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Scunthorpe General Hospital Inadequate

Inspection Summary


Overall summary & rating

Inadequate

Updated 6 April 2017

We carried out a follow-up inspection of Northern Lincolnshire and Goole NHS Foundation Trust from 22 to 25 November 2016 to confirm whether the trust had made improvements to its services since our last inspection in October 2015. We also undertook an unannounced inspection on 17 October 2016 and 08 December 2016.

To get to the heart of patients’ experiences of care and treatment we always ask the same five questions of all services: are they safe, effective, caring, responsive to people’s needs, and well-led? Where we have a legal duty to do so, we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

When we last inspected this trust, in October 2015, we rated the trust overall as ’requires improvement’. We rated safe, effective, responsive, and well led as ‘requires improvement. We rated caring as ‘good. Scunthorpe General Hospital (SGH) was rated as inadequate overall, Diana Princess of Wales Hospital (DPoW) was rated as ‘requires improvement’ overall and Goole District Hospital was rated ‘good’ overall. In community services community adult services was rated as ‘requires improvement’ overall, end of life care was rated as ‘requires improvement’ overall, children’s and young people’s services was rated as good overall with safe rated as ‘requires improvement’ and dental services was rated as ‘good’ overall.

Following the inspection in October 2015, there were six breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations. These were in relation to staffing, safe care and treatment, dignity and respect, premises and equipment, good governance and need for consent.

The trust sent us an action plan telling us how it would ensure that it had made improvements required in relation to these breaches of regulation. At this inspection we checked whether these actions had been completed.

In November 2016 we inspected:

  • Diana Princess of Wales Hospital.
  • Scunthorpe General Hospital.
  • Community Adult Services – safe and well led domains.
  • Community end of life care services – effective, responsive and well led domains.
  • Community children and young people’s services – safe domain.

We did not inspect Goole District Hospital as the services provided at this hospital were rated as good in October 2015. We carried out a follow up inspection of community services and looked specifically at the domains that were rated as ‘requires improvement’ following the October 2015 inspection.

We rated Northern Lincolnshire and Goole NHS Foundation Trust as inadequate overall. Safe and well led were rated as ‘inadequate’, effective and responsive were rated as ‘requires improvement’ and caring was rated as ‘good’.

We rated Scunthorpe General Hospital as inadequate overall.

Key Findings:

