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Scunthorpe General Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 7 February 2020

Our rating of services stayed the same. We rated it them as requires improvement because:

  • There had been little progress identified in this inspection and in some services a deterioration.
  • Within outpatients continued backlogs were identified and within diagnostic imaging there was also an increased backlog of patient awaiting diagnostic image services and the subsequent reporting of x-rays. There were unknown risks due to these backlogs.
  • There had been incidents where patients had come to harm due to delays in receiving appointments in both outpatients and diagnostic imaging. We had concerns regarding this and after the inspection, the Care Quality Commission completed a section 31 letter of intent to seek further clarification from the trust.
  • Within end of life we were concerned about the timeliness of pain relief given to patients and lack of documentation which would enable to trust to monitor the effectiveness of care and treatment and drive improvement.
  • Across most services there was still insufficient numbers of staff within the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment.
  • The service provided mandatory training in key skills to staff but had not ensured everyone had completed it. Across most services there were continued low levels of mandatory training.
  • We had ongoing concerns that patients with mental health conditions were not always cared for in a safe environment.
  • Within the emergency department there were significant numbers of black breaches and the department failed to meet the medium time to initial assessment.
  • The services did not always provide care and treatment in line with national guidance and best practice. We found examples of this in some of the core services inspected.
  • The services did not ensure that staff were competent to carry out their roles and compliance with annual appraisals continued to be low.
  • Services were not always planned to meet the needs of local services. This was particularly so in end of life services.
  • Waiting times, referral to treatment and arrangements to admit, treat and discharge across a number of core services continued to be a challenge. People could not always access the services when they needed to.
  • Investigations of complaints were not managed in a timely way and in line with trust policy.
  • Across most services there continued to be a lack of clear strategies at this level.
  • Systems to manage performance were not consistently used to improve performance.
  • There continued to be changes in the governance structures and processes which had not become embedded and therefore there was limited oversight.
  • There was limited evidence of continuous improvement and innovation across most core services.

However:

  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.
  • Overall staff felt respected, supported and valued.
  • Most services had an open culture where patients, their families and staff could raise concerns without fear.

Inspection areas

Safe

Inadequate

Updated 7 February 2020

Effective

Requires improvement

Updated 7 February 2020

Caring

Good

Updated 7 February 2020

Responsive

Requires improvement

Updated 7 February 2020

Well-led

Requires improvement

Updated 7 February 2020

Checks on specific services

Medical care (including older people’s care)

Requires improvement

Updated 7 February 2020

Our rating of this service stayed the same. We rated it as requires improvement because:

  • Several areas for improvement had been identified at our previous inspection in 2018.

At this inspection we found a number of these had not been addressed. We found issues surrounding patient safety and the governance, oversight and quality monitoring of the medical care service.

  • The service provided mandatory training in key skills to staff but had not ensured everyone had complete it. Overall mandatory training compliance did not meet the trust target of 85% for both nursing and medical staff. This was highlighted as a ‘must do' action at the last inspection.
  • Not all staff had completed training on how to recognise and report abuse. Nursing staff met three out of the five training modules and medical staff met none of the five modules against a trust target of 85%.
  • Although managers regularly reviewed and adjusted staffing levels and skill mix we were not assured the service always had enough nursing staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. The service monitored nurse staffing levels for patients receiving acute non-invasive ventilation or for patients nursed on the hyper acute stroke unit (HASU) receiving level two care, therefore we were not assured that staffing levels were always safe. The service could not assure us that patients were nursed according to BTS guidelines and the National Institute for Health and Care Excellence guidance, which recommend one nurse to two patients.
  • The service had a medical staffing vacancy rate of 26.6% at the time of inspection. There was still minimal medical cover out of hours, which was identified as a concern at the last inspection. We had concerns about the lack of support for junior doctors due to the acuity of patients and the workload of senior doctors.
  • Patient records were mostly stored securely, version control was poor, and we found examples of documentation past it’s review date in use. Confidential waste was stored in paper bags which were unsecured and accessible to patients and visitors. We observed confidential ward and patient hand over documents for three consecutive days listing patient names, dates of birth, medical history and treatment plans within the paper bag. We escalated this at the time of inspection and lacked assurance regarding senior management and oversight of this.
  • Although the service used systems and processes to prescribe, administer and record medicines we were not assured that oxygen was prescribed or recorded in line with BTS guidance or in line with trust policy on all wards that we inspected. We lacked assurance regarding senior management and oversight of this.
  • The service had a higher than expected risk of readmission for elective admissions in oncology and haematology and a higher than expected risk of readmission for non-elective admissions in respiratory medicine compared to the England average.
  • The average length of patient stay for elective specialties in medical oncology and non-elective specialties in respiratory medicine was longer than the England average.
  • There was a process surrounding staff appraisal; although not all staff had received an appraisal to assess their work performance and promote their professional development. Appraisal compliance did not meet the trust target of 95% for medical and nursing staff.
  • Waiting times from referral to treatment were not in line with national standards. Five specialties were below the England average for admitted RTT (percentage within 18 weeks).
  • The strategy for the medical division was still in draft format. Concerns remained about the pace of change and improvement implementation. We were not assured about management oversight in some areas.

