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Lister Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 18 December 2019

Our rating of services stayed the same. We rated it them as requires improvement because:

  • We rated safe, responsive and well-led as requires improvement, effective and caring were rated as good.
  • We rated six of the services we inspected as requires improvement overall.
  • The trust had taken action to address significant concerns highlighted at our previous inspection; however, these were yet to be embedded across the trust.

However,

  • The overall rating for surgery, urgent and emergency care services and children and young people’s services had improved.
Inspection areas

Safe

Requires improvement

Updated 18 December 2019

Effective

Good

Updated 18 December 2019

Caring

Good

Updated 18 December 2019

Responsive

Requires improvement

Updated 18 December 2019

Well-led

Requires improvement

Updated 18 December 2019

Checks on specific services

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.

Services for children & young people

Good

Updated 18 December 2019

Our rating of this service improved. We rated it as good because:

  • The service provided mandatory training in key skills to all staff and made sure most staff completed it.
  • 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 they knew how to apply it.
  • The service provided care and treatment based on national guidance and best practice. Managers checked to make sure staff followed guidance. Staff protected the rights of patients subject to the Mental Health Act 1983.
  • Staff monitored the effectiveness of care and treatment. They used the findings to make improvements and achieved good outcomes for patients.
  • Staff treated children, young people and their families with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.
  • The service was inclusive and took account of children, young people and their families individual needs and preferences. Staff made reasonable adjustments to help patients access services. They coordinated care with other services and providers.
  • Leaders had the skills and abilities to run the service. They understood and managed the priorities and issues the service faced. They were visible and approachable in the service for patients and staff. They supported staff to develop their skills and take on more senior roles.
  • Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. The service promoted equality and diversity in daily work, and provided opportunities for career development. The service had an open culture where patients, their families and staff could raise concerns without fear.

However,

  • The service did not always use systems and processes to safely prescribe, administer, record and store medicines.

Critical care

Good

Updated 18 December 2019

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

  • The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well.
  • The service controlled infection risk well.
  • Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. Safety incidents were managed well and learned lessons were learnt from them. Staff collected safety information and used it to improve the service.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it.
  • Managers monitored the effectiveness of the service and made sure staff were competent.
  • Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
  • Staff consistently treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could generally access the service when they needed it and did not have to wait too long for treatment.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills.
  • Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care.
  • Staff were clear about their roles and accountabilities.
  • The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

End of life care

Requires improvement

Updated 18 December 2019

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

  • Not all computer systems were available to staff which meant there was an increased risk some patient information could be missed. Patient safety incidents were not managed well. Not all incidents were reported when required and the cascading of learning from incidents was not consistent.
  • Not all audits were completed in accordance with the internal audit programme. Performance data was not captured in one place and not all staff were aware of their ward/specialty performance, or areas for improvement. Not all staff had the skills and experience to meet the needs of patients. The delivery of end of life care training across the hospital was inconsistent.
  • It was not known if waiting times from referral to achievement of preferred place of care and death were in line with good practice.
  • Governance processes did not support consistent learning from the performance of the service. Although there was some discussion of incidents and risks in meetings, such as the end of life care steering group, information was sometimes missing, and escalation of issues was unclear. Systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected were not effective. Risks to the service were not always identified or progressed.

However,

  • The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well.
  • Staff provided evidence based care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Staff worked well together for the benefit of patients, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback.

Surgery

Requires improvement

Updated 18 December 2019

Our rating of this service improved. We rated it as requires improvement because:

  • We found that there had been some improvements in some areas since our last inspection. Responsive and well-led improved from inadequate to requires improvement and effective improved from requires improvement to good. However, safe remained as inadequate.
  • The service did not have enough medical staff to care for patients and keep them safe. While staff had training in key skills, the service did not always ensure everyone completed them. Controlled infections risks were not managed well with staff not using equipment and control measures to protect patients, themselves and others from infection. The design, maintenance and use of facilities, premises and equipment did not always keep people safe. Records were not always stored securely. The service did not manage the administration, storage and recording of medicines well. Staff did not always escalate the recorded temperature of stored medicines to maintain their safety. 
  • While leaders operated effective governance processes throughout the service it did not always use the systems to manage performance to improve the quality of its services. Outcomes with mitigating actions were not always completed to reduce or increase risk. 

 However,

  • Staff understood how to protect patients from abuse. Staff assessed risks to patients and acted upon patients at risk of deterioration. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.  
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week. 
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers. 
  • Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. staff were clear about their role and responsibilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services.  

Urgent and emergency services

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.

Outpatients

Good

Updated 18 December 2019

This is the first time we have inspected outpatients separately from diagnostic imaging so we cannot compare previous ratings. We rated it as good because:

  • The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff mostly assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

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.
Other CQC inspections of services

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