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Lincoln County Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 17 October 2019

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

  • Some services did not always have enough staff to care for patients and keep them safe. In two out of five services some staff had not had training in key skills. Staff did not always assess risks to patients, act on them and keep good care records.
  • Managers monitored the effectiveness of the service and used the findings to make improvements but did not always achieve good outcomes for patients. In some services not all key services were available seven days a week.
  • Services did not always plan care to meet the needs of local people or take account of patients’ individual needs. People could not always access some services when they needed it and had to wait too long for treatment.
  • Not all leaders ran services well using reliable information systems. Not all staff felt respected, supported and valued or were clear about their roles and accountabilities. and not all staff were committed to improving services continually.

However:

  • Most staff understood how to protect patients from abuse. Services controlled infection risk well and most services managed medicines well. Services managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff mostly provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Services mostly 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.
  • Staff mostly 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.
  • Services made it easy for people to give feedback.
  • Most services supported staff to develop their skills. Most staff understood the service’s vision and values, and how to apply them in their work. Most staff were focused on the needs of patients receiving care. Services engaged well with patients and the community to plan and manage services.
Inspection areas

Safe

Requires improvement

Updated 17 October 2019

Effective

Requires improvement

Updated 17 October 2019

Caring

Good

Updated 17 October 2019

Responsive

Requires improvement

Updated 17 October 2019

Well-led

Requires improvement

Updated 17 October 2019

Checks on specific services

Medical care (including older people’s care)

Requires improvement

Updated 17 October 2019

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

  • The service did not always have enough staff to care for patients and keep them safe.
  • Managers monitored the effectiveness of the service to make improvements but did not always achieve good outcomes for patients.
  • Some key services were not available seven days a week.
  • People could not always access the service when they needed it and had wait times above the national average for treatment.
  • Leaders had the ability to run the service well, however whilst they understood and managed the priorities and issues the service faced these were not always managed effectively.
  • Staff did not always fell respected, supported and valued.

However:

  • Most staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well and kept good care records.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it.
  • 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.
  • 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.
  • Staff understood the service’s vision and values, and how to apply them in their work.
  • Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services.

Services for children & young people

Requires improvement

Updated 17 October 2019

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

  • The children’s safeguarding lead was not in receipt of regular safeguarding supervision

  • Staff were not in receipt of regular group supervision as a member of the safeguarding team who undertook this left the trust in February and their post had only just been replaced at the time of our inspection
  • The service did not have enough medical staff to keep children and young people safe, as the medical staff did not match the planned number on all shifts in each department.
  • The design of the adult outpatient’s department were children regularly attended environment did not always follow national guidance, for example, the outpatient’s department clinic waiting area for an x-ray or CT scan had no facilities for children. Staff told us the children would wait with their parents and that sometimes they had to stand as there was not sufficient seating.
  • Nursing staffing was on the risk register for Rainforest ward as a red risk and had been for five years Royal College of Nursing (RCN), Paediatric Nurse Standards recommend a ratio of one nurse to four patients over the age of two during the day and at night and a ratio of one nurse to three patients under two years of age day and night. A ratio of one nurse to two patients is recommended for patients requiring high dependency care. The guidance also recommended at least one Band six nurse on every shift. This was achieved on Rainforest ward through the extensive use of bank and agency staff over a prolonged period of time.
  • Managers did not ensure staff had access to up to date best practice guidance and carried out very few audits, to assess whether staff complied with national guidance.

However:

  • Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service-controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service. There was a medical lead for safeguarding.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. 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.
  • 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. People could access the service when they needed it and did not have to wait too long for treatment.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Most staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

Critical care

Good

Updated 17 October 2019

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

  • The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. 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.
  • 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. People could access the service when they needed it and did not have to wait too long for treatment.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

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.

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.

Urgent and emergency services

Inadequate

Updated 17 October 2019

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

  • Staff did not identify all patients at risk of deterioration in a timely way. Not all patients at risk had a sepsis screen completed within the hour, and some patients received antibiotics well in excess of an hour after the trigger point. The service did not always triage children within 15 minutes. Staffing levels depended on a disproportionate amount of bank, agency and locum nursing and medical staff. Vacancy rates, turnover and sickness were high.
  • The design, maintenance and use of facilities, premises and equipment did not always keep people safe. Children did not always receive a clinical assessment within 15 minutes. They mixed with adult patients in the main waiting area and Rapid Access and Treatment corridor. The service did not meet Royal College of Paediatrics and Child Health (RCPCH) standards to keep children safe.
  • The service did not have a comprehensive or systematic audit programme. Some evidence from serious incidents showed that staff were not always following good practice. Staff were not always able to ensure patients had enough to eat and drink, especially overnight. Checking pain and giving pain relief was also variable. Levels of medical and nursing staff competency were constrained by the high level of locum and agency staff
  • Staff did not always inform patients about their care. We spoke to nine patients in the emergency department and waiting room. Three patients in the department told us they did not know what was happening, what the next stage was, or whether they were likely to stay in hospital overnight. Friends and Family test performance for urgent and emergency service in the trust overall was consistently worse than the England average from March 2018 to February 2019
  • Patients could not access treatment in a timely way. Performance against national standards such as the four-hour target was poor. The week before we inspected the service 64% of patients were admitted, transferred or discharged within four hours at Lincoln County Hospital. Services were not systematically planned to meet local demand. The service had not reviewed or adapted its services to ensure that it met the needs of diverse patient groups such as patients with mental health difficulties, learning disabilities, autism or dementia.
  • Leaders did not manage the priorities the service faced, for example, the management of patients at risk of deteriorating because of sepsis was weak. Systems and governance around performance management, including those for checking data quality although developing, had not led to sustainable solutions. Staff did not always feel respected, supported or valued. Strategic planning was not comprehensive or coordinated and lacked plans to meet the diverse range of patients and children.

Maternity

Good

Updated 17 October 2019

We previously inspected maternity jointly with gynaecology therefore we cannot compare our new ratings directly with previous ratings. We rated it as good because:

  • The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. 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.
  • 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. People could access the service when they needed it.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However,

  • Although the service achieved good outcomes for most patients, some areas required improvement.
  • The trust did not routinely audit waiting times to ensure they were in line with national standards.
  • The service did not provide a designated midwifery led unit, however they had modified two rooms used as such while awaiting renovation and provision of an alongside midwifery led unit.
  • Systems used for identifying risks and planning to eliminate or reduce them were not embedded. The risk register was in a board level format with an overarching title that was not appropriate for clinical risk.

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.