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Lister Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 17 July 2018

A summary of services at this hospital appears in the Overall summary section at the start of this report.

Inspection areas

Safe

Requires improvement

Updated 17 July 2018

Effective

Requires improvement

Updated 17 July 2018

Caring

Good

Updated 17 July 2018

Responsive

Requires improvement

Updated 17 July 2018

Well-led

Requires improvement

Updated 17 July 2018

Checks on specific services

Outpatients and diagnostic imaging

Good

Updated 5 April 2016

Overall, we rated the service as good, with a rating of good for safety, caring, responsiveness and for being well led. We inspect but do not rate the effectiveness of outpatient services currently.

Staff reported incidents appropriately, incidents were investigated, shared, and lessons learned.

Infection control processes had been followed. The environment was visibly clean and well maintained. Hand-washing facilities and hand gels for patients and staff were available in all clinical areas.

Medicines were stored and handled safely. Diagnostic imaging equipment and staff working practices were safe and well managed.

Medical records were stored centrally off-site and were generally available for outpatient clinics. For those cases when notes were not available, staff prepared a temporary file for the patient that included correspondence and diagnostic test results so that their appointment could go ahead.

Nurse staffing levels were appropriate with minimal vacancies. Staff in all departments were aware of the actions they should take in the case of a major incident

Patients’ needs were assessed and their care and treatment was delivered following local and national guidance for best practice. Staff generally had the complete information they needed before providing care and treatment but in a minority of cases, records were not always available in time for clinics.

Staff were suitably qualified and skilled to carry out their roles effectively and in line with best practice. Staff felt supported to deliver care and treatment to an appropriate standard, including having relevant training and appraisal. Consent was obtained before care and treatment was given.

During the inspection, we saw and were told by patients, that the staff working in the outpatient and diagnostic imaging departments were kind, caring and compassionate at every stage of their treatment. Patients we spoke with during our inspection were positive about the way they were treated.

We found that outpatient and diagnostic services were generally responsive to the needs of patients who used the services. Waiting times were within acceptable timescales. Clinic cancellations were below 2%.

Patients were able to be seen quickly for urgent appointments if required. New appointments were rarely cancelled but review appointments were often changed.

There were systems to ensure that services were able to meet the individual needs, for example, for people living with dementia. There were also systems to record concerns and complaints raised within the department, review these and take action to improve patients’ experience.

Staff were familiar with the trust wide vision and values and felt part of the trust as a whole. Outpatient staff told us that whilst they felt supported by their immediate line managers and that the senior management team were visible within the department.

There were effective systems for identifying and managing the risks associated with outpatient appointments at the team, directorate or organisation levels. For example, information was consistently collected on waiting times, or how long patients waited for follow up appointments compared to recommended follow up times.

Regular governance meetings were held and staff felt updated and involved in the outcomes of these meetings. There was a strong culture of team working across the areas we visited.

Maternity

Good

Updated 17 July 2018

We previously inspected maternity jointly with gynaecology so we cannot compare our new ratings directly with previous ratings. We rated this service as good overall because:

  • Staff cared for patients with compassion, kindness, dignity and respect. Women felt involved in their care and were given an informed choice of where to give birth. Actions were taken to improve service provision in response to feedback and complaints received.
  • Staff understood their responsibilities to raise concerns and report patient safety incidents. There was an effective governance and risk management framework in place to ensure incidents were reviewed and investigated. Learning from incidents was shared with staff and changes were made to the delivery of care because of lessons learned.
  • Women’s care and treatment was planned and delivered in line with current evidence-based guidance. National and local audits were carried out and actions were taken to improve care and treatment when needed. Patient outcomes were generally in line with national averages.
  • Service provision met the needs of local people. They worked closely with commissioners, clinical networks and service users to plan and improve the delivery of care and treatment.
  • Leadership was strong, supportive and visible. The leadership team understood the challenges to service provision and actions needed to address them. There was a positive culture, which was focused on improving patient outcomes and experience. Staff were committed and proud to work at the trust.
  • The service had a vision of what it wanted to achieve and clear objectives to ensure the vision was met.

However,

  • Medical staff compliance with mandatory, maternity specific and safeguarding adults and children training was below the trust target.
  • We found swab and needle counts, carbon monoxide testing and peer reviews of cardiotocography (CTG) traces were not always carried out in line with trust policies and national recommendations.
  • Staffing levels were often lower than planned and the trust relied on bank and agency staff. However, staffing levels were regularly reviewed and women generally received one-to-one care in labour.
  • Perinatal mortality and morbidity meetings were not formally minuted and there was little evidence of the learning from them.
  • Some staff did not have up-to-date competency in CTG assessment.
  • Complaints were not always dealt with in a timely manner.
  • There were inconsistencies in the monitoring of controlled medicines and medicine storage temperatures.
  • Sharps containers did not have temporary closures in place.

