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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.

We are carrying out checks at Pilgrim Hospital. We will publish a report when our check is complete.

Inspection Summary


Overall summary & rating

Inadequate

Updated 3 July 2018

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

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

Inadequate

Updated 3 July 2018

Well-led

Inadequate

Updated 3 July 2018

Checks on specific services

Critical care

Good

Updated 11 April 2017

Overall, critical care service was rated good for safe, effective, caring, responsive and well led.

The critical care unit appeared visibly clean and promoted patient safety through established infection control processes, with no reported incidents of meticillin-resistant staphylococcus aureus (MRSA) or clostridium difficile (C.Difficile). Local audits showed staff consistently used good hand hygiene practices and were bare below the elbow in line with best practice.

There were adequate medical and nursing staff to meet the recommended staff to patient ratio, as defined in the core standards for intensive care units.

The department planned and provided care according to national and local guidelines and was an active member of the Mid Trent critical care network, where common working policies were developed and agreed.

We observed staff providing compassionate care and maintaining patient privacy and dignity at all times.

The unit was responsive to local demand by using beds flexibly according to the level of care required. The unit worked collaboratively with the colorectal cancer service to provide facilities and care for the post-operative patients at level one (enhanced ward level care).

Patients were supported on discharge by the critical care outreach team .Those receiving level three (Intensive care) had the opportunity to attend a post critical care clinic for longer-term support.

The service was led by experienced senior manager with the skills and capability to lead the service effectively .Staff told us they felt supported to carry out their roles within the unit.

However the critical care unit informed the inspection team that delayed patient discharges was a problem for the unit and this was on the departments risk register. However, the unit did not keep a comprehensive record of delayed discharges.

The critical care unit did not have the recommend number of nurses with a post registration qualification in critical care nursing as defined in the core standards for intensive care units.

Outpatients and diagnostic imaging

Inadequate

Updated 11 April 2017

We rated this service as inadequate because:

Outpatient services did not manage and maintain medical records in a way, which enabled the safe care and treatment of patients, complied with information governance requirements, or ensured patient confidentiality. This included the availability, the condition and storage of medical records.

Data showed continuous poor performance against national cancer targets. We saw significant numbers of patients overdue for appointments including new and follow up appointments. In some cases, the 2016 position was worse than the previous year. The trust performance against referral to treatment times had declined between June 2016 and September 2016.

Data showed 8,108 incomplete patient appointment outcomes, which staff did not record on the electronic record system. Data supplied by the trust showed the current position was worse than the previous year.

There had been significant delays in the reporting of diagnostic imaging results due to technical difficulties. This affected patients receiving timely access to care and treatment.

Not all staff reported incidents in line with trust policy. Therefore, not reporting incidents presented a risk to patients because it meant departments could not put mitigating in place to prevent an incident from happening again.

There were delays in staff typing and sending clinic letters to GPs and patients. We saw significant numbers of letters waiting to be typed.

Not all staff received appraisals in a timely manner. Some staff we spoke with said their appraisals were not meaningful and did not provide opportunities to develop. In particular, administrative staff did not benefit from regular or meaningful appraisals.

Progress against some poor performance and identified risks was slow. We saw issues identified since our last inspection had not been address 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.

We had concerns in relation to the culture in some outpatient departments. Some staff said they had experience bullying and intimidating behaviour particularly from managers. The majority of administrative staff we spoke with said managers did not support or listen to them. There were shortages in administrative staffing.

However we also found:

Staff delivered patient care in line with evidenced based care and best practice guidelines. Staff had access to relevant trust policies and national guidelines to support them deliver patient care. Staff reported incidents in line with the Ionising Radiation (Medical Exposure) Regulations 2000 (IR(ME)R

There was effective multidisciplinary working with staff, teams and services working together to deliver care and treatment to meet the patient’s needs. Staff from different specialties and roles provided one-stop clinics in some departments.

Staff were caring, compassionate and involved patients in their care and treatment. We saw positive interactions between staff. Patients were positive about their care and treatment. Staff supported patients in the event of bad news.

Services met the needs of local people with some specialist services available for patients. Some clinics developed new ways of working to meet demand and address overdue appointments for example virtual clinics.

Staff had access to translation and interpretation services and where possible used their resources to enhance the patient’s care pathway.

We saw some examples of patient and staff involvement. We saw where changes had occurred because of patient and staff involvement.

We saw examples of departments innovating to improve care for patients.

