternity patients are arranged at separate times.

  • Ensure that the vision for maternity is consistent in all documents.

  • Produce a viable strategy for children and young people’s services.

  • Ensure that children and young people have an appropriate child-friendly waiting area in the outpatient clinics.

  • Review the lack of equipment across the C&YP service and a more timely response to procuring equipment when necessary. Where there is a wait for replacement equipment risk assessments should be carried out and documented

  • Review readmission rates for paediatric care.

  • Review the tools used to monitor the deteriorating child.

  • Ensure that care and treatment complies with the mental capacity act. There was no evidence of mental capacity assessments being used in the decision making process to decide if a person had capacity to make a decision about DNACPR. Patients’ mental capacity must be assessed and recorded when making decisions about DNACPR.

  • Ensure that all end of life documentation is completed fully in accordance with trust policy.

  • Review the DNACPR forms to ensure they reflect all aspects of national guidance, especially with reference to mental capacity.

  • Ensure systems are in place to collect information of the percentage of patients achieving discharge to their preferred place within 24 hours to enable them to monitor the effectiveness of the service in line with national guidance.

  • Ensure that patient records are available for all clinic appointments.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 5 April 2016

Effective

Requires improvement

Updated 5 April 2016

Caring

Good

Updated 5 April 2016

Responsive

Requires improvement

Updated 5 April 2016

Well-led

Requires improvement

Updated 5 April 2016

Checks on specific services

Maternity and gynaecology

Requires improvement

Updated 5 April 2016

Maternity and gynaecology services required improvement for safety and responsiveness but were good for effective, caring and for well led.

We found that incidents were not always reported and there were delays in investigating those that were reported. Investigations were not always completed but there was good evidence of shared learning where full investigations had taken place.

We observed most of the service areas to be visibly clean during the inspection.

Equipment was regularly checked and maintained, although we identified some equipment which had not had the required checks performed.

There were good medicines’ management arrangements in place, although the temperature for one of the fridges in the maternity unit was higher than expected and this had not been escalated.

We were told that staffing arrangements within gynaecology were suitable to meet the needs of patients and that medical staffing for obstetrics and gynaecology worked well most of the time.

Some of the midwives we spoke with told us that the unit could become stretched and that staff did not always have time to take their break or provided the amount of time with each woman as required. We saw that most women in labour received 1:1 care. There was an escalation process in place which outlined action to be taken in the event of high levels of acuity and/or staffing shortages. Triage processes were in place but were not always consistent.

There was an audit plan in place to assess and monitor national guidelines as well as progress made with implementation of action plans since the previous audit.

Pain relief was provided and outcomes reported for women were positive, although we noted some key data had not been reported on and some key targets were not being met, for example the 62 day cancer target. Not all staff had received an appraisal or completed their mandatory training and the trust’s target had not been met.

The wards and units provided a caring environment for women and feedback was largely positive.

There were arrangements in place to meet patients’ individual needs, although the bereavement arrangements were not suitable and women also shared a waiting room for gynaecology and maternity appointments which was not sensitive to the reasons women attended their appointment.

Governance arrangements were good with a clearly defined strategy and governance structure, although meeting minutes did not always provide detailed discussion. 

Medical care (including older people’s care)

Requires improvement

Updated 5 April 2016

The medical care services required improvement in

some aspects of patient safety, such as nursing staffing levels, infection control procedures, medicine management and record keeping. There was a consistently high number of medical patients cared for on other speciality wards where nursing staff did not always feel they had the appropriate skills for example; cardiac care. We observed the environment was visibly clean. Patients whose condition deteriorated were not always appropriately escalated.

This was brought to the attention of the trust and we saw urgent action was taken to ensure harm free care which included the review of all patient records.

Care was provided in line with national best practice guidelines, and outcomes for patients were often better than average. Most staff had appropriate training to ensure they had the necessary skills and competence to look after patients. Patients had access to services seven days a week, and were cared for by a multidisciplinary team working in a co-ordinated way. Where patients lacked capacity to make a decision for themselves, staff did not always act in accordance with legal requirements by completing the appropriate mental capacity assessments.

Patients received compassionate care that respected their privacy and dignity. Patients told us they felt involved in decision-making about their care although this was not reflected in the records reviewed.

Services were developed to meet the needs of the

local population. There was specific care for patients living with dementia and mental health conditions. There were arrangements to meet the needs of patients with complex needs. The trust was working with partners to decrease delayed discharges, and to improve internal process to ensure daily discharge targets could be met.

There were effective governance arrangements, and staff felt supported by the division and trust management. The culture within medical services

was caring and supportive. Staff were actively engaged and the division supported innovation and

learning.

