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Grantham and District Hospital Good

Reports


Inspection carried out on 18 and 19 October 2016

During an inspection to make sure that the improvements required had been made

The United Lincolnshire Hospitals NHS Trust has three main hospitals and provides a range of hospital-based medical, surgical, paediatric, obstetric and gynaecological services to the 700,000 people of Lincolnshire. The trust employs 7,500 staff

We inspected Grantham Hospital between the 18 and 19 October 2016. We did not carry out an unannounced inspection to this hospital.

We inspected Urgent and Emergency care at Grantham Hospital; we did not inspect any of the other core services that were offered at this hospital.

We rated the urgent and Emergency Care service overall as Good, with safety requiring improvement.

Our key findings were as follows:

Safe

  • There was not a robust system in place for checking availability of life saving equipment.
  • We found staff had not checked resuscitation equipment in line with trust policy. Several single-use items in the paediatric resuscitation trolley were out of date.
  • There were not sufficient numbers of children’s nurses in the department and four out a possible 20 (20%) adult nurses had completed paediatric competencies
  • The environment in the department was visibly aged; we saw exposed plaster in a number of areas for example in the children’s cubicle and dirty utility room.
  • Nurses and doctors told us the department was not big enough for the number of patients now accessing the department, one nurse said they had “outgrown” the department. We saw doctors bringing patients into the department to cubicles, which were already in use. There was no dedicated receiving area for patients arriving by ambulance. Staff allocated ambulance stretchers to the corridor until a cubicle was available. There was a risk to safety as it would be difficult to evacuate the area in an emergency or to assess and treat a patient who became unwell.
  • There were insufficient numbers of nurses and doctors trained in paediatric resuscitation.
  • We saw effective and reliable systems and processes in place for medicines management, patient records and assessing and responding to patient risk.
  • We saw an effective system in place to ensure patients received appropriate initial assessment by appropriately qualified clinical staff within 15 minutes of arrival to the emergency department (ED) in line with best practice.
  • Emergency preparedness plans were in place and staff knew of these.
  • Openness and transparency about safety was encouraged.
  • When staff reported incidents, these were investigated and learning was shared.
  • Staff gave sufficient priority to safeguarding vulnerable adults and children.
  • The environment posed a risk to patients’ privacy and dignity. There were no “in use” signs on treatment room doors, the surgical procedures room was not closed off from a storage area and adjacent resuscitation room and staff did not always seek permission to enter closed cubicle curtains.
  • It was not always possible to maintain patients’ confidentiality due to the position of the waiting room and the glass partition at the reception desk.

Effective

  • Care and treatment was mostly planned in line with current evidence based guidance, standards and best practice. Patient needs were mostly assessed throughout their care pathway in line with National Institute of Health and Care Excellence (NICE) quality standards and Royal College of Emergency Medicine (RCEM) guidelines.
  • Information about patients’ care and treatment, and their outcomes was routinely collected and monitored. This information was used to improve patient care.
  • Staff could access information they needed to assess, plan and deliver care to people in a timely way.
  • Staff were supported to deliver effective care and treatment through meaningful and timely supervision and appraisal.
  • Staff demonstrated understanding of the issues around consent and capacity for adults and children attending the department.

  • The department did not audit the number of patients who were recalled to the department with a missed fracture.

Caring

  • Patients were treated with dignity, respect and kindness during all interactions with staff.
  • Staff helped people and those close to them cope emotionally with their care and treatment.
  • Staff respected patients’ rights to make choices about their care.
  • We saw staff providing specialist support to patients and those close to them in relation to their psychological needs.
  • The results of the CQC A&E Survey (2014) showed the trust scored ‘about the same’ as other trusts for most questions.

  • The environment posed a risk to patients’ privacy and dignity. There were no “in use” signs on treatment room doors, the surgical procedures room was not closed off from a storage area and adjacent resuscitation room. Staff did not always seek permission to enter closed cubicle curtains.
  • It was not always possible to maintain patients’ confidentiality due to the position of the waiting room and the glass partition at the reception desk.

Responsive

  • Waiting times and delays were minimal and managed appropriately.
  • Care and treatment was coordinated with other services and providers.
  • There were systems in place to support vulnerable patients.
  • There were arrangements in place to avoid unnecessary admissions to the hospital.
  • Complaints about the service were shared with staff to aid learning.
  • Patients could not always access the right care at the right time especially those with urgent care needs.

Well led

  • There was an effective governance framework in place. Quality, risks and performance issues for the department were monitored through monthly clinical governance meetings and there was a good feedback loop.
  • Department leaders had the experience and capability to lead the services and were committed. They prioritised safe, high quality and compassionate care.
  • Nursing and medical staff said the department manager, matron, interim head of nursing and consultants were approachable, visible and provided them with good support.
  • We saw effective team working across the department and an obvious mutual respect amongst staff.
  • Morale in the department was mixed; some staff described the overnight closure as worrying and wondered if the department would ever re-open overnight. However, some said they liked it as there were more staff on duty in the day. Consultants said morale was low; they felt that they were unable to provide the service they wanted to the local population of Grantham.
  • The risks and issues described by some leaders did not correspond to those that were currently on the department risk register.