However:

  • Staff cared for patients with compassion and involved them in decisions about their care. Feedback from patients confirmed that staff treated them well and with kindness.
  • The service achieved grade B overall in the Sentinel Stroke National Audit Programme (SSNAP).
  • The endoscopy service was achieving two-week and urgent standards for investigation; it had achieved Joint Advisory Group (JAG) accreditation in June 2019 and had a 24-hours a day, seven days a week gastrointestinal bleed rota in place.
  • Staff felt respected, supported and valued. Staff at all levels were clear about their roles and accountabilities and had regular opportunities to meet, discuss and learn from the performance of the service. There had been changes to the senior management team and they had clear ideas and early plans for how the services needed to be developed. Staff spoke highly of the new head of nursing and the appointment of senior matrons. Staff morale had improved since the last inspection.

Services for children & young people

Requires improvement

Updated 7 February 2020

Our rating of this service went down. We rated it as requires improvement because:

  • Some concerns we told the trust it must address at our last inspection in 2018 were not actioned by the leadership team. For example, staff did not receive the mental health training which we told the trust it must provide, following our last inspection in 2018.
  • There was limited assurance staff consistently completed and updated mental health risk assessments for each child and young person with mental health issues and removed or minimised environmental risks. This was because they had not received appropriate mental health training.
  • The service still did not always have enough nursing or medical staff with the right qualifications, skills, training and experience to comply with national guidance.
  • Mandatory training compliance by medical staff had dropped since our last inspection in 2018.
  • Local audits for sepsis, hand hygiene and paediatric early warning scores (PEWS) provided limited assurance. This was because sepsis tools were not always completed, departments did not consistently submit hand hygiene data and improvement was still required in clinical record keeping.
  • Staff did not always keep detailed records of children and young people’s care and treatment.
  • Some staff we spoke with were unaware of the child abduction policy on the intranet and did not know when it was last tested.
  • Mental capacity training data for medical staff indicated poor compliance.
  • Senior leaders were not always visible.
  • The service had a vision for what it wanted to achieve but no clear strategy to turn it into action.

However, we also found that:

  • There was improved mandatory training compliance by nursing staff since our last inspection in 2018.
  • Safeguarding training compliance had improved since our last inspection in 2018.
  • Appraisal compliance had improved since our last inspection in 2018.
  • The service provided care and treatment based on national guidance and evidence-based practice.
  • Doctors, nurses and other healthcare professionals worked together as a team to benefit children, young people and their families.
  • Staff treated children, young people and their families with compassion and kindness and respected their privacy and dignity.
  • People could access the service when they needed it.
  • Staff felt respected, supported and valued.
  • All staff were committed to continually learning and improving services.