  • Nursing and medical staffing had improved in some areas since the last inspection. However, there were still a number of nursing and medical staffing vacancies throughout the trust. Staff turnover in some areas were particularly high especially in medical care, emergency departments, surgical services, and services for children and young people.
  • The trust had systems in place to manage staffing shortfall as well as escalation processes to maintain safe patient care. However, a number of registered nurse shifts remained unfilled, despite these escalation processes and we saw examples of wards not meeting planned staffing levels and high patient acuity not identified appropriately.
  • There had been a lack of improvement since the inspection in 2015, areas of concern had not been fully addressed in a sustained way and there had been deterioration in a number of services. Safety processes were not always adhered to in some services.
  • In 2015, we said that the trust must ensure there is an effective process for providing consistent feedback and learning from incidents. During this inspection, learning from incidents remained inconsistent and variable between directorates. Staff we spoke to reported a varying standard of feedback and learning from incidents.  
  • Assessing and responding to patient risk was inconsistent and did not support early identification of deterioration in maternity, surgery and urgent and emergency services. This was particularly evident in the Emergency Department (ED) at Scunthorpe General Hospital (SGH), where the national early warning scores (NEWS) were not recorded in the majority of records we reviewed.
  • A Paediatric Early Warning Score (PEWS) was not used in the Emergency Department, so we were unable to be sure that the identification and escalation of deterioration in a child’s condition would be recognised.
  • The trust used the five steps to safer surgery procedures including the World Health Organisation (WHO) checklist. However, from a review of records and observations of procedures, it was apparent that this was not an embedded consistent process.
  • The standard of documentation was variable, for example in the ED at SGH; documentation was variable and at times inadequate to ensure delivery of safe care.
  • During our inspection, the ED at SGH was overcrowded with no resuscitation bays or trolleys available. Patients were queuing with paramedics waiting for a cubicle and we saw and heard evidence of patients put at risk due to unavailable space.
  • There were poor infection prevention and control processes and standards of cleanliness in the ED at SGH. Mandatory training rates in infection control were variable across the hospital with low rates in the areas where concerns were identified.
  • We found inconsistent practice with regard to resuscitation trolley checks, fridge temperature checks and medication checks across the hospital.
  • We were not assured patients had adequate nutrition and hydration whilst they were in the Emergency Department for a long period of time.
  • Patient flow through the hospital remained an issue with a significant number of patients cared for on non-medical or non-speciality wards. A ‘buddy’ ward system was in place, however there was still confusion regarding which consultant should review which patient. Patients who were moved more than once could be under the care of different consultants during their stay in hospital.
  • There was a high number of black breaches (ambulances waiting for over one hour) at this trust between December 2015 and September 2016, there were 694 black breaches.
  • Patients requiring pre-assessment prior to surgery were not always assessed according to an effective patient pathway. There remained a large number of ‘on the day’ cancellations for clinical reasons.
  • Referral to treatment times across a number of services showed a deteriorating position and was significantly below the national indicator and slightly below the England average. Patients were not always able to access services for assessment, diagnosis or treatment when they needed them. There were long wait times within surgical services and overall the service was not meeting the national referral to treatment times (RTT) or all cancer performance standards.
  • Emergency Department performance was variable and between August 2015 and July 2016 the department did not achieve the target for 95% of patients to be treated, discharged or admitted within four hours.
  • In 2015, we raised concerns regarding the numbers and reporting processes of mixed sex accommodation breaches. The trust had updated the policy for eliminating mixed sex accommodation, which was in line with Department of Health guidance (November 2010). However, the trust has continued to report mixed sex breaches in a number of core services. For example in medicine at SGH, 14 mixed sex breaches had been reported.
  • The trust participated in national and local audit programmes however, trust performance against national performance was mixed across most of the core services with many showing performance that was worse than England averages. There was also variation in patient outcomes between the two hospital sites. Patient outcomes were overall worse at SGH than DPoW.
  • Mandatory training and appraisal targets had not been met by some staff groups. This included safeguarding training targets and not all staff had the required level of safeguarding training in place.
  • At the 2015 inspection we were told that were plans to introduce a seven day 24 hour gastro-intestinal (GI) bleed rota. At this inspection we found that this was still not in place. Agreement had been reached for consultant rota cover however further work was being undertaken to agree the nursing rota.
  • The endoscopy unit had lost their Joint Accreditation Group (JAG) accreditation in August 2016 due to an audit that was not submitted within the necessary timescales and communication issues.
  • In maternity services we had concerns regarding the completion of the K2 training package (an interactive computer based training system that covered CTG interpretation and fetal monitoring) for midwives and medical staff in maternity.
  • We found poor leadership and oversight in a number of services, notably maternity services, outpatients, surgery and urgent and emergency care. In these services leaders had not led and managed required service improvements effectively or in a timely manner. In addition service leads had tolerated high levels of risks to quality and safety without taking appropriate and timely action to address them.
  • There was variability in the quality of risk registers, not all risk registers accurately reflected the risks in the service and were not always updated and reviewed effectively.
  • Concerns remained regarding the organisational culture. There were a number of themes that emerged from discussions with staff relating to a disconnection still between the executive team and staff, there was a sense of fear amongst some staff groups regarding repercussions of raising concerns and bullying and harassment. Feedback from management teams had a more positive focus.

However:

  • The trust had taken action in some areas since the 2015 inspection, for example, the trust had stopped using Band 4 nurses, awaiting professional registration numbers, within the registered nurse establishment.
  • There were improvements in critical care services, the management team were able to articulate a clear vision and governance processes were effective.
  • There was a new management team in surgery that were able to demonstrate an understanding of the challenges and the areas that required further improvement. They had only recently come into post and had not had sufficient time to implement the changes required to address the ongoing concerns.
  • At SGH the Ambulatory Care Unit (ACU), which opened in September 2015, had a positive impact on patient flow.
  • There was evidence of good multidisciplinary working in most of the services. A frail elderly assessment team (FEAST) attended ED liaising with the community teams and the service offered hyper acute stroke services with acute stroke nurses attending ED.
  • In critical care patient outcomes, for example, mortality, early readmissions, delayed and out of hours discharges had improved and were in line with similar units.
  • There were improvements in the ophthalmology service specifically with regard to the cancellation of clinics and clinical oversight of this process
  • All radiology staff had received training regarding the ionising radiation (medical exposure) regulations (IR (ME) R 2000).
  • Overall we observed staff treating patients with dignity and respect. Patients told us staff were caring, attentive and helpful. Staff responded compassionately to pain, discomfort, and emotional distress in a timely and appropriate way..

