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Pilgrim Hospital Requires improvement

In November 2011 we carried out a full investigation into care provided by United Lincolnshire Hospitals NHS Trust. Read the press release and the investigation report here:
CQC investigation finds improvements at Pilgrim Hospital but further progress still needed to protect patients

In April 2013, we published an update report showing a number of improvements made at Pilgrim Hospital since our investigation.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 17 October 2019

Our rating of services improved. 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 three out of five services some staff had not had training in key skills. Some services did not always control infection risk well. Staff did not always assess risks to patients, act on them and keep good care records. Not all services managed safety incidents well and learned lessons from them.
  • Managers did not routinely monitor the effectiveness of the service and make sure staff were competent. In services for children and young people action to address some of the issues threatening the safety and effectiveness of care, had not been not progressed in an acceptable timeframe. Staff had access to information however, this was not always up to date. In some services key services were not available seven days a week.
  • Not all services planned care to meet the needs of local people or, took account of patients’ individual needs. People could not always access services when they needed it and sometimes had to wait too long for treatment.
  • Leaders did not always run services well using reliable information systems and support staff to develop their skills. Services did not always engage well with patients and the community to plan and manage services and not all staff were committed to improving services continually.

However:

  • Staff understood how to protect patients from abuse. They managed medicines well. Staff collected safety information and used it to improve the service.
  • Most 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 and supported them to make decisions about their care.
  • Most 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.
  • Services made it easy for people to give feedback.
  • Staff felt respected, supported and valued and were focused on the needs of patients receiving care. Most staff understood the service’s vision and values, and how to apply them in their work. Staff were clear about their roles and accountabilities.
Inspection areas

Safe

Inadequate

Updated 17 October 2019

Effective

Requires improvement

Updated 17 October 2019

Caring

Requires improvement

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. Staff did not always maintain up to date training in key skills. The service did not always control infection risk well. Staff did not always assess risks to patients, act on them or keep good care records. The service did not always manage safety incidents well and did not always learn lessons from them.
  • Not all key services were available seven days a week.
  • Staff did not always treat patients with compassion and kindness, respect their privacy and dignity and take account of their individual needs.
  • Local leaders supported staff to develop their skills, but trust resources were very limited. Staff did not always understand the service’s vision and values, or how to apply them in their work.

However:

  • Staff understood how to protect patients from abuse, and managed safety well. They managed medicines well. 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.
  • Staff provided emotional support to patients, families and carers. and helped them understand their conditions.
  • 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 at a local level ran services well using reliable information systems and 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.

Services for children & young people

Inadequate

Updated 17 October 2019

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

  • Staff did not always assess risks to patients appropriately and did not always learn lessons and share learning from incidents. The service did not always have enough permanent medical staff to care for patients and keep them safe. Staff did not always have training in key skills such as safeguarding children. Staff did not consistently follow good hand hygiene practice, increasing the risk of infection.
  • 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. Staff did not follow best practice guidance to reduce the time fluids were withdrawn prior to surgery. Some key services were not available seven days a week. There were gaps in the management and support arrangements for staff, such as appraisal.
  • Services did not always meet people’s individual needs, as the environment in some departments children visited was not suitable and staff did not always make the adjustments needed to help patients access services. The operational policy of the paediatric assessment unit in relation to the transfer of patients was not always followed.
  • Adequate action to address some of issues threatening the safety and effectiveness of care, had not been not progressed in an acceptable timeframe. Actions we advised the service to take following the inspection in March 2018 had not been fully addressed. The arrangements for governance and risk management were not fully effective, although a new governance framework was being implemented.

However:

  • 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 managed medicines well and kept good records of the care provided. There was a good culture of incident reporting and staff were open and honest with people when things went wrong.
  • The service worked with stakeholders and commissioners to plan services and staff coordinated care with other services and providers. They listened to complaints and took them seriously.
  • Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. Staff were focused on the needs of patients receiving care. They were clear about their roles and accountabilities.

Critical care

Good

Updated 17 October 2019

Our rating of this service stayed the same. 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 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.

However,

  • Staff were not always completing patient records on the electronic clinical information system (CIS) such as oral care and tissue viability assessments.
  • Speech and language therapists (SALT) were not always available to review patients for swallowing assessments which could cause a delay for patient weaning onto oral feeding.
  • There was not adequate pharmacist cover for the critical care unit at Pilgrim Hospital. A pharmacist did not always attend the unit’s multidisciplinary ward handover meeting each morning or attend the unit for the agreed one day a week. The out of hours on-call pharmacist was not always able to attend the unit from home.
  • Some policies on the CIS were out of review date. The tracheostomy policy and sedation hold guidelines were out of review date. The enteral feed guideline was not dated.

End of life care

Good

Updated 27 March 2015

The service was safe. There was a good culture of reporting and learning from incidents. Records were in place, documenting patients’ wishes regarding resuscitation that were appropriate. Some records did not always document the involvement of relatives in the decision-making process.