Critical care

Good

Updated 7 February 2020

  • We found that the Guidelines for the Provision of Intensive Care Services (GPICS) standard which states 50% of all nursing staff should hold a post graduate qualification in critical care nursing was met. Data showed that 55% of staff had the appropriate qualification.
  • 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. Managers ensured that actions from patient safety alerts were implemented and monitored.
  • The service used systems and processes to safely prescribe, administer, record and store medicines. During our inspection we found stock medicines within the unit were handled safely and stored securely. Controlled drugs were appropriately stored with access restricted to authorised staff.
  • 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 staff working on HDU and ICU at Scunthorpe General Hospital had achieved an appraisal rate of 100% against a trust target of 85%.
  • Doctors, nurses and other healthcare professionals worked together as a team to benefit patients. They supported each other to provide good care. Multidisciplinary team working was in line with GPICS recommendations. Physiotherapy staff confirmed that in line with GPICS recommendations they were able to provide the respiratory management and rehabilitation components of care.
  • Staff supported patients to make informed decisions about their care and treatment. They followed national guidance to gain patients’ consent. They knew how to support patients who lacked capacity to make their own decisions or were experiencing mental ill health. The information provided by the trust showed 94.3% of nursing and 88% of medical staff were compliant with MCA training. This met the trust target of 85%. We found the processes for sepsis and delirium screening was undertaken on the unit.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.
  • The service was inclusive and took account of patients’ individual needs and preferences. We saw that there were measures taken to reduce noise in the main unit. There had been implementation of sleep bundles (soft close bins, eye masks, ear plugs, clocks which show night and day etc). There was an electronic ear which changed colour when the volume was too high.
  • People could access the service when they needed it and received the right care promptly. The decision to admit to the unit was made following a discussion between the critical care consultant and the consultant or doctors already caring for the patient. From the notes we reviewed all the patients had been reviewed by a consultant within 12 hours of admission. This met the GPICS standard.
  • We were provided with the most recent ICNARC quarterly quality report. This showed that between April 2018 and 31 March 2019 the percentage of care post eight-hour delay rate was 1.5% this was significantly better than similar units which had an average of 5.5%.
  • It was easy for people to give feedback and raise concerns about care received. The service treated concerns and complaints seriously, investigated them and shared lessons learned with all staff. From June 2018 to June 2019 the trust received only one complaint.
  • Leaders had the skills and abilities to run the service. They were visible and approachable in the service for patients and staff. Leadership of the service was in line with 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. The frontline leadership differed on each site.
  • There was a strong and embedded ward management team. Staff we spoke with reported feeling very supported by their team and managers and stated they were able to escalate any concerns.
  • HDU and ICU continued to function as one unit with full inter-unit working.
  • Staff felt respected, supported and valued. Staff at all levels were clear about their roles and accountabilities and had regular opportunities to meet, discuss and learn from the performance of the service.

However:

  • 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 GPICS standards. Not all care was delivered by intensivists, and on call consultants had other areas of responsibility.
  • The medical staffing rota did not provide continuity of care for patients as a different consultant attended each day. This was not in line with GPICS standards.
  • The percentage of staff assessed as competent to use the ventilators across the critical care division was 91% as of September 2019. All staff had received theory training on the use of ventilators with three remaining staff members to complete the competency statement.
  • We were advised that staff were moved from the ward to work on other areas on a frequent basis. We observed that when this occurred it resulted in the co-ordinator no longer being in a position to provide supernumerary support. This does not meet with GPICS standards.
  • Intensive Care National Audit and Research Centre (ICNARC) data showed there had been six unit acquired infections in the ITU / HDU between 1 April 2018 and 31 March 2019. This was worse compared to similar units (2.6 against 1.1 unit acquired infections in blood per 1000 patient bed days). Just over 81.4 percent of nursing staff had completed infection control training. This did not meet the trust target of 85%.
  • The service 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.
  • 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 nine mandatory training modules for which qualified nursing staff were eligible.  
  • Not all staff had training on how to recognise and report abuse. In addition, the 85% target was not met for one of the three safeguarding training modules for which qualified nursing staff were eligible.  
  • Not all services were available seven days a week to support timely patient care. We saw from patient records daily consultant led ward rounds took place, however these were not always led by a consultant intensivist due to the lack of these consultants within the trust. This was not in line with GPICS recommendations.