We saw several areas of good practice including:

  • An ambulance handover team, to see ambulance patients and provide an initial assessment, had been introduced and was providing a positive impact on the ambulance turnaround times.
  • There was a new initiative called the virtual ward. Two health care assistants were available all day Sunday to Friday and half days on Saturdays. They were deployed to an elderly medical ward at the start of their shift, and then re-deployed to any area with short notice absence or where one to one patient care was required.
  • The Ambulatory Care Unit (ACU) opened in September 2015 and had a positive impact on patient flow at the Scunthorpe General Hospital site. This had resulted in a significant reduction in length of stay of almost 2 days, an increase in zero length of stay patients and a significant reduction in medical outliers.
  • A online call service run by the infant feeding co-ordinator was being offered to support breast feeding mothers within the community setting.
  • The trust had held 'Dying Matters' roadshows at a number of local venues in May 2016, including supermarkets and community centres. These had been advertised as events to provide advice and sign-posting to members of the public on all aspects of planning end of life care, bereavement, dying, organ donation, and will-writing.
  • The Macmillan end of life care clinical coordinator had been in post for ten months. During that time, 400 staff had attended educational sessions and the new end of life care plan had been implemented on 11 wards. An end of life care facilitator had also been appointed recently.
  • The diagnostic imaging departments had begun a pilot in conjunction with primary care for radiologists to refer patients straight to CT following an abnormal chest x-ray. When patients were seen in clinic as a two-week wait, they already had CT scans and results available for the clinician at their first appointments. This potentially reduces lung cancer patients’ length of pathway.

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

  • The trust must ensure that service risk registers are regularly reviewed, updated and include all relevant risks to the service.
  • The trust must monitor and address mixed sex accommodation breaches.
  • The trust must continue to improve its Paediatric Early Warning Score (PEWS) system to ensure timely assessment and response for children and young people using services.
  • The trust must ensure that, following serious incidents or never events, root causes and lessons learned are identified and shared with staff, especially within maternity and surgery.
  • The trust must ensure that effective processes are in place to enable access to theatres out of hours, including obstetric theatres, and that all cases are clinically prioritised appropriately.
  • Ensure that the five steps to safer surgery including the World Health Organisation (WHO) safety checklist is implemented consistently within surgical services
  • The trust must ensure there are effective planning, management oversight and governance processes in place, especially within maternity, ED and outpatients. This includes ensuring effective systems to implement, record and monitor the flow of patients through ED, outpatients and diagnostic services.
  • The trust must ensure the proper and safe management of medicines including: checking that fridge temperatures used for the storage of medication are checked on a daily basis in line with the trust’s policy
  • The trust must ensure that there are effective processes in place to support staff and that staff are trained in the recognition of safeguarding concerns including all staff caring for children and young people receiving the appropriate level of safeguarding training and in outpatient services.
  • The trust must ensure that actions are taken to enable staff to raise concerns without fear of negative repercussions.
  • The trust must ensure that a patient’s capacity is clearly documented and where a patient is deemed to lack capacity this is assessed and managed appropriately in line with the Mental Capacity Act (2005).
  • The trust must ensure that policies and guidelines in use within clinical areas are compliant with NICE or other clinical bodies.

Emergency and Urgent Care

  • The trust must ensure that there are the appropriate systems in place to maintain the cleanliness of the ED at SGH to prevent the spread of infections.
  • The trust must ensure that effective timely assessment and/or escalation processes are in place, including the use of the National Early Warning Score (NEWS), so that patients’ safety and care is not put at risk, especially within ED.
  • The trust must ensure that timely initial assessment of patients arriving at ED takes place and that the related nationally reported data is accurate.
  • The trust must ensure that ambulance staff are able to promptly register patients on arrival at the ED.
  • The trust must ensure that patients are assessed for pain relief; appropriate action is taken and recorded within the patients’ notes.
  • The trust must ensure that patients in ED receive the appropriate nursing care to meet their basic needs, such as pressure area care and being offered adequate nutrition and hydration, and that this is audited.