Urgent and emergency services

Inadequate

Updated 3 July 2018

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

  • Patients were not always protected from avoidable harm. There were significant handover delays for patients arriving by ambulance, no clear streaming and/or triage process in place for patients arriving at the front door of the department and no effective system(s) in place to assess and monitor the ongoing care and treatment to patients, including monitoring patients for signs of clinical deterioration.
  • Staffing levels and skill mix were not sufficient to meet the needs of patients as a result; patients did not have their care and treatment carried out in a timely manner. There was not a minimum of one children’s nurse present on each shift nor was there consultant presence in the department for 16 hours per day, both were not meeting national guidance.
  • The emergency department did not manage patient safety incidents well. Whilst staff recognised incidents they did not always report them appropriately and lessons learned were not always shared with the whole team and the wider service.
  • The layout of the emergency department was not suitable for the number, or age, of admissions the service received. There was significant overcrowding and, at times, patients were being cared for on trolleys in the central area of the department as there were no free cubicles to use.
  • Patients care, treatment and support did not always achieve good outcomes, promote a good quality of life and was not always based on the best available evidence. Audit participation was low and results were not used to improve poor patient outcomes. Sufficient priority was not given to patients’ nutrition and hydration or pain needs.
  • Staff did not always work together as a team to deliver effective care and treatment. There was not always consistency in working practices, practices would change on a daily basis depending on who was leading the team that day and medical staff faced challenges when referring patients to individual specialties, with patients often waiting a significant length of time to be seen.
  • Patients were not always involved and treated with compassion, kindness, dignity and respect. Staff shortages within the department negatively impacted on the care patients were receiving and limited the time staff had to spend with patients. We observed patients upset and agitated, patients who had not been offered food and/or drink for a significant amount of time and patient’s whose privacy and dignity needs had not been met appropriately.
  • Patients could not access care and treatment in a timely way. Waiting times for treatment and arrangements to admit, treat and discharge patients were worse than the England average and national standard.
  • There was not the leadership capacity and capability to deliver high-quality, sustainable care. Leadership within the department was not effective, there did not appear to be one individual taking overall responsibility for the day to day running of the department. Front line staff did not feel supported, respected or valued by their immediate line manager(s). Staff were not engaged and morale in the department was low; frustrations around leadership, low staffing, capacity and flow and the environment had led to a culture of acceptance with staff lacking the drive to challenge systems and processes within the department.
  • Leaders were not committed to improving services. Whilst some improvements had been made since our last inspection we were not assured sufficient improvements had been made in order to protect patients from avoidable harm. The pace of change within the department had been slow and ineffective systems and processes, lack of adequate resources and poor leadership had been allowed to continue.

However:

  • Feedback from patients, we spoke with, confirmed that staff treated them well and with kindness. Patients told us they had been given enough information about their condition and/or treatment in a way that they could understand.

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.

Maternity and gynaecology

Requires improvement

Updated 11 April 2017

We rated this service overall as requires improvement.

Many of the audits did not provide plans for presentation of findings to colleagues or current timelines.

Staff had not received recovery update training.

The unit struggled to gain feedback from the non-English speaking population.

Maternal choice for a midwife led unit delivery was limited.

There were no designated bereavement areas for families who had lost a baby.

The gynaecology ward often included non-gynaecology patients.

The labour ward recovery area was not set up for use or in a private room.

Data collection was not robust due to discrepancies in collection.

Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. Lessons were learned and communicated to staff.

Clinical areas were visibly clean and attempts were made to improve the working environment.

Safeguarding support for staff had increased with the introduction of specialist midwives.

Women’s care and treatment was planned and delivered in line with current evidence based guidance.

Staff gained consent prior to all care and treatment, including for disposal of fetal remains.

Staff received appraisals and were supported in training with practice development staff.

Staff responded compassionately and families were treated with kindness and respect.

Women were aware of how to complain and their complaints were taken seriously.

The women’s and children’s service was driven by quality. Despite an unknown future short term changes were performed to improve services for women.

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

Medical care (including older people’s care)

Requires improvement

Updated 3 July 2018

  • Staff vacancies remained persistently high and this had a demonstrable effect on the ability of each ward or clinical team to provide consistent, safe care.
  • Audits to benchmark the standards of patient records against national standards demonstrated highly variable practice, which was also reflected in the investigations of serious incidents.
  • Standards of medicine management were variable and pharmacy cover on wards was inconsistent due to short staffing. We found concerns with the use of temperature monitoring policies, the storage of Controlled Drugs and the documentation of medicine administration.
  • The outcomes of incident investigations found a need for a significant, sustained improvement in how staff accessed, interpreted and applied trust policies.
  • The trust had implemented a CQUIN action plan to improve sepsis screening and treatment following our findings at our last inspection. However there was limited evidence of sustained, embedded improvement.
  • Standards of documentation relating to nutrition and hydration were variable and did not always reduce risks to patients. However, the dietetics team represented a range of specialties and experience and had adapted care to meet individual needs.
  • We found evidence of appropriate use of the Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards (DoLS) in all clinical areas, including through liaison with independent advocates. However, there was a need to improve documentary evidence of this.
  • Between November 2016 and September 2017 the trust achieved an average of 75% in the national target for referral to treatment time of 18 weeks, against a national target of 90%.
  • Medical care services received the highest number of formal complaints out of all hospital services and the trust was generally slow to resolve these, at an average of 75 days.
  • Although the directorate used a risk register to track risks and track resolutions, these were sometimes slow to progress and risks sometimes remained in place for several years without demonstrable progress.
  • Results from the NHS Friends and Family Test indicated variable results in the hospital’s recommendation rates, with an overall average of 89%. Although some wards demonstrated a recommendation rate of 100% in up to eight months, other wards had low ratings. This included a recommendation rate of 50% in one ward in one month and a ward with an overall average of 77%.
  • Some senior staff described the service as unsustainable and ongoing, significant challenges with recruitment contributed to this.