End of life care

Inadequate

Updated 7 February 2020

  • The service had not addressed many of the concerns from our last inspection, there were still areas where we told the trust they must improve that had not been actioned.
  • At the last inspection in 2018 we told the trust it must ensure that sufficient numbers of palliative care staff are employed to provide care and treatment. At this inspection the service still did not have enough nursing or medical staff with the right qualifications, skills, training and experience to meet national guidance. Managers did not regularly review and adjust staffing levels and skill mix.
  • The service did not have enough medical staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and provide the right care and treatment.  
  • Staff did not always keep detailed records of patients’ care and treatment. Records were not consistently clear and up-to-date or easily available to all staff providing care.
  • The service did not always provide care and treatment based on national guidance and evidence-based practice.
  • There was very limited monitoring of patients care and treatment. Therefore, staff did not always monitor the effectiveness of care and treatment or use the findings to make improvements and achieve good outcomes for patients.
  • Preferred place of death was consistently documented for patients receiving end of life care.
  • Staff did not consistently assess and monitor patients regularly to see if they were in pain and did not give pain relief in a timely way. Staff did not always complete documentation specific to end of life and palliative care.
  • Staff did not support those unable to communicate using suitable assessment tools and give additional pain relief to ease pain.
  • The service did not make sure staff were competent for their roles. Managers did not appraise staff’s work performance and or hold supervision meetings with them to provide support and development.
  • At the last inspection in 2018 we saw the trust was not providing a seven-day service. Key services were still not available seven days a week to support timely patient care.
  • The service did not always take account of patients’ individual needs and preferences. Multi faith facilities were not fully in place and access to chaplains was limited.
  • The service did not consistently monitor performance to enable improvements for people at the end of their life. This included rapid discharge arrangements to enable people to meet their preferred place of care and death and referral to treatment times.
  • There had been no improvement in the complaint’s management for the service.
  • There were insufficient leaders with the skills and abilities to run the service. They did not understand or manage the priorities and issues the service faced. Due to the small numbers of staff their visibility was limited. There was no clear leadership of the service and lines of accountability were blurred.
  • Key senior management staff roles had been vacant for some time and remained unfilled at the time of inspection.
  • There was no current local strategy or vision for the service.
  • Staff working within the service told us they did not feel valued and respected. There was no sense that staff were fully engaged in making dying everyone’s responsibility.
  • There was a lack of governance structures in place with processes and systems of accountability to support a sustainable service.
  • There was little understanding or management of risk. There was no risk register to identify that there was oversight of the current risks or that these had been escalated. For example, the lack of audit completion and staff vacancies. Therefore, risks were not shared within this speciality.
  • Leaders and staff undertook limited engagement with patients and staff to plan and manage services.
  • We saw limited evidence of any information to support learning, continuous improvement or innovation in the service.

However:

  • The service provided mandatory training in key skills and most staff had completed it.
  • Staff treat patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. Staff provided emotional support to patients, families and carers to minimise their distress. Staff supported and involved patients, families and carers to understand their condition and make decisions about their care and treatment.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.

Surgery

Requires improvement

Updated 7 February 2020

Our rating of safe stayed the same. We rated it as requires improvement because:

  • The division had limited evidence to show that all areas requiring improvement from the last inspection had been acted upon, embedded or sustained.
  • The service had a vision for what it wanted to achieve and had developed a draft strategy to turn it into action, however we saw limited evidence that this had been developed with all relevant stakeholders.
  • Leaders had governance processes, however we did not see issues escalated and discussed in an effective way.
  • Leaders and teams had systems to manage performance. However, these were not consistently used to improve performance. We saw limited evidence of identifying and escalating relevant risks and issues and identified actions to reduce their impact.
  • Records used within the division were not completed consistently or controlled in a safe manner.
  • Documentation of consent was not always completed in line with national guidance. Consent forms we reviewed did not provide assurance with best practice requirements and the hospital policy in relation to the recording of consent.
  • Complaints investigations were not carried out in a timely way. The division took an average of 120.9 working days to investigate and close complaints, this was worse than the trust policy of investigation and closure within 60 working days.

  • The division did not always respond to incidents appropriately or in a timely way, and there was not always appropriate oversight of incident themes and trends. The service had declared serious incidents relating to missed appointments and referrals because of a backlog people waiting for outpatients’ appointments; we were not assured this risk was mitigated and would not reoccur.
  • The service did not consistently provide care and treatment based on national guidance and evidence-based practice. There was not an effective process to enable access to theatres and ensure cases were clinically prioritised appropriately.
  • We had previously highlighted that pre-assessment service required improvement in relation to clinical pathways, clinical cancellations of patients and competence of staff. At this inspection we only saw limited improvement.
  • People were not consistently able to access the service when they needed it and receive the right care promptly. A number of patients were waiting longer than 52 weeks for treatment or had their operations cancelled. When cancelled the service did not consistently ensure that patients were treated within 28 days.
  • Staff did not consistently record fluid provided to patients. Fluid charts we reviewed were not consistently record the daily intake and output on all fluid charts we reviewed.
  • Staff monitored the effectiveness of care and treatment but did not consistently use the findings in a timely way to make improvements and achieve good outcomes for patients.
  • The design, maintenance and use of facilities, premises and equipment did not consistently keep people safe. We did not receive assurance that all theatres had received verification testing in the previous 12 months.
  • The service did not consistently plan or provide care in a way that met the needs of local people and the communities served.
  • The service continued to breach mixed sex accommodation policies in the high observation bays.
  • The service did not have effective systems and processes to ensure mandatory training was completed by all staff, including safeguarding and mental capacity act training was completed by all staff. Compliance rates for medical staff compliance significantly below the target.
  • Appraisal rates for staff did not meet the trust target of 95%, however this was improving, and staff we spoke with said they felt support by managers.
  • The service had a vision for what it wanted to achieve and had developed a draft strategy to turn it into action, we saw limited evidence that this had been developed with all relevant stakeholders.

