You are here

Lister Hospital Requires improvement

Reports


Other CQC inspections of services

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

Inspection carried out on 17th May 2016

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

Lister Hospital is a 720-bed district general hospital in Stevenage. It offers general and specialist hospital services for people across much of Hertfordshire and south Bedfordshire and provides a full range of medical and surgical specialties.

The Care Quality Commission (CQC) previously carried out a comprehensive inspection on 20 to 23 October 2015, which found that overall, the hospital had a rating of 'requires improvement'.

We carried out an unannounced, focused inspection on 17 May 2016 to review concerns found during our previous comprehensive inspection. The inspection focused on the adult emergency department (ED) and Bluebell ward, part of the children’s and young people’s service. We inspected parts of the five key questions for both services but did not rate them. Whilst we saw that significant improvements had been made since the last inspection, there was, in some areas, further work required to ensure all patients received safe and high quality care and treatment.

Our key findings were as follows:

  • We observed that all staff were caring and compassionate towards patients and visitors within the department.
  • Patients and those close to them felt involved in their care and had all intended treatments and procedures explained to them fully. Parents told us they were fully involved in plans of care for their children and were provided with appropriate information.
  • During the previous inspection, the triage system within the ED was not effective in recognising potential patient safety risks, however, the department had taken significant work to address this and the new process appeared to be efficient and safe at this inspection.
  • There were improvements to hand hygiene and overall cleanliness of the ED.
  • The recording of patients’ allergies had improved.
  • Systems were in place to monitor patients at risk of deterioration in the ED, including regular patient safety rounds.
  • Care records generally reflected the patient care that had occurred whilst a patient was in the ED; nursing records were generally more detailed and documented communications and interactions with patients.
  • The risk assessments we reviewed, including falls and pressure area risk assessments, were generally completed appropriately and reflected patients’ needs.
  • There had been improvements in compliance with information governance and in the protection of patients’ confidential information.
  • At this inspection, the trust was on track with their planned trajectory for compliance for all mandatory training as 81% of ED staff had had planned education days.
  • Staffing levels met patients’ needs at the time of the inspection.
  • Communication and care of patients with additional needs had been developed through additional training.
  • An effective ED development plan was in place to document necessary improvements and current progress against them.
  • The delivery of this development plan was being monitored with key actions which had accountable clinicians to maintain an effective oversight of risks.
  • Within the ED, policies and procedures to support staff had improved to ensure staff understood their responsibilities whilst caring for patients. Departmental risks were being assessed and managed effectively.
  • Whilst attendances remained high, the ED appreciated the importance of developing staff and ensuring they had the appropriate training for their roles, ensuring that staff attended necessary courses and training. Staff engagement had improved within the department.
  • Staff culture and morale within the ED had improved and staff felt valued within their roles even during times of high pressure and demand.
  • Data collection and its use to monitor and improve the service had generally improved within the ED.
  • The care being provided to children with complex care needs, demonstrated learning from incidents had taken place and improvements had been implemented.
  • Staff were using a paediatric early warning score (PEWS) chart appropriately to identify early signs that a child was at risk of deteriorating. The use of PEWS was being monitored through regular audits.
  • Bluebell ward had recently introduced the NHS children and young people’s safety thermometer to measure harm free care and to drive improvements.
  • The ward was visibly clean and staff followed infection prevention and control guidelines in accordance with trust policy. There was the appropriate amount and type of medical equipment on the ward to meet the needs of the patients.
  • Actual nurse staffing met patients’ needs on the day of the inspection. After our previous inspection, nurse staffing levels had increased. However, recruitment was ongoing so there was a reliance on agency and bank staff to maintain the planned rota.
  • Patients and parents told us that pain was regularly assessed and well controlled.
  • There had been an improvement in the number of staff that were trained to care for a child with complex needs.
  • Following our previous inspection, the trust had an improvement plan for children and young people’s services. We found there had generally been progress with improvements, for example, the ward had introduced an acuity tool to plan staffing to meet the dependency of patients.
  • The service’s risk register reflected the key risks highlighted on the improvement plan and was being reviewed and updated regularly.
  • Since February 2016, an educational facilitator had been supporting the ward team, working with the ward manager and focusing on leadership, support and staff engagement.
  • The culture on Bluebell ward had improved and we observed respectful, professional interactions between medical and nursing teams.