Critical Care

  • The trust must audit compliance with NICE CG83 rehabilitation after critical illness and act on the results.
  • The trust must review and reduce the number of non-clinical transfers from ICU.

Maternity

  • The trust must ensure that effective timely assessment and/or escalation processes are in place, including the use of the Modified Early Obstetric Warning Score (MEOWS).
  • The trust must continue to improve obstetric skills and drills training among medical staff working in obstetrics.
  • The trust must continue to improve midwifery and medical staff competencies in the recognition and timely response to abnormalities in cardiotocography (CTGs) including the use of ‘Fresh eyes’.

Children and Young People’s Service

  • The trust must ensure the number of staff who have received training in advanced paediatric life support, is in line with national guidance and the trust’s own target.

Outpatients and Diagnostic Imaging

  • The trust must complete the clinical validation of all outpatient backlogs and continue to address those backlogs, prioritised according to clinical need.
  • The trust must continue to take action to reduce the rates of patients who DNA.
  • The trust must continue to take action to reduce the numbers of cancelled clinics.
  • The trust must continue to strengthen the oversight, monitoring and management of outpatient bookings and waiting lists to protect patients from the risks of delayed or inappropriate care and treatment.
  • The trust must continue to work with partners to address referral to treatment times and improve capacity and demand planning to ensure services meet the needs of the local population.

There were also areas of poor practice where the trust should make improvements which are detailed at the end of this report.

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 6 April 2017

Effective

Requires improvement

Updated 6 April 2017

Caring

Good

Updated 6 April 2017

Responsive

Requires improvement

Updated 6 April 2017

Well-led

Inadequate

Updated 6 April 2017

Checks on specific services

Maternity and gynaecology

Updated 12 October 2017

  • The World Health Organisation (WHO) surgical safety checklist was not consistently embedded.

  • Actual midwifery staffing levels were often below the planned staffing level.
  • The service had introduced a patient safety midwife. Their role was to audit maternity records and undertake safety checks on aspects of women’s care. However, midwifery staffing levels were impacting on the ability to consistently carry out the role.
  • High rates of staff sickness were having an impact on midwifery staffing levels. In June 2017, the sickness rate was 16%.
  • We found inconsistencies in how the service recorded delays in patient care.

However;

  • Processes had been put in place to ensure staff had checked emergency equipment.

  • The service had commenced submitting data to the maternity safety thermometer.
  • Clinical records were fully completed. We saw evidence of ‘fresh eyes’ and hourly assessment of cardiotocography (CTG) in line with trust policy.
  • We saw evidence of appropriate escalation of women to the coordinator and plans were clearly documented using the situation, background, assessment and recommendation response (SBAR) tool.

Medical care (including older people’s care)

Requires improvement

Updated 6 April 2017

In the previous CQC inspection in October 2015, we rated the service as requires improvement overall.

At this inspection we rated medical care service as requires improvement because:

  • We had concerns about the safety of medical care services, which required improvement. The number of nursing staff on duty was below the minimum agreed level in order to provide safe care and there was minimal medical cover at night with one registrar and two junior doctors covering the stroke unit, the clinical decisions unit and all medical wards.
  • There were mixed results in national audits and the endoscopy unit was no longer meeting the requirements for JAG accreditation and had lost this is in July 2016.
  • The trust’s referral to treatment time (RTT) for admitted pathways for medical services was worse than the England overall performance. Patient flow through the hospital remained an issue with a significant number of patients cared for on non-medical or non-speciality wards. We also found two week breaches were still occurring in endoscopy.
  • There was no action plan to demonstrate how the medicine group were going to meet their business objectives. We found staff engagement varied. Although staff appeared dedicated to patient care and worked well with colleagues, morale was low because of staff shortages, ward moves and working additional shifts. Ward managers had limited time to carry out their management duties as they were counted in the nursing numbers four days out of five.

However:

  • We found the monitoring and reporting of medicine fridge temperatures had improved and nurses awaiting their PIN were no longer counted in the nursing numbers.
  • Staff were caring and patients were treated with respect and compassion.
  • On the Scunthorpe General Hospital site, the Ambulatory Care Unit (ACU), which opened in September 2015, had a positive impact on patient flow.