However:

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The trust provided training on how to recognise and report abuse, and they knew how to apply it.
  • On the majority of occasions, the service had enough nursing and support 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 saw improvements in the fractured neck of femur pathways, with the majority of patients now having surgery on the day of or the day after admission. This progress needs to be sustained.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.

Urgent and emergency services

Requires improvement

Updated 7 February 2020

Our rating of this service stayed the same. We rated it as requires improvement because:

  • At the previous inspection we found that the department did not meet the trust standard for completion of mandatory training. At this inspection the department still did not meet the mandatory training standards.
  • At the previous inspection we found that not all staff had a completed up to date appraisal. At this inspection we found that not all staff had completed appraisals.
  • At the previous inspection the department had insufficient numbers of registered sick children’s nurses (RSCNs) to meet the intercollegiate emergency standard. At this inspection the department had no RSCNs. This did not meet the national guidance.
  • At the previous inspection we found that the department was not in line with the Royal College of Emergency Medicine (RCEM) guidance of providing 16 hour consultant. At this inspection we saw that this was met between Monday to Friday but not met over the weekend period.
  • The mental health assessment room did not meet the Psychiatric Liaison Accreditation Network (PLAN).
  • Patients were not always given pain relief medication.
  • We were not assured the department had a stable leadership team.

However:

  • Staff provided good care and treatment and gave patients enough to eat and drink. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information.
  • Key services were available seven days a week.
  • We observed good multidisciplinary working.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback.

Diagnostic imaging

Inadequate

Updated 7 February 2020

Our rating of this service went down. We rated it as inadequate because:

  • Patients could not always access the service when they needed it. Waiting and result reporting times were not in line with national standards.
  • There had been incidents where patients had come to harm due to delays in reporting results. We had significant concerns regarding this and after the inspection, the Care Quality Commission completed a section 31 letter of intent to seek further clarification from the trust.
  • Safety was not a sufficient priority. Although there was measurement and monitoring of safety performance, there was a limited response leading to unacceptable levels of incidents and potential harm.
  • There had been a lack of pace to address the backlogs and therefore there were concerns that incidents and near misses were not recognised which had caused harm and put patients at risk of harm or potential harm.
  • From May 2018 to April 2019, the percentage of patients waiting more than six weeks to see a clinician (12%) was higher than the England average (3%).
  • Substantial, ongoing and frequent staff shortages increased risks to people who used services.
  • Although, the trust had systems for identifying risks in place, opportunities to prevent and minimise harm were missed.
  • Since our last inspection in 2018, the backlog in unreported results had increased from 5,364 examinations (3,686 patients) to 10,701 examinations (7,045 patients) in July 2019.
  • The contract with the external reporting company to address the backlog had been put in place in August 2019. This delay increased the potential risk of harm to patients.
  • At the time of inspection, the overall backlog in unreported results across all modalities was 7,942 delays (4,719 patients).
  • Following inspection, the initial trajectory for clearing the backlog in unreported results had changed and extended, increasing the risk of potential and actual harm to patients still within the backlog of unreported and delayed results.
  • There were trust wide shortages of radiologists. This impacted on reporting rates across the trust, including Scunthorpe General Hospital.
  • Although there was some resistance from existing radiologists to supporting the long-term development of radiographers’ capacity to report on results, the expansion of plain film reporting to chest and abdomen was supported and the Trust had also put in place other initiatives to improve their reporting capacity.
  • From June 2018 to June 2019, the trust received 19 complaints in relation to diagnostic imaging (3.9% of total complaints received by the trust). Nine complaints were still open and under investigation or partially upheld with no closed date. Of the closed complaints, the trust took an average of 67.8 working days to investigate and close. This was not in line with their complaints policy, which states complaints should be completed within 60 working days.
  • Local rules were not clear as to which procedures could be requested by individual clinicians.
  • Local dosage reference levels (DRLs) were not in place or displayed in all appropriate rooms.
  • There were inconsistencies within the electronic records we reviewed. Of the records we checked over half were missing key documents such as recording of consent to treatment.
  • A finalised divisional strategy was not in place and had been developed to draft stage only.

