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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. You can download this report below.

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We are carrying out checks at Pilgrim Hospital using our new way of inspecting services. We will publish a report when our check is complete.

Details of this locations CQC registration


Here you will find the list of services and areas where we, the Care Quality Commission, authorise and regulate this service to operate. If you think this service is operating services not listed here please contact us

Type of service
  • Community services - Healthcare
  • Hospital
Specialisms/services
  • Services for everyone
Local authority
  • Lincolnshire

Regulated services/activities

CQC register Pilgrim Hospital to carry out the following legally regulated services here:

Maternity and midwifery services

  • Michelle Rhodes is responsible for these services.

Termination of pregnancies

  • Michelle Rhodes is responsible for these services.

Treatment of disease, disorder or injury

  • Michelle Rhodes is responsible for these services.
Condition of this registration relating to carrying out this regulated activity

6. The registered provider must ensure that there is an effective system in place to assess and monitor the ongoing care and treatment to patients whilst in the emergency department. This includes, but is not exclusive to, the monitoring of pain, administration of medicines, tissue viability assessments, nutrition and hydration and early warning scores with regular ongoing monitoring. This applies to the Emergency Department at Pilgrim Hospital.

7. The registered provider must ensure that there are sufficient numbers of suitably qualified staff competent to care for children on duty in the emergency department at all times. In accordance with the ‘Intercollegiate Committee for Standards for Children and Young People in Emergency Care Settings’ document titled, “Standards for Children and Young People in Emergency Care Settings” (2012) which recommends that ‘all clinical staff should have minimum competencies including recognition of the sick or injured child, basic life support skills, the ability to initiate appropriate treatment in accordance with locally agreed protocols’. This applies to the Emergency Department at Pilgrim Hospital.

8. The registered provider will ensure that there are a sufficient number (based on demand) of suitably qualified, skilled and experienced nurses and Healthcare Assistants (HCAs) deployed throughout the emergency department to support the care and treatment of patients. The staffing levels and deployment of staff must be reviewed and adapted as required at regular intervals throughout the day. This applies to the Emergency Department at Pilgrim Hospital.

9. The Registered Provider must ensure that there is an effective system in place for providing an induction to wards and departments where locum, agency and bank staff, including nurses, allied health professionals, healthcare assistants who work at the location of Pilgrim Hospital so that the trust is assured that those staff are suitably competent, skilled and experienced to work in that area. This is to include, but is not exclusive to, ensuring that the staff referred to above are suitably competent, skilled and experienced to use the resuscitation equipment.

10. From 2 March 2018 and on the Friday of each week by 16:00 the Registered Provider must submit a report to the Care Quality Commission which (a) describes the actions taken to ensure that the conditions listed above are complied with and (b) sets out the evidence that demonstrates that those actions are being taken.

1. The registered provider must ensure that there is an effective system in place to undertake an initial assessment all patients who present to the emergency department. The initial assessment processes should be resourced to meet variation in demand, and be delivered by trained clinical staff. This applies specifically to the Emergency Department at Pilgrim Hospital.

2. The registered provider must ensure that there is an effective system to undertaken triage of patients within 15 minutes of arrival. Triage must be a face-to-face encounter and must be undertaken by a registered healthcare professional who is experienced in emergency/urgent care and has received specific triage training.

3. For the purpose of condition one and two, ‘initial assessment’ and ‘triage’ will be undertaken in such a manner as to have regard to the guidance issued by the Royal College of Emergency Medicine titled “Initial assessment of Emergency Department Patients” (February 2017), a copy of which is attached to this notice.

4. The registered provider will ensure that there is an effective escalation process in place for staff in the streaming area at the front door of the Emergency Department, and in the ambulance waiting areas of Pilgrim Hospital, to fast track patients who clinically present as unwell, are unstable, deteriorating or have a recognised early warning trigger scores through to the main department to receive clinical intervention within an appropriate timeframe.

5. The registered provider must operate an effective process to ensure there is a Senior Doctor Assessment, Rapid Assessment and Treatment or Early Senior Assessment process in place for patients brought in by ambulances, and those who are waiting in the corridors and in the ambulances. This clinician (typically, but not exclusively, a senior emergency department doctor) must make decisions about that patient’s care and prioritise their treatment as soon as possible after arrival.

Assessment or medical treatment for persons detained under the 1983 Act

  • Michelle Rhodes is responsible for these services.

Surgical procedures

  • Michelle Rhodes is responsible for these services.
Condition of this registration relating to carrying out this regulated activity

1. The registered provider must ensure that there is an effective system in place to undertake an initial assessment all patients who present to the emergency department. The initial assessment processes should be resourced to meet variation in demand, and be delivered by trained clinical staff. This applies specifically to the Emergency Department at Pilgrim Hospital.

2. The registered provider must ensure that there is an effective system to undertaken triage of patients within 15 minutes of arrival. Triage must be a face-to-face encounter and must be undertaken by a registered healthcare professional who is experienced in emergency/urgent care and has received specific triage training.

3. For the purpose of condition one and two, ‘initial assessment’ and ‘triage’ will be undertaken in such a manner as to have regard to the guidance issued by the Royal College of Emergency Medicine titled “Initial assessment of Emergency Department Patients” (February 2017), a copy of which is attached to this notice.

4. The registered provider will ensure that there is an effective escalation process in place for staff in the streaming area at the front door of the Emergency Department, and in the ambulance waiting areas of Pilgrim Hospital, to fast track patients who clinically present as unwell, are unstable, deteriorating or have a recognised early warning trigger scores through to the main department to receive clinical intervention within an appropriate timeframe.