Urgent and emergency services (A&E)

Inadequate

Updated 26 August 2016

We carried out a focused inspection on 17 May 2016 to review concerns found during our previous comprehensive inspection on 20 to 23 October 2015. We inspected parts of four of the five key questions but did not rate them. Overall, we observed the following improvements had been made to the emergency department (ED) since our last inspection:

  • We observed that all staff were caring and compassionate towards patients and visitors within the department.

  • Patients and those close to them felt involved in their care and had all intended treatments and procedures explained to them fully.

  • During the previous inspection, the triage system within the ED was not effective in recognising potential patient safety risks, however, the department had taken significant work to address this and the new process appeared to be efficient and safe at this inspection.

  • There were improvements to hand hygiene and overall cleanliness of the department.

  • The recording of patients’ allergies had improved.

  • Systems were in place to monitor patients at risk of deterioration in the ED, including regular patient safety rounds.

  • Care records generally reflected the patient care that had occurred whilst a patient was in the ED; nursing records were generally more detailed and documented communications and interactions with patients.

  • The risk assessments we reviewed, including falls and pressure area risk assessments, were generally completed appropriately and reflected patients’ needs.

  • There had been improvements in compliance with information governance and in the protection of patients’ confidential information.

  • At this inspection, the trust was on track with their planned trajectory for compliance for all mandatory training as 81% of ED staff had had planned education days.

  • Staffing levels met patients’ needs at the time of the inspection.

  • There was a wider awareness between staff of how the department was performing against the four-hour target and which areas impacted on this performance.

  • Communication and care of patients with additional needs had been developed through additional training.

  • An effective ED development plan was in place to document necessary improvements and current progress against them.

  • The delivery of this development plan was being monitored with key actions having accountable clinicians to maintain an effective oversight of risks.

  • Policies and procedures to support staff had improved to ensure staff understood their responsibilities whilst caring for patients.

  • Departmental risks were being assessed and managed effectively.

  • Whilst attendances remained high, the department appreciated the importance of developing staff and ensuring they had the appropriate training for their roles, ensuring that staff attended necessary courses and training.

  • Staff engagement had improved within the department.

  • Staff culture and morale within the ED had improved and staff felt valued within their roles even during times of high pressure and demand.

  • Data collection and its use to monitor and improve the service had generally improved within the ED.

However, we found that:

  • The department was consistently not meeting the 15 minute time to triage target but had systems in place to monitor all patients at risk of deteriorating.

  • The time to initial clinical assessment for patients’ data was not yet being collected but plans were in place to achieve this by the end of October 2016.

  • The ED had not consistently met the four hour treat, transfer or discharge national performance measure since June 2015 but performance was improving.

  • Some leaders felt that the improvements in the ED had had to been made without the full support of other specialties in the hospital.

  • Staff knowledge of duty of candour had not improved since the previous inspection.

  • The ED mental health room was not always used in line with trust policy.  

Surgery

Good

Updated 5 April 2016

We rated surgical services as good for all five key questions.

Medical staffing was appropriate and there was good emergency cover, consultant-led, seven-day services had been developed and were embedded into the service. There was a high number of nursing vacancies; agency and bank staff were used and sometimes staff worked longer hours to cover shifts.

There was a culture of incident reporting, but staff said they did not always receive feedback on the incidents submitted. However, staff said they received feedback and learning from serious incidents.

The environment was visibly clean and most staff followed the trust policy on infection control. Although there was variable cleaning schedules available within the wards and theatres. Some ward areas did not have dedicated cleaning schedules, for both the environment and equipment.

Treatment and care were provided in accordance with evidence-based national guidelines. There was good practice, for example, in pain management, and in the monitoring of nutrition and hydration of patients in the perioperative period. Multidisciplinary working was evident.

Staff said they had received annual appraisals. The trust records showed that appraisal levels were below the required target.

Patients told us that staff treated them in a caring way, and they were kept informed and involved in the treatment received. We saw patients being treated with dignity and respect.

We reviewed patient care records; these were appropriately completed with sufficient detail. We saw systems were in place to monitor patient risk and maintain a safe service. Patients reported that they were satisfied with how complaints were dealt with.

We found surgical services were responsive to people’s needs. However, at times there were capacity pressures, and a lack of available beds was resulting in some patients’ procedures being cancelled on the day of surgery. There was support for people with a learning disability and reasonable adjustments were made to the service.

Surgical services were well-led. Senior staff were visible on the wards and theatre areas and staff appreciated this support. There was variable awareness amongst staff of the hospitals values. Staff were not aware of patients’ outcomes relating to national audits or the safety thermometer.

Intensive/critical care

Good

Updated 5 April 2016

Overall, we have judged the critical care services as good.

