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Lincoln County Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 3 July 2018

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

A summary of this hospital appears in the overall summary above.

Inspection areas

Safe

Requires improvement

Updated 3 July 2018

Effective

Requires improvement

Updated 3 July 2018

Caring

Good

Updated 3 July 2018

Responsive

Requires improvement

Updated 3 July 2018

Well-led

Requires improvement

Updated 3 July 2018

Checks on specific services

Critical care

Good

Updated 27 March 2015

Outpatients and diagnostic imaging

Requires improvement

Updated 11 April 2017

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

The concerns we found during this inspection were the same as our findings in 2014 and 2015, this was despite actions plans to address the areas of concern following both of these inspections.

We saw significant numbers of patients overdue for appointments including new and follow up appointments. Performance against some cancer waiting targets was consistently below the national standards placing patients at risk of potential harm from delayed treatment. Where the trust made progress to address the backlog of waiting list appointments this negatively affected the trust meeting the referral to treatment standards for new patients across many specialities.

Data showed 8,108 patient appointment outcome records, which had not been completed and closed on the electronic record system. Data supplied by the trust showed the current position was worse than the previous year.

The trust had not maintained an accurate record of patients who required outpatient appointments. The trust was tracking thousands of computer records to establish the patients who should have received appointments.

There were delays of up to several months in the reporting of some diagnostic reports due to failures in the information technology systems used by the regional picture archiving and communication system (PACS).

Progress against some poor performance and identified risks was slow. We saw issues identified since our last inspection had not been addressed for example, overbooking of clinics. Reports showed there had been long standing issues for example, condition of health records, which the trust had not addressed.

There was a potential risk to patient safety because managers did not always share learning from incidents with all staff. Safety procedures and maintenance contracts were not always in place to ensure the environment and equipment were adequately assessed, risks identified and equipment maintained.

Nursing staff were not always managed effectively as not all staff had received up to date mandatory training. Medical staffing vacancies affected the trust’s ability to meet the demand for outpatient services.

The condition of patient health recording had a negative impact across all clinic areas and posed a potential risk to patient confidentiality. The lack of availability of records affected most clinic areas.

Staff provided patients with evidenced based care and treatment and followed national guidelines. Patients received care delivered by staff that were experienced, skilled and had knowledge to deliver care that met patient’s needs.

Staff in outpatient and diagnostic services provided a caring, professional and compassionate service. Staff ensured patients received the best possible care. Patients were happy with the care they received. Staff had been flexible and worked their weekends to provide additional clinics in many specialities to try to meet the demand for outpatient services.

Diagnostic radiology services delivered care and treatment in a safe environment. Systems were in place to protect patients from harm during radiological investigations and ensured compliance with the departments legal responsibilities.

Urgent and emergency services

Requires improvement

Updated 3 July 2018

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

  • Patients could not always access the service when they needed to. Information provided by the trust showed from November 2016 to February 2018, patients were not triaged within the recommended time of 15 minutes and patients arriving by ambulance were waiting between zero and 133 minutes to be handed over to the department staff.
  • The department performed worse than the national average from November 2016 to October 2017 for their time of arrival to treatment and four-hour target for patients being admitted, transferred and discharged. Since June 2017, the department had performed worse than the national average for patients waiting between four and 12 hours to be admitted, following decision to admit. Information for this standard also showed a continuous steep incline for the number of patients waiting for admission. The department also consistently scored higher than national average for the mean time patients spent with the department.
  • The service did not participate in many national audits to benchmark patient outcomes and those they did participate in demonstrated poor performance against specific Royal College of Emergency Medicine (RCEM) standards.
  • Nurse and medical staffing levels were low. The nurse rota we reviewed demonstrated only four days out of 28 days where planned staffing met actual staffing. Medical staffing consisted of four substantive consultant positions and as result did not meet the 16 hours of consultant presence as recommended by RCEM. Both nursing and medical staff relied on agency and locum usage to ensure staffing levels remained safe.
  • The department did not have a sound incident reporting, investigating and learning culture embedded. There was a historical backlog of incidents from 2014 which had yet to be investigated and any learning identified and cascaded from these. Staff told us they did not always receive feedback from incidents they had raised and subsequently did not always report all incidents. Time constraints and the pressures of the department also impacted on staffs ability to report all incidents. However, staff did tell us they would raise all incidents they considered as serious and demonstrated learning from trust wide serious incidents.
  • The department continued to perform below the trust target for completing appraisals. Information received from April 2017 to October 2017 identified only 74.5% of staff had received an appraisal. The worst staff group recorded was the medical staff who reported only 33.3% of this staff group had received an appraisal.