Maternity and gynaecology

Requires improvement

Updated 5 April 2016

Maternity and gynaecology services required improvement for safety and responsiveness but were good for effective, caring and for well led.

We found that incidents were not always reported and there were delays in investigating those that were reported. Investigations were not always completed but there was good evidence of shared learning where full investigations had taken place.

We observed most of the service areas to be visibly clean during the inspection.

Equipment was regularly checked and maintained, although we identified some equipment which had not had the required checks performed.

There were good medicines’ management arrangements in place, although the temperature for one of the fridges in the maternity unit was higher than expected and this had not been escalated.

We were told that staffing arrangements within gynaecology were suitable to meet the needs of patients and that medical staffing for obstetrics and gynaecology worked well most of the time.

Some of the midwives we spoke with told us that the unit could become stretched and that staff did not always have time to take their break or provided the amount of time with each woman as required. We saw that most women in labour received 1:1 care. There was an escalation process in place which outlined action to be taken in the event of high levels of acuity and/or staffing shortages. Triage processes were in place but were not always consistent.

There was an audit plan in place to assess and monitor national guidelines as well as progress made with implementation of action plans since the previous audit.

Pain relief was provided and outcomes reported for women were positive, although we noted some key data had not been reported on and some key targets were not being met, for example the 62 day cancer target. Not all staff had received an appraisal or completed their mandatory training and the trust’s target had not been met.

The wards and units provided a caring environment for women and feedback was largely positive.

There were arrangements in place to meet patients’ individual needs, although the bereavement arrangements were not suitable and women also shared a waiting room for gynaecology and maternity appointments which was not sensitive to the reasons women attended their appointment.

Governance arrangements were good with a clearly defined strategy and governance structure, although meeting minutes did not always provide detailed discussion. 

Medical care (including older people’s care)

Requires improvement

Updated 17 July 2018

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

  • Risks to people who use the service were not consistently assessed and hence patient safety was not always monitored and maintained. There were clear and comprehensive risk assessment tools available but they were not always fully completed for all patients.
  • The service did not always have enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment.
  • Staff did not always keep appropriate records of patients’ care and treatment. Records were clear, but not always comprehensively completed or up-to-date.
  • The service provided mandatory training in key skills to all staff but did not always make sure everyone completed it.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. However, not all staff had training on how to recognise and report abuse.
  • Although the service generally had suitable premises and equipment, there was a backlog of routine maintenance issues which had not been addressed.
  • The service did not use a systematic approach to continually improving the quality of its services and safeguarding high standards of care by creating an environment in which excellence in clinical care would flourish.
  • The service had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. However, the division’s mandatory training rates were below the trust’s target. This had been the subject of a requirement notice at the last inspection and there had been little improvement.

However,

  • The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.
  • All staff worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
  • Feedback from patients confirmed that staff treated them well and with kindness.
  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with all staff.
  • The service had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care.
  • Managers across the division promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
  • The service engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively.

Urgent and emergency services (A&E)

Good

Updated 17 July 2018

  • The service provided mandatory training in key skills to all staff and made sure everyone completed it. Nursing staff’s compliance was an improvement since the last inspection in 2016.
  • The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment.
  • The service controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection.
  • The environment and equipment were suitable and detailed checks were carried out of resuscitation equipment. There was a compliant mental health assessment room, which had been redesigned following the last inspection.
  • Staff responded appropriately and identified changing risks to people who used the service. Risks to patients were assessed and their safety monitored and managed so they were supported to stay safe. The triage system used was an improvement from the last inspection in 2016.
  • The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable and to provide the right care and treatment for the majority of shifts. However, there were shifts which were short and needed the use of bank and agency.
  • Staff kept appropriate records of patients’ care and treatment. Records were clear, up-to-date and available to all staff providing care.
  • The service prescribed, gave, recorded and stored medicines in accordance with best practice. Patients received the right medication at the right dose at the right time.
  • The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness.
  • Staff gave patients enough food and drink to meet their needs and improve their health.
  • Patients pain was assessed and managed using pain assessment tools. Assessment of pain in patients with difficulties communicating was assessed using a specific pain management tool and managed appropriately.
  • The service monitored the effectiveness of care and treatment and used the findings to improve them.
  • The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support. Although this had only been carried out for 74% of the nursing staff.
  • Staff worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
  • Staff provided emotional support to patients to minimise their distress.
  • Staff involved patients and those close to them in decisions about their care and treatment.
  • The service planned and provided services in a way that met the needs of local people.
  • The service took account of patients’ individual needs.
  • People could access the service when they needed it.
  • There was a specific team for the care and treatment of the frail older patient. This team responded efficiently to referrals and impacted positively on patient flow.
  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with all staff.
  • The service had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care.
  • Different directorates managed urgent and emergency care services for adults and children and each had different operational and clinical leads. However, they worked closely together and we saw evidence of this during our inspection.
  • The service had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff and key groups representing the local community.
  • Managers across the service promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
  • The service used a systematic approach to continually improve the quality of its services and safeguarding high standards of care by creating an environment in which excellence in clinical care would flourish.
  • The service had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.
  • The service collected, analysed, managed and used information well to support all its activities, using secure electronic systems with security safeguards.
  • The service engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively.
  • The service was committed to improving services by learning from when things go well and when they go wrong, promoting training, research and innovation.