We saw several areas of outstanding practice including:

  • The department inputted hourly data into an ED specific risk tool. The tool gave an “at a glance” look at the number of patients in ED, time to triage and first assessment, number of patients in resuscitation room, number of ambulance crews waiting and the longest ambulance crew wait. This gave a focus across the trust on where pressure was building and there were local actions for easing pressure.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • The trust must take action to ensure that the environment in the emergency department is fit for purpose
  • The trust must take action to ensure staff have the appropriate qualifications, competence, skills and experience, in excess of paediatric life support, to care for and treat children safely in the emergency department.
  • The trust must ensure there are sufficient numbers of medical and nursing staff working in the emergency department who have up to date and appropriate adult and children resuscitation qualifications.

The trust should:

  • The trust should take action to ensure there are effective and consistent systems for learning from deaths to be shared across the emergency department.
  • The trust should ensure there is a robust system in place for checking safety and suitability of life saving equipment in the emergency department.
  • The trust should ensure ligature cutters are immediately available in the emergency department.
  • The trust should ensure there is a protocol in place for management and manipulation of fractures.
  • The trust should review the process for patients presenting to the ED reception at Grantham to maintain patient’s privacy and dignity.
  • The trust should ensure the emergency department risk register is reflective of the risks identified by senior leaders.
  • The trust should ensure there is a hearing loop system in the emergency department at Grantham.
  • The trust should ensure there are adequate processes in place to ensure handovers between the ambulance and the emergency department take place within 15 minutes with no patients waiting more than 30 minutes.
  • The trust should consider the process in place for children awaiting triage in order to meet the 2012 Intercollegiate Committee Standards for Children and Young People in Emergency Care Settings.
  • The trust should consider how the emergency department can comply with the accessible standard for information.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 30 April 2014; Focused review 4 February 2015

During an inspection to make sure that the improvements required had been made

The inspection of Grantham and District Hospital was carried out on 30 April 2014 as part of the wider inspection of United Lincolnshire Hospitals NHS Trust. The trust was chosen for inspection because it was an example of a high-risk trust. In 2013, the Keogh Mortality Review found significant concerns, and the trust was placed in ‘special measures’ as a result. We returned in February 2015 and inspected only those key questions where the service had been rated as requiring improvement or inadequate. We did not undertake a full comprehensive inspection on 2 February 2105.

In 2014 the hospital was rated as ‘requires improvement’ overall. Core services for accident and emergency (A&E) and medical care were found overall to require improvement. When we returned in 2015, we saw that significant improvements had been implemented, and that all services were rated as good.

Our key findings were as follows:

  • There was significant improvement in clinical staff engagement, with senior clinicians sitting on the Clinical Executive Committee making decisions, and reporting directly to the trust board.
  • There was an increase in the numbers of consultants and paediatric staff in A&E.
  • Completion of patient records in surgery had improved.
  • The service to paediatric patients attending the A&E department had improved, through recruitment of nursing staff and training of existing staff.
  • The time taken for patients to be handed over from ambulance crews to the A&E department was in excess of targets set.
  • The hospital had improved signage to meet the needs of the large Eastern European population in the county.
  • There was an adequate supply of electronic profiling beds and other equipment in the Critical Care Unit.
  • Staff throughout the hospital were observed to be kind, caring and compassionate.
  • The hospital was clean, and hand-washing facilities and alcohol gel were available in all areas. Staff used gloves and aprons when providing care to patients. The infection control team were holding a hand-washing awareness session in the corridors. The infection control team were very enthusiastic.
  • Patients were supported to have appropriate nutrition and hydration in most areas of the hospital.

We saw several areas of good practice including:

  • The A&E department had a robust system for reporting incidents, known as IR1s. These were discussed and staff had changed their practices as a result of them.
  • There was a designated and suitably decorated cubicle for children in A&E.
  • Patients stated that they were cared for with compassion, and were very supportive of staff.
  • Staff were using an assessment tool for pain, specifically designed for patients with dementia, where this was applicable.

However, there were also areas of poorer practice where the trust needs to make improvements:

The trust should:

  • Review arrangements for the provision of medications and transport on discharge.

Following this focused inspection and in light of the significant improvements made by the trust I have recommended that the trust is removed from special measures.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 30 April 2014

During a routine inspection

The inspection of Grantham and District Hospital was carried out on 30 April 2014 as part of the wider inspection of United Lincolnshire Hospitals NHS Trust. The trust was chosen for inspection because it was an example of a high-risk trust. In 2013, the Keogh Mortality Review found significant concerns, and the trust was placed in ‘special measures’ as a result. We returned in February 2015 and inspected only those key questions where the service had been rated as requiring improvement or inadequate. We did not undertake a full comprehensive inspection on 2 February 2105.

In 2014 the hospital was rated as ‘requires improvement’ overall. Core services for accident and emergency (A&E) and medical care were found overall to require improvement. When we returned in 2015, we saw that significant improvements had been implemented, and that all services were rated as good.