However:

  • Since our previous inspection there had been an improvement in the management of deteriorating patients. There was effective use of early warning scores and timely escalation. The introduction of an electronic observation system had further improved this.
  • Sepsis identification, treatment and management had improved since the previous inspection and we observed good use of sepsis screening and completion of the sepsis bundle in line with trust policy.
  • Staffing was planned to ensure the skill mix was appropriate to meet the needs of patients. There was a minimum of either one paediatric trained or an adult nurse with paediatric competencies on each shift.
  • The department was working towards providing a suitable environment for all patients to be cared in (for example paediatric and mental health patients); however, at the time of our inspection, this was still a work in progress.
  • There was evidence of learning from serious incidents in the department. A quality improvement project implemented in the department following a serious incident had provided positive results which meant positive results for patients.

Outpatients

Requires improvement

Updated 3 July 2018

We previously inspected outpatients jointly with diagnostic imaging so we cannot compare our new ratings directly with previous ratings.

We rated it as requires improvement because:

  • Mandatory training figures for five out of 11 eligible training modules was not met by nursing staff, including basic life support and basic infection prevention and control.
  • Safeguarding level three training targets were not met by eligible medical staff.
  • There was a system in place to record patient outcomes after each clinic appointment. Managers audited patient outcome results to identify whether some patients did or did not have recorded outcomes. However, we saw there were significant numbers of patients without recorded outcomes, the oldest missing outcome was from March 2017.
  • Whilst we found some improvement in the availability and storage of medical records, most staff, particularly within health records and medical secretaries, did not feel the quality of records had improved. Staff told us a large quantity of records were very large or badly filed.
  • The trust had instigated a harm review process to assess the harm that may have been caused to some patients as a result of longer waiting times. However, this was a retrospective process and might not prevent harm whilst patients were currently waiting for appointments. The trust did, however, attempt to mitigate this risk by writing to patients who were waiting over certain timeframes.
  • Some services were delivered in older buildings which meant parts of the environment presented challenges for staff in delivering services. Some of the waiting areas were small and became overcrowded at times of peak activity.
  • From November 2016 to September 2017 the trust’s referral to treatment time (RTT) for non-admitted pathways was worse than the England overall performance.
  • The trust was performing worse than the 93% operational standard for people being seen within two weeks of an urgent GP referral. The trust performed significantly worse than the national average for the percentage of people seen by a specialist within two weeks of an urgent GP referral (all cancers). The trust consistently failed to meet the operational standard set at 85% for the percentage of people waiting less than 62 days from urgent referral to first definitive treatment. The trust is performing below the 85% operational standard for patients receiving their first treatment within 62 days of an urgent GP referral.
  • People could not always access the service when they needed it. Data from the trust as of 3rd April 2018, there were 2276 patients on the open referrals waiting list over 12 weeks awaiting their first appointment. This was a slight improvement from our previous inspection. Thirteen patients had been waiting on the incomplete pathway for over 52 weeks.
  • The rapid deterioration of the waiting times in February 2018, highlighted that changes although reactive were not embedded and demonstrating a prolonged improvement.
  • The general manager did not have sufficient capacity or administrative support to manage the trust wide workload for outpatient services.
  • We saw improvements in the governance arrangements although there was a degree of inconsistency in the ratings within the risk register.

However:

  • Staff understood their roles and responsibilities regarding safeguarding vulnerable adults and children. Qualified nursing staff had received appropriate levels of safeguarding training and could tell us about examples where they had identified and raised concerns.
  • There was a system in place to review the harm that may have been caused to patients on the long waiting lists. Patients waiting over 12 weeks and over 24 weeks were sent letters to apologise for the delay.
  • We saw nursing and non-nursing staffing levels were appropriate. There were no national guidelines for the staffing of outpatient clinics but senior nurses were undertaking a staffing review to ensure safe and appropriate staffing levels.
  • There were reliable systems in place to prevent and protect people from a healthcare-associated infection. We saw staff adhere to policies in relation to hand hygiene and infection control.
  • A daily huddle, or ‘time to talk’ had improved staff awareness of current issues on a day by day basis.
  • We saw good examples of multi-disciplinary working and involvement of other agencies and support services.
  • Staff had the appropriate skills and experience for their roles. Clinical nurse specialists had undertaken additional training and competencies. All staff we spoke with confirmed they had received an appraisal, although the department had not achieved the trust target for appraisals.
  • Staff spoke with patients with respect whilst seeking consent, taking observations and delivering care.
  • Most patients we spoke with were complimentary about the service and described staff as ‘brilliant’ ‘helpful’ and ‘approachable.
  • Patients felt fully informed around the appointment that day, but some patients told us there was a lack of future planning and were not always aware of what to expect.
  • The trust planned and provided services in a way that met the needs of local people.
  • The ‘did not attend’ (DNA) rate for outpatient services in Lincoln was better than the England average. Staff had procedures in the event of patients not turning up for appointments. Services had started to use a text reminder service to help improve performance. The trust was performing similarly to the 96% operational standard for patients waiting less than 31 days before receiving their first treatment following a diagnosis (decision to treat).
  • Staff said and we saw managers shared learning from complaints and concerns through briefings and team meetings. Senior staff were able to give examples of learning from complaints. The trust sought out patient feedback and used it to make improvements to the patient experience.