However,

  • The service provided training in key skills to all staff and provided guidance to ensure everyone completed it. There was variable compliance for mandatory and safeguarding training for medical staff. However, when we spoke with staff, all knew the processes and policies in place to protect their patients from abuse and worked well with other agencies to do so.
  • The department did not have 16 hours a day, seven days a week consultant cover in line with RCEM guidance.
  • The ED measured their performance against the RCEM national clinical audits. However, they did not always meet the standards in line with the England average.
  • Nursing staff’s compliance for appraisals was 72%. However, the matron had developed a new way of conducting staff appraisals to improve compliance.
  • Nursing staff’s compliance with adult immediate life support was only at 73%. However, in the ED, doctors were always present.
  • The service did not meet the 95% national standard for four hour waits between January 2017 to December 2017. However, this target was not met by the majority of EDs nationally.

Surgery

Inadequate

Updated 17 July 2018

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

  • The service provided mandatory training in key skills to all staff. There were some areas of poor compliance with mandatory training, including fire training, basic life support and information governance. We also found theatre staff did not have the appropriate level of Advanced life support training (ALS).
  • The service did not control infection risk well in all areas. Staff did not always keep themselves and equipment clean, although some control measures were in place to prevent the spread of infection.
  • Most areas did not have enough staff with the right qualifications, skills, training, and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment.
  • Records of patients’ care and treatment were not always completed appropriately. We found that some records were not always stored securely and that patient confidentiality was not always maintained.
  • The service did not always provide care and treatment based on national guidance and evidence of its effectiveness. Managers did not always check to make sure staff followed guidance. Some audits were not completed and results were not always followed up. For example WHO audits were only carried out retrospectively.
  • The service monitored the effectiveness of care and treatment but did not always use the findings to improve them. Outcomes for patients were variable with the trust performing better than the national average for some indicators, for example risk of readmission after planned urology surgery, but worse for others. The risk of readmission following elective surgery was worse than the national average, and the risk of readmission following unplanned plastic surgery was much worse than the national average. Action plans to improve outcomes were not embedded across all specialities provided by the service.
  • Patients could not always access the service when they needed it. Waiting times for treatment were not in line with good practice.
  • The trust had managers at some levels with the right skills and abilities to run a service providing high-quality sustainable care. However, not all leaders had the necessary experience, capability, or capacity to lead the service effectively. In addition, many of the senior nursing staff had dual roles which distracted them.
  • Not all managers across the service promoted a positive culture that supported and valued staff, and created a sense of common purpose based on shared values. Staff satisfaction was mixed and some staff did not feel empowered. Some teams worked in silos and did not work cohesively together.
  • The service did not always demonstrate its commitment to improving services by learning from when things go well and when they go wrong, promoting training, research and innovation. Some of the issues we raised during our last inspection in October 2015 had not been improved. For example, staffing levels, feedback for staff from incidents and learning from serious incidents, cancelled operations and sharing of patient outcomes.

Intensive/critical care

Good

Updated 5 April 2016

Overall, we have judged the critical care services as good.

Safety was a high priority for critical care services. When something went wrong there was an appropriate response including an investigation involving key personnel and actions taken to prevent recurrence. Improvements to safety were made and changes monitored.

Nursing staffing levels were managed so that despite current shortages and use of agency nurses, patients received the appropriate level of care.

Care and treatment was delivered in line with current evidence and they were working towards compliance with National Institute for Health and Clinical Excellence (NICE) guidance for rehabilitation of critically ill patients. Local audits were also undertaken to ensure effective care and treatment.

Medical and nursing staff were qualified and had skills to practice, consistent with core standards for critical care services.

Areas for improvement included ensuring that paper copies of policies and procedures held on the unit were reviewed and up-to-date.

Critical care services were providing good, compassionate care. Patients were unanimously positive about the care they had received. Inspectors saw many kind and caring interactions. All staff maintained the highest regard for patients’ dignity and privacy.