However:

  • The service provided mandatory training in key skills to all staff and made sure everyone completed it.
  • The design, maintenance and use of facilities, premises and equipment kept people safe. Staff were trained to use equipment.
  • Staff we spoke with were aware of their responsibilities in relation to duty of candour.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.
  • Doctors, nurses and other healthcare professionals worked together as a team to benefit patients. They supported each other to provide good care.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.
  • In August 2019, 86% of people who completed the Friends and Family Test (FFT) were extremely likely or likely to recommend this service to their family and friends.
  • The service planned and provided care in a way that met the needs of local people and the communities served.
  • The service was inclusive and took account of patients’ individual needs and preferences. Staff made reasonable adjustments to help patients access services.

Maternity

Requires improvement

Updated 7 February 2020

Our rating of this service went down. We rated it as requires improvement because:

  • The design, maintenance and use of facilities, premises and equipment did not always keep people safe; there was a risk of delayed access to the central delivery suite and theatres. Out of hours (duty) anaesthetist cover was shared with the intensive care unit; and we were not assured the anaesthetist could be immediately available to cover emergency work on delivery suite, without potentially placing patients at risk.
  • Not all staff were up to date with key mandatory training; including obstetric emergency, resuscitation, adults safeguarding and Mental Capacity training. The service had not provided quarterly ‘live’ (unannounced) emergency skills and drills training, in line with trust policy. The appraisal rate for medical staff was low and did not meet trust target.
  • Leaders and senior staff had the necessary experience and knowledge to lead effectively. However, there was an unstable leadership team structure. Staff expressed concerns about leadership stability and the implementation of new models of care; and described morale within the service had wavered. The service did not have an agreed vision for what it wanted to achieve and the strategy to turn it into action was in draft. In addition, the divisional strategy was also in draft.

  • We were not assured leaders had oversight of clear and reliable midwifery and nurse staffing data; and we saw sickness rates and use of bank staff were high. Community caseloads, allowing for some changes in allowances and changes in NICE Guidance since 2009, exceeded the recommended ratio of 96 to 98 cases per WTE midwife. A high proportion of community clinics had been cancelled in the 12 months prior to inspection.
  • Leaders did not always operate effective governance processes or manage performance effectively. The service did not always collect and collate reliable data; for example, we were not assured NICE red flag data was valid and reliable, and we observed some inaccuracies in other key data we reviewed. The frequency of perinatal morbidity and mortality meetings was not compliant with trust policy, the quality of women’s and children’s divisional meeting minutes varied, and action plans were not always sufficiently robust.
  • Audit data showed improved compliance with medicine management on the central delivery suite, WHO safer surgery documentation checklist, and maternity record keeping was required.
  • The time taken to investigate, and close complaints was not in line with the trust’s complaints policy.

However:

  • The service provided care and treatment based on national guidance and best practice. Staff completed and updated risk assessments for each woman and took action to remove or minimise risks. Staff identified and quickly acted upon women at risk of deterioration. The service made sure staff were competent for their roles.
  • Staff understood how to protect women and children from abuse and the service worked well with other agencies to do so.
  • Staff carried out daily and weekly safety checks of specialist and emergency equipment, and the service controlled infection risk well.
  • Staff treated women with compassion and kindness, provided emotional support, respected their privacy and dignity, and took account of their individual needs. Staff supported women to make informed decisions about their care and treatment and followed national guidance to gain patients’ consent.
  • The service had an open culture where patients, their families and staff could raise concerns without fear. The service treated concerns and complaints seriously, investigated them and shared lessons learned with staff.