The service was effective, working to the Gold Standard Framework. Patients’ pain relief was prescribed and administered in a timely manner. The trust had taken part in the National Care of the Dying Audit, the results of which were awaited at the time of our inspection.

The service was caring. Patients received care from staff that was attentive and sensitive to their needs. Patients and the families we spoke with were positive about the care they received. Patients’ privacy and dignity was maintained.

The service was responsive to patients’ individual needs. In 2014 staff told us that end of life care services were planned on the principle of person-centred care. This meant that patients’ wishes were at the centre of decisions made about their care. However, in 2014, only 17.5% of patients who died in the hospital were seen by the palliative care team. Staff reported a high demand for support from the palliative care team, which they were not able to provide. We were told that the trust was going to address this through the recruitment of an additional palliative care nurse. In 2015, we found that the trust had implemented link nurses on each ward, who identified patients at the end of their life.

The service was well-led. We found that staff shared the visions and values of the trust; namely, that the patients were at the centre of decisions made about how the service was run. The views of patients and staff were being proactively sought to drive up standards in the service.

Surgery

Good

Updated 3 July 2018

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

  • Patients were protected from avoidable harm and there was a culture of learning from incidents. Staff recognised incidents and reported them appropriately. Lessons learned were shared with the surgical teams.
  • Staff in the operating theatres and day case Unit followed the World Health Organisation (WHO) surgical safety checklist and five steps to safer surgery, and monitored this to make sure this was completed accurately.
  • Records were appropriately assessed and their safety monitored and maintained.
  • There were robust processes to assess and escalate deteriorating patients.
  • Infection prevention and control policies and protocols were in place and regularly audited and surgical site infections were being monitored.
  • Staff had a good understanding of safeguarding and was aware of their responsibilities in relation to safeguarding adults. The service worked with other agencies to share relevant safeguarding information.
  • The environment was visibly clean, tidy and well maintained.
  • Staff had the skills, knowledge and experience to deliver effective care and treatment to patients.
  • Staff used external evidenced based standards and information to monitor and benchmark their practice. Patients care and treatment mostly achieved good outcomes and was based on the best available evidence.
  • The service monitored the effectiveness of care and treatment through continuous local and national audits and presented their data at national and international conferences.
  • The service regularly took part in national and international research programmes which supported the development of innovative and new ways of working and improving standards of care for patients.
  • Patients were at the centre of the service and the quality care was a priority for staff. Patients were involved in their care and treated with compassion, kindness, dignity and respect. Most patients that we spoke with during this inspection were very complimentary about the level of care they had received.

However:

  • At the last inspection in April 2017 staffing levels across the service were challenging. This was still the case at this inspection.
  • There were daily bed meetings which looked at demand, capacity and staffing issues to ensure there was sufficient resources to support elective surgery. But staff were constantly moved to other wards in order to sustain safe practice which had a negative impact on staff morale.
  • Patients could not always access care and treatment in a timely way. Waiting times for referral to treatment were worse than the England average and national standard.
  • Front line staff told us they felt supported by their immediate line manager(s). Morale in operating theatres and some wards was low due the continual moving of staff from their normal working environment.
  • Leaders were committed to improving services. Whilst some improvements had been made since our last inspection there was evidence of repetitiveness and over monitoring of similar governance processes which staff felt was over burdensome.

Urgent and emergency services

Inadequate

Updated 17 October 2019

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

  • The service did not have enough permanent staff to care for patients and keep them safe relying heavily on agency and locum staff. Staff had training in key skills but completion rates for the training was low. Nursing staff understood how to protect patients from abuse, and managed safety well but training completion rates for medical staff were low. The department was too small for the number of patients it dealt with and this impacted on patient care. Staff did not always assess risks to patients or act on those assessments.
  • Staff did not demonstrate sufficient knowledge of the Mental Health Act 1983. Pain relief was not always given in a timely manner. Participation in national audit was low and lessons were not well learnt.
  • People could not always access the service when they needed it because of limited capacity and they often had to wait too long for treatment.
  • Staff were only starting to understand and manage the priorities and issues the service faced, the management team responsible for delivering this were very new in post and work was at an early stage. There were still issues with some staff’s behaviours and the positive changes were not yet fully embedded.

However:

  • The service controlled infection risk well. They did keep good care records and they managed medicines well. The service managed safety incidents and learned lessons from them.
  • Staff provided care and treatment based on national guidance.
  • Patients were given 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.
  • 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 encouraged people to give feedback.
  • Leaders had the abilities to run the service and they were visible and approachable in the service for patients and staff. The service had a developing vision for what it wanted to achieve and was an emerging strategy to turn it into action, developed with all relevant stakeholders. Staff felt respected, supported and valued and they were focused on the needs of patients receiving care.

