You are here

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.

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

  • Mrs Michelle Rhodes is responsible for these services.

Termination of pregnancies

  • Mrs Michelle Rhodes is responsible for these services.

Treatment of disease, disorder or injury

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

a) The registered provider by 15 July 2019 must implement an effective system to manage patients presenting with possible signs of sepsis and in line with clinical guidelines such as Sepsis: recognition, diagnosis and early management NICE guideline [NG51]: within four weeks the Trust will demonstrate 90% compliance of screening of all children, young people and adults attending the Emergency Departments at Lincoln County

Hospital and Pilgrim Hospital. The registered provider must ensure harm reviews are undertaken for all patients where this has not been achieved

b) The provider must ensure all patients presenting to the Emergency Departments at Lincoln County Hospital and Pilgrim Hospital with signs of sepsis are treated within 60 minutes of the sepsis screen: within 2 weeks the Trust will demonstrate 90% compliance of treatment of the full sepsis six bundle for all children, young people and adults. The registered provider must ensure harm reviews are undertaken for all patients whe

From 5 July 2019 and on the Friday of each week thereafter by 4pm until further notice, the registered provider shall report to the Care Quality Commission confirming:

a) In relation to condition (Sepsis) the action taken to ensure that an effective system and process is implemented including progress on its implementation.

b) In relation to condition (Sepsis), the process and outcome of auditing, monitoring and implementing of these systems.

c) Copies of all audits undertaken, and assurance given to the Board of United Lincolnshire Hospitals NHS Trust that an effective system required by condition (sepsis) are in place.

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.

On the last Friday of each month 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 which remain are complied with and

b) sets out the evidence that demonstrates that those actions are being taken with the exception of the following condition whereby we would expect the Registered Provider to inform us of significant periods of under staffing only, 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.

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.

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.

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.

The registered provider must ensure that it implements an effective system to ensure that all patients who present to the emergency department at Pilgrim Hospital, Boston, commence active treatment within 60 minutes of arrival. i.e. all patients should be seen by a clinical decision maker who can diagnose the problem, decide a plan of care and start or arrange the necessary treatment.

The registered provider must ensure that there are systems in place across the emergency department at Pilgrim Hospital Boston so that patients are assessed and cared for in the area appropriate for their acuity at all times.

The registered provider must ensure that the systems make provision for effective monitoring of the service user�s pathway through the emergency department at Pilgrims Hospital Boston.

The registered provider must ensure there are appropriate systems in place to monitor the condition and risk of deterioration for all patients awaiting admission (e.g. on ambulances or in corridor areas awaiting triage) to the emergency department at Pilgrims Hospital Boston.

The registered provider must ensure that appropriate emergency department escalation procedures are maintained and followed by all staff including at times of peak capacity and demand at Pilgrim Hospital Boston

The registered provider must ensure that at all times, there is sufficient capacity in the emergency department to accommodate all patients at risk of deterioration or who require time critical care and treatment; this must be provided in an appropriate clinical setting.

The registered provider must provide the Care Quality Commission with a report setting out the steps it has taken to implement the systems as required in conditions one to six, by 15:00 on Wednesday 15 January 2020.

For conditions one to seven above, from 17:00 on Wednesday 22 January 2020 and on alternate Wednesday�s thereafter, the registered provider shall report to the Care Quality Commission describing the system in place for effective management of patients through the emergency care pathway at Pilgrim Hospital Boston. The Care Quality Commission requires the trust to provide them with a recognised and appropriate method of analysis, such as statistical process control charting or similar, to demonstrate improvements delivered through the processes required above. Further, the Care Quality Commission requires the trust to provide them from 17:00 on Wednesday 22 January 2020 with:

a. The number of patients not seen and treated by an appropriate clinical decision maker within 60 minutes of arrival to the emergency department; and details of any harm or potential harm arising as a result of the delay and the number of times escalation procedures have had to be used.

b. Results of all mon

The registered provider must ensure the privacy and dignity of patients receiving care and treatment in the emergency department is protected at all times.

Assessment or medical treatment for persons detained under the 1983 Act

  • Mrs Michelle Rhodes is responsible for these services.

Surgical procedures

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

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.

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.

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.

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.

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. Vary to From 6 July 2018 on the last Friday of each month 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 which remain are complied with and (b) sets out the evidence that demonstrates that those actions are being taken with the exception of the following condition whereby we would expect the Registered Provider to inform us of significant periods of under staffing only, 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

Diagnostic and screening procedures

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

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.

On the last Friday of each month 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 which remain are complied with and

b) sets out the evidence that demonstrates that those actions are being taken with the exception of the following condition whereby we would expect the Registered Provider to inform us of significant periods of under staffing only, 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.

a) The registered provider by 15 July 2019 must implement an effective system to manage patients presenting with possible signs of sepsis and in line with clinical guidelines such as Sepsis: recognition, diagnosis and early management NICE guideline [NG51]: within four weeks the Trust will demonstrate 90% compliance of screening of all children, young people and adults attending the Emergency Departments at Lincoln County

Hospital and Pilgrim Hospital. The registered provider must ensure harm reviews are undertaken for all patients where this has not been achieved

b) The provider must ensure all patients presenting to the Emergency Departments at Lincoln County Hospital and Pilgrim Hospital with signs of sepsis are treated within 60 minutes of the sepsis screen: within 2 weeks the Trust will demonstrate 90% compliance of treatment of the full sepsis six bundle for all children, young people and adults. The registered provider must ensure harm reviews are undertaken for all patients whe

From 5 July 2019 and on the Friday of each week thereafter by 4pm until further notice, the registered provider shall report to the Care Quality Commission confirming:

a) In relation to condition (Sepsis) the action taken to ensure that an effective system and process is implemented including progress on its implementation.

b) In relation to condition (Sepsis), the process and outcome of auditing, monitoring and implementing of these systems.

c) Copies of all audits undertaken, and assurance given to the Board of United Lincolnshire Hospitals NHS Trust that an effective system required by condition (sepsis) are in place.

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.

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.

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.