Outpatients

Inadequate

Updated 7 February 2020

Our rating of this service stayed the same. We rated it as inadequate because:

  • The trust had identified incidents in 2018 and 2019 where patients had come to harm due to delays in receiving appointments in out-patients.  We had significant concerns regarding this and requested further information from the trust on what it was doing to limit risk in a section 31 “letter of intent to seek further clarification from the trust”. The trust provided a response to this. CQC continue to have concerns about the risks of harm and potential harm to patients when waiting times remain lengthy. However, we were assured that the trust had put in place oversight mechanisms and processes to limit the risks.
  • Following the inspection, the trust provided more information which showed they had revised the inclusion criteria for patients to be added to the clinical harm review in ophthalmology to include any delay that exceeded the speciality/department risk stratification criteria. For example, in September 2019, this new risk stratification criteria had identified 83 patients to be added to the clinical harm review. Of these 83 patients, 37 patients had been seen and assessed for harm and the trust highlighted there was no harm in 24 of these patients, there was low harm in ten patients and one moderate harm and two severe harm. Out of the 83 patients identified, the remaining 46 patients were due to have a clinical harm review in November 2019.
  • Whilst the trust had implemented clinical validation to help ensure patients were seen in order of clinical need, there remained risk in some waiting lists due to the volume of patients on the waiting list and the service not meeting the operational standard for patients receiving their first treatment within 62 days of an urgent GP referral for a suspected cancer diagnosis. This was an ongoing concern since our previous inspection. The trust provided information after the inspection stating they were taking steps to address the challenges with cancer performance in accordance with the trust’s performance management framework.
  • We did not see evidence of safety checklists being used in any areas other than in ophthalmology.
  • Staff did not consistently tell us they had received shared learning from incidents.
  • Although records were now stored securely, which was an improvement since our last inspection, records were not always timed and staff did not always provide their role or designation. Written notes were not consistently legible. These concerns were ongoing since our previous inspection.
  • Although the oversight of waiting lists and backlogs had improved, the July 2019 board papers showed there remained 33,673 overdue outpatient review appointments in May 2019. Overall there had been improvements with the referral to treatment indicators, however there remained specialties which did not always achieve the referral to treatment indicators.
  • From June 2018 to May 2019 the trust’s referral to treatment time (RTT) for non-admitted pathways has been worse than the England overall performance. The latest figures for May 2019, showed 78.7% of this group of patients were treated within 18 weeks versus the England average of 87.6%.
  • From June 2018 to May 2019 the trust’s referral to treatment time (RTT) for incomplete pathways has been worse the England overall performance, although there has been an improving trend from January to May 2019. The latest figures for May 2019 showed 77.8% of patients still waiting for treatment had been waiting for less than 18 weeks, versus the England average of 86.4%.
  • From June 2018 to June 2019, the trust received 134 complaints in relation to outpatients at the trust (27.6% of total complaints received by the trust). 66 complaints were still open and under investigation or partially upheld with no closed date. Of the 68 complaints that were closed, the trust took an average of 82.2 working days to investigate and close complaints. This was not in line with their complaints policy, which states complaints should be closed within 60 working days.
  • From March 2018 to February 2019, the did not attend rate for Diana, Princess of Wales Hospital was higher (worse) than the England average. At the previous inspection, there was no strategy in place and although the trust had developed a strategy and provided the draft strategy for outpatients, this was still a draft version.

However, we also found:

  • The service provided mandatory training in key skills to all staff and made sure everyone completed it. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.
  • The service controlled infection risk well. Staff used equipment and control measures to protect patients, themselves and others from infection. They kept equipment and the premises visibly clean. Staff managed clinical waste well.
  • The service had enough nursing and support staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed staffing levels and skill mix and gave bank staff a full induction. The service used systems and processes to safely prescribe, administer, record and store medicines.
  • Doctors, nurses and other healthcare professionals worked together as a team to benefit patients. They supported each other to provide good care. Staff gave patients practical support and advice to lead healthier lives. Staff supported patients to make informed decisions about their care and treatment. They followed national guidance to gain patients’ consent.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. Staff provided emotional support to patients, families and carers to minimise their distress. Patients were given contact details for specialist nurses to contact with any worries or questions.
  • Staff supported and involved patients, families and carers to understand their condition and make decisions about their care and treatment. Patients we spoke with gave positive feedback about their care and treatment in outpatients at this hospital.
  • The service had a vision for what it wanted to achieve and a strategy to turn it into action, developed with all relevant stakeholders. Leaders and teams used systems to manage performance.
  • There had been improvement in some areas and improved oversight and governance regarding the challenges across outpatient services. The services had implemented procedures to support the work regarding the challenges in outpatients, for example outpatient leaders monitored performance through performance reports and regular meetings.

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.