Maternity

Requires improvement

Updated 17 October 2019

We previously inspected maternity jointly with gynaecology so we cannot compare new ratings directly with previous ratings. We rated it as requires improvement because:

  • Some of the problems we found during the previous inspection still existed; maternal choice for a midwife led delivery unit was limited. There was no designated bereavement area for families who had lost a baby. At the time of this inspection the labour ward did not have an electronic emergency call buzzer system.
  • The labour ward co-ordinator was not always supernumerary. Local audits showed between December 2018 and May 2019, there were 243 occasions when the labour ward co-ordinator was not supernumerary equating to 22% of the time. However, an improvement plan was in place.
  • Although the service achieved good outcomes for some patients, some areas required improvement. The still birth rate, proportion of women having induction of labour and proportion of blood loss (greater than 1500mls) were higher than trust targets or national average.
  • The trust was only able to offer scans on four weekly basis to women identified as high risk for ‘small for gestational age’ (SGA) or fetal growth restriction (FGR). The trust was unable to offer routine scanning to women with BMI of 35 – 39.99. This was not in line with national guidance.
  • 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. There was no dedicated bereavement room available for women and families suffering a bereavement.
  • Systems used for identifying risks and planning to eliminate or reduce them were efficient. The risk register was revised in a board level format with an overarching title that was not appropriate for clinical risk.

However:

  • There were effective systems to safeguard women and their babies from harm. Women identified as “high risk” where offered enhanced care by specialist midwives.
  • There was a good culture of incident reporting and staff were open and honest with people when things went wrong.
  • Patient records were comprehensive with appropriate risk assessments completed. Staff identified and quickly acted upon patients at risk of deterioration.
  • The unit had specialist midwives, which ensured that women received specialist care suited to them.
  • Feedback for the services inspected were mostly positive. Staff treated women with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.
  • The service worked with commissioners and stakeholders to plan services. Community midwives covered specific geographical areas thereby ensuring women had access to midwives in their local area.
  • Staff felt valued, were supported in their role and had opportunities for learning and development. Staff understood the service’s vision and values, and how to apply them at work. They were clear about their roles and responsibilities.
  • The service had opened a new maternity ward with modern facilities to enhance patient care. Local goals were set for each of the metrics monitored on the maternity dashboard. The service carried out regular audits, with an action plan to improve patient outcomes.

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:

  • 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.
  • The trust provided mandatory training in key skills to all staff but did not ensure everyone had completed it. Qualified nursing and health visiting staff met the trust target in six out of the 11 mandatory training modules, and unqualified and support staff met the trust target in five modules. Unqualified staff support and the trust target did not meet the trust target for any of the safeguarding training modules for which they were eligible.
  • 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. We observed a large quantity of records that were still poor quality, very large or badly filed. We found three was inconsistency in the security of medical records to protect patient confidentiality.
  • 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 waiting for appointments. The trust did, however, attempt to mitigate this risk by writing to patients who were waiting over certain timeframes.
  • Services were delivered in an older building which meant parts of the environment presented challenges 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.
  • Data from the trust as of March 2018 showed the total number of patients waiting more than six weeks for a follow up appointment was 3,333. The number of people overdue six months or more was 561. This was a slight improvement from our previous inspection.
  • The general manager did not have sufficient capacity or administrative support to manage the workload.
  • Although improvements had been made to the culture within the outpatients nursing team, there were significant numbers of administrative staff within health records and medical secretaries who reported a bullying, unsupportive culture. The majority of staff we spoke with were unaware of the existence of the Freedom to Speak up Guardian.
  • Whilst we saw improvement in the governance arrangements and oversight of performance, we were not assured the improved access to data was driving significant improvement of the services, including constitutional standards and waiting lists. There was there was poor oversight of the risk register.

However:

  • 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.
  • 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 of where they had identified and raised concerns.
  • Staff demonstrated good practice with regards to hand hygiene and infection control. We saw hand gel available in clinical areas and the majority of clinic areas and equipment were visibly clean. Staff cleaned equipment in between patients.
  • Staff had a good understanding of their responsibilities to report incidents and we saw learning from incidents was shared as part of the daily team meetings. Outpatient services based local medical policies on national best practice. Clinical specialities worked in accordance with National Institute for Health and Care Excellence (NICE) guidance and standards.
  • We saw good examples of multi-disciplinary working and involvement of other agencies and support services. Staff also provided lots of information to enable patients to manage their own and health.
  • Staff assessed patient nutrition and hydration requirements. Patients had access to refreshments while waiting for clinic appointments or transport home.
  • 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.
  • All patients we spoke with were positive about their experience at the hospital. Patients described staff as friendly, compassionate and supportive. Staff displayed their passion for providing good patient care and emotional support to patients. Staff understood the impact of care and treatment on the patient and discussed the impact with patients.
  • Staff involved patients in their treatment and care. We observed staff provide patients with choices about their treatment and care. Staff communicated in a way patients understood and gave patients plenty of time to ask questions. Most patients said they felt involved in their treatment and care.
  • The trust planned and provided services in a way that met the needs of local people. We saw improvements were being made to the waiting areas. Certain specialities were operating ‘one stop shops’ for some patients for example dermatology, vascular and respiratory.
  • The ‘did not attend’ (DNA) rate for outpatient services was better than the England average. Staff had procedures in the event of patients not turning up for appointments. Services had started use a text reminder service to help improve performance. The trust was performing similar 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.