Maternity and gynaecology

Requires improvement

Updated 11 April 2017

We rated this service as requires improvement because:

The grading of incidents was not always consistent. Collection of data was also inconsistent across the service.

Staff did not demonstrate learning from audits such as CTG audits or post-partum haemorrhage audits.

The maternity dashboard data was not utilised fully. The data lacked red amber and green rating, which meant that staff could not assess the data against trust targets.

Staff did not receive regular recovery training.

Only 51% of health care assistants had received training in basic life support.

Patient confidentiality could be compromised by the location of staff handover on Nettleham Ward.

There was no midwife led unit, reducing patient’s choice for a home from home environment. Sensitive patient groups were mixed within the gynae-oncology clinic and antenatal clinic.

The lack of a dedicated elective caesarean section operating teams meant that in the event of an emergency patient’s surgery would be delayed.

Governance structures functioned effectively and interacted appropriately. Teamwork throughout the hospital was apparent and staff felt they were listened to.

A strong business unit team had increased the visibility of the patient’s and children business unit in the last 18 months.

When something went wrong staff told us people received a sincere apology. Openness and transparency was encouraged. Staff were aware of their responsibilities for reporting incidents, and learning was shared.

Medicines were stored safely with clean secure preparation areas. Clinical areas were clean and staff had made efforts to improve the environment for patients.

Patients care and treatment was planned and delivered in line with current evidence-based guidance. Normal birth rates and still birth rates were better than the national average. A seven day antenatal maternity day assessment service was available for patients with concerns or high risk pregnancies.

Staff were caring and compassionate in the care they provided. The service had increased the number of trust wide specialist midwives. Some of these such as the bereavement midwife had not started.

Patients and families knew how to raise a concern and were treated compassionately when they did.

Medical care (including older people’s care)

Requires improvement

Updated 3 July 2018

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

  • Nurse staffing levels were not always sufficient to keep people safe at all times. The hospital relied heavily on agency nurses who were not always willing or able to carry out clinical tasks required in their assigned area. Between December 2016 and November 2017 18% of nurse shifts were uncovered.
  • Compliance with mandatory training was variable although nursing teams had made significant efforts to improve completion rates.
  • There had been instances of significant violence towards staff from patients and this was entered into a divisional risk register. It was not evident that the security team responded consistently to such instances and staff lacked training to handle escalating aggressive behaviour.
  • The trust participated in multiple national audits to benchmark care, including for lung cancer and ischaemic heart diseases. Results across all audits demonstrated wide variance in performance, including some performance significantly below national standards in the lung cancer audit.
  • Referral to treatment times in four specialties were worse than the national average, including significant differences of up to 29%.
  • The trust was slow to investigate and close complaints, with an average time of 75 days between October 2016 and September 2017. In addition, a significant proportion of complaints were reopened and medical care attracted the most formal complaints out of all hospital services.

However;

  • Although our rating remains the same we acknowledge the substantive and well-coordinated work hospital teams have completed in improving safety and quality standards, particularly in relation to sepsis, dementia care and ward quality assurance.
  • Infection prevention and control practices were consistently good in most areas and we observed staff adhere to appropriate standards. Monthly audits indicated a need for this to be further embedded.
  • A sepsis practitioner had significantly improved training and resources for staff in the screening and management of sepsis and between October 2016 and January 2018 96% of patients started antibiotics within 60 minutes.
  • The incident-reporting procedure was clearly embedded and all staff were confident in its use. In addition, there was evidence of learning and improvements as a result of never events and serious incidents and staff could demonstrate how these applied to their area of work.
  • Overall performance in the Sentinel Stroke National Audit Programme rated the hospital as better than the national average, with a level B in the latest results. This indicated good performance in most measures with the exception of therapy, in which there was a need for increased occupational therapy in particular.
  • There was a demonstrable drive to improve staff clinical competencies through the provision of more opportunities for learning and development. A dedicated clinical education team delivered one-to-one opportunistic training to staff on each ward in addition to a planned programme of teaching. Additional opportunities had been made available for assistant practitioners and healthcare assistants.
  • Staff delivered care that was kind and compassionate and helped patients to maintain privacy and dignity. Patients generally felt involved in their care and understood their treatment plan although this was not always the case with discharge information.