However:

  • Medical inpatient wards demonstrated improved scores in five out of six measures of the patient-led assessment of the care environment (PLACE) in 2017 based on 2016 scores.
  • A matron-led ward accreditation programme had contributed significantly to improving staff quality and safety performance. This comprehensive approach enabled staff to engage with all aspects of care, treatment and governance and initial results from the second cycle of assessments indicated evidence of rapid improvement.
  • The directorate senior team and each clinical team acted on the outcomes of investigations from incidents and never events and we found a safety culture in which practice was actively improved as a result.
  • Staff had a clear focus on reducing preventable falls and hospital-acquired pressure ulcers. The acute medical unit team had acted on poor results from a catheter care audit and had implemented a new safety structure to address this.
  • A clinical education team was active in all clinical areas and had demonstrably contributed to improved clinical competency, including in the care of patients living with dementia and diabetic ketoacidosis.
  • We observed consistently kind and compassionate care from staff and embedded practice of including patients and their relatives or carer in treatment plans and decision-making.
  • A team of volunteers worked in the hospital to provide social stimulation to patients and to relieve relatives and carers.
  • The hospital demonstrated the ability to adapt to the needs of the local population.
  • The directorate teams and quality matrons had introduced improved governance and quality processes, including through the use of a ward accreditation scheme and new clinical governance strategy.

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.

Services for children & young people

Inadequate

Updated 3 July 2018

  • We were not assured that a sufficiently robust clinical risk assessment had been undertaken to ensure that children waiting surgery have been clinically triaged and prioritised. We were not assured that there was sufficient mitigation in place to meet the needs of those children requiring elective surgical procedures.
  • There had been significant delays in the investigation of serious incidents that had happened in previous years and we found examples of how learning from serious incidents had not always been implemented robustly or systematically.
  • Defined governance structures did not exist to assure the board of the quality and delivery of surgical care to children. There was no multi-disciplinary children’s surgery committee which reported to the board.
  • Concerns over staffing levels and the retention and recruitment of skilled and qualified staff had existed for some two years prior to the inspection. The trust had held a number of internal risk summits to consider the impact and implications however there had been little in the way of effective management of the situation
  • There was no formalised mechanism for instigating paediatric morbidity and mortality reviews across children’s services. This was despite there being recognition of the importance of mortality reviews within a serious incident investigation report from relating to an incident in 2014.
  • There existed a feeling of low morale within the nursing workforce, in part compounded by a sense of lack of future direction of paediatric in-patient services at Pilgrim Hospital. Whilst senior leaders reported actions such as “Sending virtual hugs” to staff through emails and letters explaining that roles would be secured in the long term, this had had little impact on front-line staff.
  • Staff reported they had not been fully engaged with the discussions regarding the future of children’s services at Pilgrim Hospital.
  • There was limited capacity amongst the medical workforce to conduct audit activity to demonstrate staff were consistently applying evidence-based care.
  • Care and treatment was not always delivered in line with evidence based practice. A number of care bundles had not been updated to reflect changes to guidance. Examples included the management of the febrile child.

However:

  • All areas of the clinical setting were visibly clean. Staff demonstrated good adherence to hand hygiene practices, including washing their hands and using antibacterial hand gel at appropriate intervals. We also saw appropriate use of personal protective equipment (PPE) such as disposable gloves and aprons, which were readily available in the clinical areas.
  • We observed some good examples of where various health professionals worked together to ensure appropriate delivery of care for children and young people.
  • Patient outcomes were mostly in line with the England averages.
  • Parents we spoke with were complimentary about the care and treatment their child had received.
  • We observed staff from different clinical settings, including radiology, speaking to children, using age appropriate language. Staff adapted their body language, for example, bending down to make eye contact with the child; this demonstrated an understanding of the needs of the child and is consistent with best practice.
  • Nursing staff were observed supporting parents and children by providing information and advice which was both age appropriate and in a language which was easy to understand and not complicated with medical terminology. Staff took the time to speak with families to explain procedures before they commenced.

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.