2 December 2022
Diana Princess of Wales Hospital (DPoW) is one of the three hospital sites for Northern Lincolnshire and Goole NHS Foundation Trust. It is located in Grimsby and provides acute hospital services to the North East Lincolnshire area.
DPoW is the trust’s largest hospital. It offers a range of inpatient and outpatient services including urgent and emergency care, medical care, surgery, critical care, maternity, end of life and outpatients and diagnostic services for children, young people and adults primarily in the North East Lincolnshire area.
7 February 2020
Our rating of service stayed the same. We rated it as requires improvement because:
- The service did not have enough nursing and support staff. Not all had the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Information provided by the trust showed that 37% of nurses in ICU had a post registration award in critical care nursing. Several staff we spoke with highlighted that whilst the number of staff on duty was appropriate, the mix of skills and competence was sometimes a concern.
- The service did not have enough medical staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. We found the same situation with regards to medical staffing as at the previous inspection, in that it was not in line with Guidelines for the Provision of Intensive Care Services (GPICS) standards. Not all care was delivered by intensivists, and on call consultants had other areas of responsibility. In addition, the rota did not provide continuity of care for patients.
- Staff did not always have measures in place to keep people free from infection. ICNARC data showed there had been six unit acquired infections between 1 April 2018 and 31 March 2019. This was higher compared to similar units (3.0 against 1.6 unit acquired infections in blood per 1000 patient bed days). Observations of hand hygiene frequency was variable between staff on the ICU. On three occasions, between January 2019 and September 2019, the hand hygiene audit dropped below the trust target of 85%. On one occasion compliance was 74%. Hand hygiene data for the HDU showed that there were two occasions between January 2019 and September 2019 when the compliance rate did not meet the target of 85%.
- The service provided mandatory training in key skills to staff but had not ensured everyone had complete it. The 85% target was not met for three of the 10 mandatory training modules for which qualified nursing staff were eligible.
- Not all staff had training on how to recognise and report abuse. The 85% target was not met for two out of three safeguarding training modules for which qualified nursing staff and medical staff were eligible.
- Although, the service used systems and processes to safely prescribe, administer, and record medicines. We had concerns regarding the inappropriate storage of medicines on the ICU. All fluids were stored appropriately on HDU, however there were potassium based fluids stored alongside other IV fluids. This did not adhere to the trust policy.
- Critical care services did not always provide care and treatment based on national guidance and evidence-based practice. Information from the July 2019 governance meeting minutes showed that the division were not meeting compliance against all the National Institute for Health and Care Excellence (NICE) guidance, with a few outstanding. However, the minutes were not specific to which NICE guidance this linked to.
- Not all services were available seven days a week to support timely patient care. ICU medical team reviewed all patients at the weekend. Out of hours cover was provided by an anaesthetist on call or the medical out of hours team and not by an intensivist as per GPICS standards.
- Doctors, nurses and other healthcare professionals did not always work together as a team to benefit patients. Multidisciplinary staffing was generally in line with GPICS recommendations; however, it did not meet the full recommendations. We observed that there was not always full attendance during multidisciplinary ward rounds.
- People could not access the service in a timely way. For the intensive care unit there were also 4.2% had a non-clinical transfer out of the unit. Compared with other units, non-clinical transfers for this unit was worse than expected. Similar units had an average of 1.3% non-clinical transfers.
- For the intensive care unit at there were 12.7% non-delayed, out-of-hours discharges to the ward. These are discharges which took place between 10:00pm and 6:59am. Compared with other units (4.4%), the unit’s performance was significantly worse. This did not meet the national standard.
- For the high dependency unit at there were 12.7% non-delayed, out-of-hours discharges to the ward. Compared with other units (4.2%), the unit’s performance was significantly worse. This did not meet the national standard.
- Investigations were not timely. The service treated concerns and complaints seriously, investigated them and shared lessons learned with all staff. At the time of inspection, there were six complaints open and under investigation. Two complaints relating to Diana, Princess of Wales Hospital (DPoW) had been closed. Of these, the trust took an average of 82.5 working days to investigate and close.
- From our observation and from speaking with staff, it was clear that staff lacked confidence in their immediate line managers leadership. We heard staff state that actions were not always followed up and that outcomes were slow. Nonetheless, all staff we spoke with felt able to escalate concerns. This was also highlighted on the previous inspection.
- The HDU and ICU continued to function separately and there remained limited inter-unit working.
- Staff at some levels were not clear about their roles and accountabilities.
- There was limited improvement of leaders and staff engagement with patients and relatives. Limited work had been done to improve engagement with families and patients. However, the use of patient diaries was not embedded, and there was no support group for relatives.
- There was limited learning and improvement of services. We were provided with limited examples of innovative working. We were not aware of any involvement or participation in research.
- The service managed patient safety incidents well. Staff recognised and reported incidents and near misses. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
- Staff completed and updated risk assessments for each patient and removed or minimised risks. Staff identified and quickly acted upon patients at risk of deterioration.
- The critical care outreach team (CCOT) provided cover seven days a week from 8am to 8pm. Overnight cover was provided by the hospital out of hours team.
- Managers appraised staff’s work performance and held supervision meetings with them to provide support and development. Data submitted at the time of inspection showed that nursing and medical staff working on HDU and ICU at Diana, Princess of Wales Hospital had achieved an appraisal rate of 100% against a trust target of 95%.
- We found the processes for sepsis and delirium screening was undertaken in ICU and HDU.
- Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.
- We saw evidence in patient records that care plans included assessment and interventions for any patients with additional needs. This information would be communicated to all staff during handovers.
- Leadership of the service was in line with Guidelines for the Provision of Intensive Care Services (GPICS) standards. From discussions with the leadership team it was clear they understood the current challenges and pressures impacting on service delivery and patient care.