Safety was a high priority for critical care services. When something went wrong there was an appropriate response including an investigation involving key personnel and actions taken to prevent recurrence. Improvements to safety were made and changes monitored.

Nursing staffing levels were managed so that despite current shortages and use of agency nurses, patients received the appropriate level of care.

Care and treatment was delivered in line with current evidence and they were working towards compliance with National Institute for Health and Clinical Excellence (NICE) guidance for rehabilitation of critically ill patients. Local audits were also undertaken to ensure effective care and treatment.

Medical and nursing staff were qualified and had skills to practice, consistent with core standards for critical care services.

Areas for improvement included ensuring that paper copies of policies and procedures held on the unit were reviewed and up-to-date.

Critical care services were providing good, compassionate care. Patients were unanimously positive about the care they had received. Inspectors saw many kind and caring interactions. All staff maintained the highest regard for patients’ dignity and privacy.

Critical care services were organised to respond to patients’ needs. The service had been designed and planned to meet people’s needs. There were suitable facilities for delivering critical care services particularly in the newer refurbished areas.

There was a low formal complaint rate (one between January and September 2015) and staff took complaints and concerns seriously.

The unit was performing as expected compared to similar units regarding delayed discharges from critical care.

The governance of critical care services did not always support the delivery of high quality person centred care. Arrangements for governance and performance management did not always operate effectively.

There was a limited approach to obtaining the views of people using the services.

The leaders of the unit were strong, motivated, accessible and experienced. The senior nursing team worked well together. However, staff engagement opportunities required improvement due to lack of unit meetings and low nursing staff appraisal rates (32%).

Services for children & young people

Requires improvement

Updated 26 August 2016

We carried out a focused inspection on 17 May 2016 to review concerns found during our previous comprehensive inspection on 20 to 23 October 2015. We inspected parts of the five key questions but did not rate them. This was a focused inspection of Bluebell Ward and we did not give the service an overall rating. Overall, we observed the following improvements had been made since our last inspection:

  • The care being provided to children with complex care needs, demonstrated learning from incidents had taken place and improvements had been implemented.

  • Staff were using a paediatric early warning score (PEWS) chart appropriately to identify early signs that a child was at risk of deteriorating. The use of PEWS was being monitored through regular audits.

  • The ward had recently introduced the NHS children and young people’s safety thermometer to measure harm free care and to drive improvements.

  • The ward was visibly clean and staff followed infection prevention and control guidelines in accordance with trust policy.

  • There was the appropriate amount and type of medical equipment on the ward to meet the needs of the patients.

  • Actual nurse staffing met patients’ needs on the day of the inspection. After our previous inspection, nurse staffing levels had increased. However, recruitment was ongoing so there was a reliance on agency and bank staff to maintain the planned rota.

  • Patients and parents told us that pain was regularly assessed and well controlled.

  • There had been an improvement in the number of staff that were trained to care for a child with complex needs.

  • Generally, we observed staff treating patients and their family members with dignity and respect.

  • Parents told us they were fully involved in plans of care for their children and were provided with appropriate information.

  • Following our previous inspection, the trust had an improvement plan for children and young people’s services. We found there had generally been progress with improvements, for example, the ward had introduced an acuity tool to plan staffing to meet the dependency of patients.

  • The service’s risk register reflected the key risks highlighted on the improvement plan and was being reviewed and updated regularly.

  • Since February 2016, an educational facilitator had been supporting the ward team, working with the ward manager and focusing on leadership, support and staff engagement.

  • The culture on the ward had improved and we observed respectful, professional interactions between medical and nursing teams.

However, we found:

  • The improvement plan for children and young people’s services stated that actions related to equipment on Bluebell Ward were fully implemented. However, some of the equipment had not been maintained correctly. We were not assured that processes had been put in place to ensure that medical equipment was being serviced and therefore safe to use. We escalated this to the trust during the inspection and immediate actions were taken with new monitoring processes set up immediately.

  • There was not always evidence that bank and agency staff had received a local induction to familiarise them with working on Bluebell Ward.

  • There were further improvements required regarding staff training for example; senior trained nurses were required to attended advanced life support courses. In the meantime, appropriately trained staff from the children’s emergency department and assessment units were available to support the ward.

  • A strategy and vision for the children and young people’s service was under development.

  • At the time of the inspection, there was not a non-executive director representing the children and young people’s service on the trust board.

  • A parent of a young baby who has being cared for on the ward had not been offered breakfast.

  • One member of staff had referred to a child who appeared distressed as ‘naughty’ when talking with inspectors.

End of life care

Requires improvement

Updated 5 April 2016

We rated the service as requires improvement overall.

Not all Do Not Attempt Cardiopulmonary resuscitation forms were completed in accordance with trust procedures.