Surgery

Good

Updated 3 July 2018

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

  • Staff understood their responsibilities to raise concerns and report incidents and near misses.
  • Lessons were learned and communicated widely to support improvement. For example, changing equipment /products to ensure patient safety.
  • Risks to patients were assessed, monitored and managed on a day-to-day basis. These included signs of deteriorating health and medical emergencies.
  • Monitoring and audit of safety systems was robust. There was an effective audit for the World Health Organisation (WHO) five steps to safer surgery checklists.
  • There were systems, processes and standard operating procedures in infection prevention control, records, and maintenance of equipment, which were mostly reliable and appropriate to keep patients safe.
  • Patients were protected from abuse; staff had an understanding of how to protect patients from abuse.
  • Care and treatment was planned and delivered in line with current evidence based guidance, standards, best practice and legislation and patients received effective care and treatment.
  • We saw where patients symptoms of pain were mostly managed in both ward and department areas with good comfort outcomes. We observed staff positively interacting with patient and patients were treated with kindness, dignity, respect and compassion while they received care and treatment. Feedback from patients was positive about the care and treatment they had received.
  • Surgical care services were responsive to patient’s needs; patients could access services in a way and at a time that suited them and there was a proactive approach to understanding and meeting the needs of individual patients and their families.
  • The leadership, governance and culture in surgical care services supported the delivery of high quality person-centred care; governance and risk management arrangements were effective and as such able to protect patients from avoidable harm.

However:

  • During the last inspection in October 2016 staffing levels across the service were challenging. This was still evident at this inspection. Leading to regular staff moves to unfamiliar areas.
  • Housekeeper staffing numbers were reduced throughout surgical areas. This was highlighted on risk registers as an increased risk of patient harm due to post-operative infection.

Services for children & young people

Good

Updated 11 April 2017

We rated this service as good because:

There was a good understanding of the incident reporting system with most incidents reported being of the no harm to low harm category. The service had not reported any never events in the 12 months prior to the inspection.

There were good infection prevention and control measures within the service and this was reflected in the zero cases of healthcare acquired infections.

The use of the paediatric early warning score (PEWS) and neonatal early warning score (NEWS) was embedded within the service and aided timely recognition of the deteriorating patient.

The service delivered care according to local and national policies which were evidence based, and also contributed to national audits to benchmark care against other providers.

We observed many positive examples of compassionate and dignified care being provided to all patients. Feedback from parents, carers and the children themselves was complimentary about the care they had received and felt the level of information provided was adequate. They were also complimentary about the involvement of siblings in the patient experience and how staff extended the compassionate care to them.

The service was responsive and met the needs of the children and young people accessing the service. The hospital had engaged with local parent groups about service planning and delivery and also provided facilities for parents to stay with their child whilst admitted.

The service was well-led at local ward/unit level and staff told us and we found the leadership above this level was also good.

Nurse and medical staffing did not meet requirements of the Royal College of Nursing (RCN) and Royal College for Paediatric and Child Health (RCPCH). Nurse staffing on the children’s ward did not have an experienced member of staff on for each 24 hour period and did not provide at least one member of staff with advanced paediatric life support (APLS) or European paediatric life support (EPLS) qualification on each shift. There were insufficient members of the medical tram to provide paediatric consultant cover seven days per week. In addition consultant cover provided did not cover the busy 12 hour period up to 10pm.

There was a lack of awareness on the children’s ward in relation to ligature risks, for example we did not see a ligature risk assessment had been carried out and there were no ligature cutters immediately available in the ward area. There was no abduction policy; therefore we were not assured that all staff would know what actions to take in the eventuality of a missing child.

We could not be assured that sepsis management was embedded within the service and this was supported by information provided by the trust.

We could not be assured that staff followed the did not attend (DNA) policy for the children’s outpatient department, and there was no DNA monitoring of paediatric patients in departments where children attended.

End of life care

Good

Updated 27 March 2015

The specialist palliative care team provided positive information and advice to general ward staff on the care of the dying patient. However in 2014, the service was not well developed, and there was a disconnect between what managers wanted to happen and what some of the palliative care team were undertaking. Patients using the service had only praise for the staff and felt involved in their care. At our inspection in 2015, we found that this disconnect was no longer apparent, as staff within the specialist palliative care team now felt well supported by the trust. The team had begun to use patient demographics to drive service delivery and training, and implementation of palliative care link nurses was well underway.

In 2014 we stated that improvements to the service, in terms of ensuring that the overarching strategy was accomplished, addressing challenges within the completion of the 'do not attempt cardio-pulmonary resuscitation' (DNA CPR) form, and the training of nursing staff on general wards, were required to ensure a safe, effective and responsive service. However, at our inspection in 2015 we found that significant improvements to training and overarching strategy had been implemented. The completion of DNA CPR forms still requires further improvement to ensure that patients who may lack capacity are protected when these decisions are made about their care.