Urgent and emergency services (A&E)

Updated 12 October 2017

  • The daily cleaning checklists and medicine fridge temperature recordings were not always completed daily.
  • The daily checking of resuscitation trolleys and emergency equipment remained inconsistent.
  • The completion of nursing documentation remained inconsistent.
  • Paediatric early warning scores (PEWS) were not completed in 89% of patient’s notes.
  • We found that sepsis pathways were not always completed or completed fully and antibiotics were not always given in a timely manner.
  • Patients were not always assessed appropriately for nutrition and hydration, falls or pressure damage risk and this was not always documented.
  • We found no assurance that safeguarding assessments had taken place.
  • We had security concerns regarding the electronic medicine key system for controlled drugs.
  • Entry to the resuscitation room remained a security risk.
  • We found that 30% of nursing shifts were not filled with substantive staff.

However;

  • The department was visibly clean and tidy, additional support workers had been employed to assist with this.
  • A new children’s waiting area and ambulance entrance was open.
  • National early warning scores (NEWS) were recorded in all adult patients’ notes we checked.
  • A shift handover sheet had been introduced where the shift leader allocated tasks.
  • A keypad had been installed on the medicine room in the majors’ area.
  • New nursing documentation was in place.
  • Daily issues were discussed in the huddle and appropriately escalated.
  • We observed staff offering patients food and drinks.
  • We found that the management of patients with mental health problems had improved. The room was ligature free and a standard operating procedure had been introduced.

Surgery

Requires improvement

Updated 6 April 2017

In the previous CQC inspection in October 2015, we rated the service as requires improvement overall.

At this inspection we rated surgery as requires improvement because:

  • Skill mix and experience of staff remained an issue even though, when staff shortages existed, the trust did try to fill the vacancy.

  • Access to emergency theatres was not consistent or in conjunction with national guidelines. Staff we spoke with said that clinicians held discussions in accordance with the National confidential enquiry into patient outcome and death (NCEPOD) guidelines. However, data we reviewed showed that patients were not consistently booked to accord with NCEPOD classifications.
  • Patients requiring pre-assessment prior to surgery were not always assessed according to an effective patient pathway. There remained a large number of ‘on the day’ cancellations for clinical reasons. The senior management team were aware of the issues and had been working with the pre-assessment team to develop a business case for improvements in the pre-assessment pathway, but this work was still to be approved.
  • Services did not always meet patients’ needs. Patients were not always able to access services for assessment, diagnosis or treatment when they needed them. There were long wait times within surgical services and overall the service was not meeting the national referral to treatment times (RTT) or all cancer performance standards. Since June 2016 the trust performance of meeting referral to treatment standards for patients admitted for treatment within 18 weeks of referral has been worse than the England overall performance. Data for October 2016 showed 73.7% of patients were treated within 18 weeks (national standard of 92%) against an England performance of 75.5%. Trust performance over the period showed a deteriorating trend. Patients also experienced cancellations of operations and procedures for clinical reasons. A number of medical patients were cared for in surgical beds which limited the availability of beds for elective surgical patients.
  • Performance in national audits was variable with the majority of indicators in the national emergency laparotomy, bowel cancer and national hip fracture audits being worse than national averages for a number of performance measures, including the time taken for a patient with a fractured neck of femur to access theatre. This had been a concern since our 2014 inspection, and although performance had improved slightly year on year, it still remained below national performance.
  • The surgical directorate had a clinical strategy for surgical services, and while it did make detailed reference to national reports and recommendations, it did not reference the trust values and strategy or have deadlines for actions identified. We discussed this with the senior management team who explained that they were new in post and so required further time to populate and embed all of the actions required but they said they were aware of the issues and said that this document was a list of immediate priorities to focus on.
  • The trust used the five steps to safer surgery procedures including the World Health Organisation (WHO) checklist. However, from a review of records and observations of procedures, it was apparent that this was not an embedded consistent process. In one case we observed that the checklist was completed slightly prior to the end of the operation.
  • The trust used the national early warning score (NEWS) tool to identify deteriorating patients; surgical areas used an electronic based system to record the early warning score. From seven sets of notes we reviewed we did not see consistent effective escalation of all deteriorating patients. Four patients we reviewed had deteriorating early warning scores; however, documentation of escalation and review was not available. For three patients, escalation and action was documented as being taken. 