5. The registered provider must operate an effective process to ensure there is a Senior Doctor Assessment, Rapid Assessment and Treatment or Early Senior Assessment process in place for patients brought in by ambulances, and those who are waiting in the corridors and in the ambulances. This clinician (typically, but not exclusively, a senior emergency department doctor) must make decisions about that patient’s care and prioritise their treatment as soon as possible after arrival.

6. The registered provider must ensure that there is an effective system in place to assess and monitor the ongoing care and treatment to patients whilst in the emergency department. This includes, but is not exclusive to, the monitoring of pain, administration of medicines, tissue viability assessments, nutrition and hydration and early warning scores with regular ongoing monitoring. This applies to the Emergency Department at Pilgrim Hospital.

7. The registered provider must ensure that there are sufficient numbers of suitably qualified staff competent to care for children on duty in the emergency department at all times. In accordance with the ‘Intercollegiate Committee for Standards for Children and Young People in Emergency Care Settings’ document titled, “Standards for Children and Young People in Emergency Care Settings” (2012) which recommends that ‘all clinical staff should have minimum competencies including recognition of the sick or injured child, basic life support skills, the ability to initiate appropriate treatment in accordance with locally agreed protocols’. This applies to the Emergency Department at Pilgrim Hospital

8. The registered provider will ensure that there are a sufficient number (based on demand) of suitably qualified, skilled and experienced nurses and Healthcare Assistants (HCAs) deployed throughout the emergency department to support the care and treatment of patients. The staffing levels and deployment of staff must be reviewed and adapted as required at regular intervals throughout the day. This applies to the Emergency Department at Pilgrim Hospital.

9. The Registered Provider must ensure that there is an effective system in place for providing an induction to wards and departments where locum, agency and bank staff, including nurses, allied health professionals, healthcare assistants who work at the location of Pilgrim Hospital so that the trust is assured that those staff are suitably competent, skilled and experienced to work in that area. This is to include, but is not exclusive to, ensuring that the staff referred to above are suitably competent, skilled and experienced to use the resuscitation equipment.

10. From 2 March 2018 and on the Friday of each week by 16:00 the Registered Provider must submit a report to the Care Quality Commission which (a) describes the actions taken to ensure that the conditions listed above are complied with and (b) sets out the evidence that demonstrates that those actions are being taken.

Diagnostic and screening procedures

  • Michelle Rhodes is responsible for these services.
Condition of this registration relating to carrying out this regulated activity

1. The registered provider must ensure that there is an effective system in place to undertake an initial assessment all patients who present to the emergency department. The initial assessment processes should be resourced to meet variation in demand, and be delivered by trained clinical staff. This applies specifically to the Emergency Department at Pilgrim Hospital.

2. The registered provider must ensure that there is an effective system to undertaken triage of patients within 15 minutes of arrival. Triage must be a face-to-face encounter and must be undertaken by a registered healthcare professional who is experienced in emergency/urgent care and has received specific triage training.

3. For the purpose of condition one and two, ‘initial assessment’ and ‘triage’ will be undertaken in such a manner as to have regard to the guidance issued by the Royal College of Emergency Medicine titled “Initial assessment of Emergency Department Patients” (February 2017), a copy of which is attached to this notice.

4. The registered provider will ensure that there is an effective escalation process in place for staff in the streaming area at the front door of the Emergency Department, and in the ambulance waiting areas of Pilgrim Hospital, to fast track patients who clinically present as unwell, are unstable, deteriorating or have a recognised early warning trigger scores through to the main department to receive clinical intervention within an appropriate timeframe.

5. The registered provider must operate an effective process to ensure there is a Senior Doctor Assessment, Rapid Assessment and Treatment or Early Senior Assessment process in place for patients brought in by ambulances, and those who are waiting in the corridors and in the ambulances. This clinician (typically, but not exclusively, a senior emergency department doctor) must make decisions about that patient’s care and prioritise their treatment as soon as possible after arrival.

6. The registered provider must ensure that there is an effective system in place to assess and monitor the ongoing care and treatment to patients whilst in the emergency department. This includes, but is not exclusive to, the monitoring of pain, administration of medicines, tissue viability assessments, nutrition and hydration and early warning scores with regular ongoing monitoring. This applies to the Emergency Department at Pilgrim Hospital.

7. The registered provider must ensure that there are sufficient numbers of suitably qualified staff competent to care for children on duty in the emergency department at all times. In accordance with the ‘Intercollegiate Committee for Standards for Children and Young People in Emergency Care Settings’ document titled, “Standards for Children and Young People in Emergency Care Settings” (2012) which recommends that ‘all clinical staff should have minimum competencies including recognition of the sick or injured child, basic life support skills, the ability to initiate appropriate treatment in accordance with locally agreed protocols’. This applies to the Emergency Department at Pilgrim Hospital.

8. The registered provider will ensure that there are a sufficient number (based on demand) of suitably qualified, skilled and experienced nurses and Healthcare Assistants (HCAs) deployed throughout the emergency department to support the care and treatment of patients. The staffing levels and deployment of staff must be reviewed and adapted as required at regular intervals throughout the day. This applies to the Emergency Department at Pilgrim Hospital.

9. The Registered Provider must ensure that there is an effective system in place for providing an induction to wards and departments where locum, agency and bank staff, including nurses, allied health professionals, healthcare assistants who work at the location of Pilgrim Hospital so that the trust is assured that those staff are suitably competent, skilled and experienced to work in that area. This is to include, but is not exclusive to, ensuring that the staff referred to above are suitably competent, skilled and experienced to use the resuscitation equipment.

10. From 2 March 2018 and on the Friday of each week by 16:00 the Registered Provider must submit a report to the Care Quality Commission which (a) describes the actions taken to ensure that the conditions listed above are complied with and (b) sets out the evidence that demonstrates that those actions are being taken.