Critical care services were organised to respond to patients’ needs. The service had been designed and planned to meet people’s needs. There were suitable facilities for delivering critical care services particularly in the newer refurbished areas.

There was a low formal complaint rate (one between January and September 2015) and staff took complaints and concerns seriously.

The unit was performing as expected compared to similar units regarding delayed discharges from critical care.

The governance of critical care services did not always support the delivery of high quality person centred care. Arrangements for governance and performance management did not always operate effectively.

There was a limited approach to obtaining the views of people using the services.

The leaders of the unit were strong, motivated, accessible and experienced. The senior nursing team worked well together. However, staff engagement opportunities required improvement due to lack of unit meetings and low nursing staff appraisal rates (32%).

Services for children & young people

Requires improvement

Updated 17 July 2018

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

  • The service provided mandatory training in key skills to all staff but did not make sure everyone completed it. Medical staff mandatory compliance was poor.
  • The service did not always control infection risk well. Staff did not always use control measures to prevent the spread of infection.
  • Potential risks to the service were not always anticipated and planned for in advance. Risks to people who use the service were not always assessed and their safety was not always monitored and maintained. Not all risks identified during the inspection were documented on the service’s risk register for example there was a backlog of discharge letters to be sent
  • The service did not always have enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment.
  • The service did not always prescribe, give and record and store medicines well. Patients did not always receive the right medication at the right dose at the right time.
  • The service did not always manage patient safety incidents well. Staff recognised incidents but did not always report them appropriately. Managers investigated incidents but did not always share lessons learned with the whole team and the wider service. When things went wrong staff apologised and gave patients honest information and suitable support.
  • People could not always access the service when they needed it. Waiting times from treatment met national standards and arrangements to admit, treat and discharge patients were not in line with good practice.

However,

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and knew how to apply it.
  • The service generally had suitable premises and equipment and looked after them well.
  • Staff kept appropriate records of patient’s care and treatment. Records were clear, up to date and available to staff providing care
  • The service used current evidence-based guidance and best practice standards to inform the delivery of care and treatment.
  • The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service
  • Staff worked together as a team for the benefit of patients. Medical staff, nurses and other healthcare professionals supported each other to provide care.
  • Staff cared for patients with compassion. Feedback from patients and parents confirmed that staff treated them well and with kindness
  • The service took account of patient’s individual needs
  • Local management at matron and ward manager level promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values

End of life care

Requires improvement

Updated 5 April 2016

We rated the service as requires improvement overall.

Not all Do Not Attempt Cardiopulmonary resuscitation forms were completed in accordance with trust procedures.

The trust’s DNA CPR form did not ask if the patient had capacity to make and communicate decisions about CPR as recommended by Guidance from the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing. However the DNACPR forms had a problem solving chart (an algorithm) on the reverse of the form that referred to capacity.

There was no documented evidence that staff assessed and recorded patients’ mental capacity in the DNACPR decision-making process.

The organisation did not have all the processes and information to manage current and future performance. The Trust collected information on the preferred place of death for all patients known to the specialist palliative care team. Outcomes were monitored through the East Hertfordshire and North Hertfordshire Specialist Palliative Care MDTs and reported to the Bedfordshire and Hertfordshire Specialist Palliative Care Group. However, the trust did not collect information on the percentage of patients who achieve discharge to their preferred place within 24 hours. Without this information, we were unable to monitor if the trust was able to honour patients’ wishes. Without collecting this information, the trust was unable to assess if they needed to improve on this..

The trust did not meet six of seven organisational standards in the National Care of the Dying Audit (NCDA) 2013/14. They showed a poor performance for care of the dying, continuing education, training and audit and formal feedback processes regarding bereaved relatives/friends views of care delivery.

The trust showed a poor performance for multi-disciplinary recognition that the patient was dying. We saw that the trust had produced an action plan in March 2015 called End of Life Care Strategy to address the shortfalls and issues raised by the NCDA 2013/14. The SPCT monitored and reviewed this on a monthly basis.

Staff did not always have the complete information they needed before providing care and treatment. Systems to manage and share care records and information were uncoordinated. Staff told us medical notes not always available when patients re-admitted.

The trust had a replacement for the Liverpool Care Pathway (LCP): the Individual Care Plan for the dying person (ICP). (The LCP was a UK care pathway that covered palliative care options for patients in the final days or hours of life.

Feedback from patients and those who were close to them who had support from the SPCT, chaplaincy team, mortuary service and bereavement team, were positive about the way staff treated patients. We heard that staff treated patients with dignity, respect and kindness. We observed positive interactions between patients and staff.

Staff delivering end of life care received appropriate training in communication and end of life care.

Oversight and management of risks was not robust.

Other CQC inspections of services

Community & mental health inspection reports for Lister Hospital can be found at East and North Hertfordshire NHS Trust.