Intensive/critical care

Good

Updated 6 April 2017

In the previous CQC inspection in October 2015, we rated the service as requires improvement overall.

At this inspection we rated critical care as good because:

  • The service had taken action on most of the issues raised in the 2015 inspection. There was an effective governance process in place with a clear structure for escalation in the directorate and there was evidence of regular review of the risk register and controls in place for the risks.
  • Staff were positive about the recent changes to the senior management team, morale had improved, staff were happy in their work and felt supported and valued.
  • There was a clear critical care strategy and staff understood the vision for the service.
  • Patient outcomes, for example, mortality, early readmissions, delayed and out of hours discharges had improved and were in line with similar units.
  • There was a good track record in safety. There had been no never events, or serious incidents and staff understood their responsibilities to raise concerns and report incidents. The incidents staff reported mainly resulted in low or no harm.
  • Staffing levels and skill mix were planned and reviewed to keep people safe.
  • Staff were supported to maintain and develop their professional skills and the number of nurses that had an up to date appraisal was better than the trust target. A clinical educator had been appointed and was due to commence in post.
  • Seventy-two percent of nurses had a post registration qualification in critical care; this was better than the minimum recommendation of 50% in the Guidelines for the Provision of Intensive Care Services 2015 (GPICS).
  • There had been no complaints about the service in the last 12 months and feedback from patients and relatives was positive about the way staff treated them.

However:

  • Some of the issues raised at the 2015 inspection remained a concern. For example, medical and nurse staffing was still not yet in line with the GPICS. The critical care strategy had plans in place to address this.
  • The rehabilitation after critical illness service was very limited and not in line with GPICS.
  • The number of non-clinical transfers was not in line with national guidance and was worse than similar units and the service did not formally monitor the number of patients ventilated outside of critical care.
  • Reporting of mixed sex occurrences had improved, but there was evidence of nine mixed sex accommodation breaches in two months where patients had not been discharged in line with trust policy.

Services for children & young people

Requires improvement

Updated 6 April 2017

In the previous CQC inspection in October 2015, we rated the service as good overall. At this inspection we rated services for children and young people as requires improvement because

  • There was a shortage of qualified nursing and medical staff available within the service. Staffing levels did not meet professional guidance and had resulted in services being closed at times of peak demand. There was a lack of senior nursing or medical cover available out of hours and at weekends.
  • Mandatory training and appraisal targets had not been met by all staff groups. This included safeguarding training targets and not all staff had the required level of safeguarding training in place.
  • We were not assured that staff had received the necessary paediatric life support training. This was because data provided by the trust suggested low rates of compliance. However, staff we spoke with told us that they had training in place.
  • The Neonatal Intensive Care Unit had been closed to admissions on a number of occasions due to capacity or staffing concerns.
  • Identified risks to the service were not always appropriately recorded or monitored via the risk register.

However:

  • The ward environments were clean and we observed good infection prevention and control techniques. Medicines were stored securely and managed appropriately.
  • Children and their families told us that they received compassionate and dignified care. Parents told us that they understood the care provided to their child and had been involved in decision making. Parents told us that they would be confident in seeking emotional support from staff.

End of life care

Good

Updated 6 April 2017

In the previous CQC inspection in October 2015, we did not inspect end of life care. At this inspection we rated end of life care as good because

  • There were low numbers of incidents involving end of life care patients. Staff we spoke with were aware of the duty of candour. All areas appeared clean and well maintained. The trust had policies and procedures in place for the safe handling and administration of medicines. There were also specific policies available to support staff caring for patients at the end of their life. Nurse staffing was appropriate, patient records were stored securely and record keeping was of a good standard.
  • We saw that trust polices referenced national best practice guidance such as the National Institute for Health & Clinical Excellence (NICE). This included policies relating to care at the end of life, such as anticipatory drug prescribing for end of life care and the pain and symptom management guidance in the last days of life. We saw evidence of local and national audit participation. We saw that patient’s pain levels and nutrition and hydration needs were assessed and managed effectively. Staff had effective clinical supervision. The trust had been involved in the development of a Northern Lincolnshire multi-agency end of life care strategy; from this, the trust had identified seven work streams, each of which had developed key performance indicators to measure the trust performance and patient outcomes.
  • We observed staff being compassionate and caring to patients and their families without exception. Patients and relatives we spoke with described staff as ‘brilliant’ and ‘excellent’. They said staff could not do enough for them. We saw that staff provided emotional support to patients and their families.
  • Staff on the wards told us that the SPCT were visible, available and that they regularly reviewed end of life patients and had discussions with patients and their families. Information received from the trust indicated that 86.5% of patients referred to the SPCT were seen within 48 hours. The bereavement team had developed robust processes to help and support bereaved relatives. 82% of patients audited were asked about and 71% achieved their preferred place of death.
  • The trust had been involved in the development of a multi-agency end of life strategy that encompassed the whole of the local health economy. The trust was collating and monitoring quality measures such as patient outcomes through seven strategy sub-working groups. There was a non-executive director, at board level. Staff reported a positive culture and good working relationships between teams. The trust were supporting the development of staff that were caring for patients at the end of life and we saw good examples of innovation and staff whose purpose was to maintain and improve the services provided to patients and their loved ones.