The trust’s DNA CPR form did not ask if the patient had capacity to make and communicate decisions about CPR as recommended by Guidance from the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing. However the DNACPR forms had a problem solving chart (an algorithm) on the reverse of the form that referred to capacity.

There was no documented evidence that staff assessed and recorded patients’ mental capacity in the DNACPR decision-making process.

The organisation did not have all the processes and information to manage current and future performance. The Trust collected information on the preferred place of death for all patients known to the specialist palliative care team. Outcomes were monitored through the East Hertfordshire and North Hertfordshire Specialist Palliative Care MDTs and reported to the Bedfordshire and Hertfordshire Specialist Palliative Care Group. However, the trust did not collect information on the percentage of patients who achieve discharge to their preferred place within 24 hours. Without this information, we were unable to monitor if the trust was able to honour patients’ wishes. Without collecting this information, the trust was unable to assess if they needed to improve on this..

The trust did not meet six of seven organisational standards in the National Care of the Dying Audit (NCDA) 2013/14. They showed a poor performance for care of the dying, continuing education, training and audit and formal feedback processes regarding bereaved relatives/friends views of care delivery.

The trust showed a poor performance for multi-disciplinary recognition that the patient was dying. We saw that the trust had produced an action plan in March 2015 called End of Life Care Strategy to address the shortfalls and issues raised by the NCDA 2013/14. The SPCT monitored and reviewed this on a monthly basis.

Staff did not always have the complete information they needed before providing care and treatment. Systems to manage and share care records and information were uncoordinated. Staff told us medical notes not always available when patients re-admitted.

The trust had a replacement for the Liverpool Care Pathway (LCP): the Individual Care Plan for the dying person (ICP). (The LCP was a UK care pathway that covered palliative care options for patients in the final days or hours of life.

Feedback from patients and those who were close to them who had support from the SPCT, chaplaincy team, mortuary service and bereavement team, were positive about the way staff treated patients. We heard that staff treated patients with dignity, respect and kindness. We observed positive interactions between patients and staff.

Staff delivering end of life care received appropriate training in communication and end of life care.

Oversight and management of risks was not robust.

Outpatients

Good

Updated 5 April 2016

Overall, we rated the service as good, with a rating of good for safety, caring, responsiveness and for being well led. We inspect but do not rate the effectiveness of outpatient services currently.

Staff reported incidents appropriately, incidents were investigated, shared, and lessons learned.

Infection control processes had been followed. The environment was visibly clean and well maintained. Hand-washing facilities and hand gels for patients and staff were available in all clinical areas.

Medicines were stored and handled safely. Diagnostic imaging equipment and staff working practices were safe and well managed.

Medical records were stored centrally off-site and were generally available for outpatient clinics. For those cases when notes were not available, staff prepared a temporary file for the patient that included correspondence and diagnostic test results so that their appointment could go ahead.

Nurse staffing levels were appropriate with minimal vacancies. Staff in all departments were aware of the actions they should take in the case of a major incident

Patients’ needs were assessed and their care and treatment was delivered following local and national guidance for best practice. Staff generally had the complete information they needed before providing care and treatment but in a minority of cases, records were not always available in time for clinics.

Staff were suitably qualified and skilled to carry out their roles effectively and in line with best practice. Staff felt supported to deliver care and treatment to an appropriate standard, including having relevant training and appraisal. Consent was obtained before care and treatment was given.

During the inspection, we saw and were told by patients, that the staff working in the outpatient and diagnostic imaging departments were kind, caring and compassionate at every stage of their treatment. Patients we spoke with during our inspection were positive about the way they were treated.

We found that outpatient and diagnostic services were generally responsive to the needs of patients who used the services. Waiting times were within acceptable timescales. Clinic cancellations were below 2%.

Patients were able to be seen quickly for urgent appointments if required. New appointments were rarely cancelled but review appointments were often changed.

There were systems to ensure that services were able to meet the individual needs, for example, for people living with dementia. There were also systems to record concerns and complaints raised within the department, review these and take action to improve patients’ experience.

Staff were familiar with the trust wide vision and values and felt part of the trust as a whole. Outpatient staff told us that whilst they felt supported by their immediate line managers and that the senior management team were visible within the department.

There were effective systems for identifying and managing the risks associated with outpatient appointments at the team, directorate or organisation levels. For example, information was consistently collected on waiting times, or how long patients waited for follow up appointments compared to recommended follow up times.

Regular governance meetings were held and staff felt updated and involved in the outcomes of these meetings. There was a strong culture of team working across the areas we visited.

Other CQC inspections of services

Community & mental health inspection reports for Lister Hospital can be found at East and North Hertfordshire NHS Trust.