Our key findings were as follows:

  • There was significant improvement in clinical staff engagement, with senior clinicians sitting on the Clinical Executive Committee making decisions, and reporting directly to the trust board.
  • There was an increase in the numbers of consultants and paediatric staff in A&E.
  • Completion of patient records in surgery had improved.
  • The service to paediatric patients attending the A&E department had improved, through recruitment of nursing staff and training of existing staff.
  • The time taken for patients to be handed over from ambulance crews to the A&E department was in excess of targets set.
  • The hospital had improved signage to meet the needs of the large Eastern European population in the county.
  • There was an adequate supply of electronic profiling beds and other equipment in the Critical Care Unit.
  • Staff throughout the hospital were observed to be kind, caring and compassionate.
  • The hospital was clean, and hand-washing facilities and alcohol gel were available in all areas. Staff used gloves and aprons when providing care to patients. The infection control team were holding a hand-washing awareness session in the corridors. The infection control team were very enthusiastic.
  • Patients were supported to have appropriate nutrition and hydration in most areas of the hospital.

We saw several areas of good practice including:

  • The A&E department had a robust system for reporting incidents, known as IR1s. These were discussed and staff had changed their practices as a result of them.
  • There was a designated and suitably decorated cubicle for children in A&E.
  • Patients stated that they were cared for with compassion, and were very supportive of staff.
  • Staff were using an assessment tool for pain, specifically designed for patients with dementia, where this was applicable.

However, there were also areas of poorer practice where the trust needs to make improvements:

The trust should:

  • Review arrangements for the provision of medications and transport on discharge.

Following this focused inspection and in light of the significant improvements made by the trust I have recommended that the trust is removed from special measures.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 24, 25 February 2014

During a routine inspection

Patients told us they were cared for and their treatment was given to them when required. They told us staff spoke with them in a language they understood. One patient said, "I feel very much so cared for. The room is clean and tidy. I get my medicine regularly."

Patients and relatives were included in decisions about end of life care. The majority of DNACPR forms had been completed correctly, but the staff recognised there was some work to be completed in some areas. Further training was underway for staff to refresh themselves about the Mental Capacity Act (2005).

The care records of patients gave details of when they had been approached about their care needs and who had discussed this with them. Where specific treatment had taken place the relevant staff member had recorded clear details about the event and what was required to help the patient further.

Patients told us their care and treatment had not been compromised because of the staffing levels. They told us they could approach staff and had confidence in the staff to do their job. One patient said, "We all think we should have more attention, but the staff are very busy."

Since our last visit staff had received appraisals to ensure they were capable of doing their jobs and looking after patients.

Patients on the day ward and outpatients were more aware of the complaints process than those on the wards.

Inspection carried out on 12, 13 February 2013

During a routine inspection

As well as inspectors from the Care Quality Commission we also took a pharmacy inspector and a theatre specialist.

During the visits we went to five wards, the theatre suites, the accident and emergency department, the pharmacy department, the critical care unit and the day care unit. We spoke with patients, staff and senior managers as well as relatives. We also looked at some hospital records.

Patients’ privacy and dignity was respected and they felt involved in their care. One patient told us, “The curtains are always drawn if a doctor wants to examine me.”

Patients were complimentary of the care they received and about how medicines were managed. However, one patient told us the administration of their intra-venous antibiotic was delayed by two hours.

Doctors and nurses raised concerns about staffing levels in wards and departments.

All the patients we spoke with told us of their confidence in the staff. We had concerns that not all staff had received appraisals and at times junior doctors did not feel they had the appropriate support.

Records were kept securely when not in use. Some documentation was not always completed.

Inspection carried out on 21 March 2012

During a themed inspection looking at Termination of Pregnancy Services

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

Inspection carried out on 23 March 2011

During a themed inspection looking at Dignity and Nutrition

In March 2011, we visited two medical wards at the hospital and spoke with many patients. During our time on the wards we observed interactions between staff and patients and saw that staff were behaving in a way that was respectful to people. All patients told us that they had been treated with dignity and respect and many patients were very complimentary about the care they had received. For example, one person said, “the staff are so caring, they look after everyone extremely well in here.”

Patients told us that their needs were always met by the staff. Without exception all of the patients and relatives that we talked to were very happy with their care. For example, one patient said “you can’t fault anything.” Another said “it’s like a holiday home here, we are treated so well.” Patients also said that they felt the staff listened to them. We observed all patients had access to their call bell and these were not left ringing.

Patients told us that meal times were very clam and the food was always warm enough and they always got the help they needed to eat their meal. The majority of the patients said they enjoyed the food. We saw staff encouraging people to eat their meal but were respectful of patient’s wishes if they did not want to eat. We observed one patient not wanting to eat and heard the staff offer them of a pudding instead as they knew they preferred puddings.

Throughout the visits to the wards we observed patients had access to drinks and they were placed within reach. Hot drinks were served regularly and we heard one patient asking for a cup of tea outside of the drinks round and saw that the healthcare support worker went to fetch them one.