However:

  • We found that mandatory training compliance was less than the trust target of 95% for all teams providing end of life care. There was limited use of the trusts last days of life documentation however the SPCT were progressing the roll out of the document across the trust. The trust employed less than the National Council for Palliative Care guidance of two whole time equivalent consultants per 250,000 population however, there had been no specialist palliative care medical staff in place during our previous inspection therefore this was an improvement. Chaplaincy support was minimal.
  • The trust did not meet the NICE guidance for palliative care provision because it did not provide a seven-day service or any out of hours advice and support system. Low numbers of staff had received a yearly appraisal. The trust did not use an electronic palliative care co-ordination system however; the development of this was part of the strategy action plan. We were concerned that consent to care and treatment was not always obtained in line with legislation and guidance, including the Mental Capacity Act 2005, for patients who lacked capacity.
  • Not all risks for the service were identified on the risk register for the end of life care service. For example, the lack of seven-day service provision, delayed roll out of the last days of life document and completion of the deceased patient audit tool were not on the risk register.

Outpatients

Inadequate

Updated 6 April 2017

In the previous CQC inspection in October 2015, we rated this service as inadequate. At this inspection we rated outpatient and diagnostic services as inadequate because

  • The trust had failed to address a number of actions, from the October 2015 inspection, in a timely manner
  • The trust had been slow to implement clinical validation and assessment of risk within waiting lists, across all specialities.
  • The trust had been slow to get to the bottom of waiting list issues and was still discovering patients in unmonitored systems in August 2016.
  • Referral to treatment times were worsening and the trust told us they were unlikely to recover a good position until March 2018.
  • There continued to be large numbers of patients’ overdue follow up appointments or with no due date on the patient administration system.
  • The trust had a continuing high number of cancelled clinics.
  • Effective oversight, monitoring and management of booking patient appointments and waiting list was not evident in all specialities.
  • There was evidence of actual harm and ongoing significant risk of potential harm to patients waiting long periods of time for first and follow up appointments.
  • Safeguarding training compliance for the outpatient staff was below the trust target.
  • There was mixed feedback from staff in a number of roles regarding leadership and an expressed reluctance to raise concerns regarding management or services, for fear of reprisals.

However:

  • The trust had taken action to stop cancellation of clinics by non-clinical staff, to improve sharing of lessons from incidents, to ensure safe storage of refrigerated drugs and had improved the facilities and premises in outpatient areas.
  • All radiology staff had received training regarding the ionising radiation (medical exposure) regulations (IR (ME) R 2000).
  • The staff working in outpatients and diagnostic imaging departments were competent and there was evidence of multidisciplinary working across teams and local networks.
  • Nursing, imaging, and medical staff understood their roles and responsibilities regarding consent and the application of the Mental Capacity Act.
  • We observed staff in all areas treating patients with kindness and respect and patients were very happy with their care.
  • Concerns and complaints were taken seriously and staff and managers responded positively to patient feedback. There were low levels of complaints for imaging services.
  • The trust performed well against cancer waiting time operational standards.
  • The diagnostic imaging department had a five-year strategy in place to ensure that the department was future proof and had governance processes in place to ensure that risks were mitigated.
Other CQC inspections of services

Community & mental health inspection reports for Scunthorpe General Hospital can be found at Northern Lincolnshire and Goole NHS Foundation Trust.