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

  • The department was consistently not meeting the 15 minute time to triage target but had systems in place to monitor all patients at risk of deteriorating.
  • The time to initial clinical assessment for patients’ data was not yet being collected but plans were in place to achieve this by the end of October 2016.
  • The ED had not consistently met the four hour treat, transfer or discharge national performance measure since June 2015 but performance was improving.
  • Some leaders felt that the improvements in the ED had had to been made without the full support of other specialties in the hospital.
  • Staff knowledge of duty of candour had not improved since the previous inspection.
  • The ED mental health room was not always used in line with trust policy.
  • The improvement plan for children and young people’s services stated that actions related to equipment on Bluebell Ward were fully implemented. However, some of the equipment had not been maintained correctly. We were not assured that processes had been put in place to ensure that medical equipment was being serviced and therefore safe to use. We escalated this to the trust during the inspection and immediate actions were taken with new monitoring processes set up immediately.
  • There was not always evidence that bank and agency staff had received a local induction to familiarise them with working on Bluebell Ward.
  • There were further improvements required regarding staff training for example; senior trained nurses were required to attended advanced life support courses. In the meantime, appropriately trained staff from the children’s emergency department and assessment units were available to support the ward.
  • A strategy and vision for the children and young people’s service was under development.
  • At the time of the inspection, there was not a non-executive director representing the children and young people’s service on the trust board.

Whilst the areas for improvement identified in the previous inspection remain in place, in addition, the trust should:

  • Seek to improve staff understanding of duty of candour in the adult ED.
  • Ensure that the ED mental health room is always used in line with trust policy.

  • Continue to develop appropriate systems to be able to monitor the time to initial clinical assessment for patients within the department.

  • Ensure effective processes are in place to ensure that medical equipment in storage is correctly maintained and available for use on Bluebell ward.
  • Ensure bank and agency staff working on Bluebell Ward receive an appropriate local induction that is recorded.

  • Ensure staff on Bluebell ward receive appropriate training including advanced life support to provide care for patients with high dependency needs or in clinical emergencies.
  • Ensure there is a non-executive director representing the children and young people’s service on the trust board.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 20 to 23 October 2015

During a routine inspection

Lister hospital is part of East and North Hertfordshire NHS Trust and it is a 720-bed district general hospital in Stevenage. It offers general and specialist hospital services for people across much of Hertfordshire and south Bedfordshire and provides a full range of medical and surgical specialities. General wards are supported by critical care (intensive care and high dependency) and coronary care units, as well as pathology, radiology and other diagnostic services. There are specialist sub-regional services in urology and renal dialysis.

We carried out this inspection as part of our comprehensive inspection programme, which took place during 20 to 23 October 2015. We undertook two unannounced inspections to this hospital on 31 October, and 11 November 2015.

We held listening events in Stevenage and Welwyn Garden City before the inspection, where people shared their views and experiences of services provided by East and North Herts NHS Trust. Some people also shared their experiences by email or telephone. We talked with patients and staff from all the departments and clinic areas. We also reviewed the trust’s performance data and looked at individual care records.

We inspected eight core services, and rated three as good overall being surgery, critical care and outpatients. Four core services were rated as requiring improvement being medical care, maternity and gynaecology, children, young people and families and end of life care. Urgent and emergency services was rated as inadequate.

We rated the Lister Hospital as good for one of the five key questions which we always rate, which was whether the service was caring. We rated the hospital as requiring improvement for safety, effectiveness, responsiveness and for being well led. Overall, we rated the hospital as requiring improvement.

Our key findings were as follows:

  • Staff interactions with patients were positive and showed compassion and empathy.

  • Feedback from patients was generally very positive.

  • The children's emergency department, if rated separately, from the adult department, would have been rated as good.

  • Most environments we observed were visibly clean and most staff followed infection control procedures.

  • Safeguarding systems were in place to ensure vulnerable adults and children were protected from abuse

  • Nurse staffing levels were variable during the days of the inspection, although in almost all areas, patients’ needs were being met.

  • Medical staffing was generally appropriate and there was good emergency cover.

  • Working towards providing a seven day service was evident in most areas.

  • Patients’ needs were generally assessed and their care and treatment was delivered following local and national guidance for best practice.

  • Outcomes for patients were often better than average.

  • Pain assessment and management was effective in most areas.

  • Most patients’ nutritional needs were assessed effectively and met.

  • Most staff had appropriate training to ensure they had the necessary skills and competence to look after patients.

  • Patients generally had access to services seven days a week, and were cared for by a multidisciplinary team working in a co-ordinated way.

  • Staff were suitably qualified and skilled to carry out their roles effectively and in line with best practice.

  • Services were generally responsive to the needs of patients who used the services.

  • 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.

  • We found surgical services were responsive to people’s needs and outcomes for patients were good.

  • In maternity, the service had some good examples of services which provided excellent care beyond that of a typical district general hospital, for example, the foetal medicine service.

  • The play specialist team provided exceptional care and support for children and young people.

  • The children's bereavement services provided empathetic and compassionate care to families.

  • In the end of life care service, feedback from patients and those who were close to them was very positive.

  • In outpatients, waiting times were within acceptable timescales and clinic cancellations were around 2%.

  • There were effective systems for identifying and managing the risks associated with Outpatient appointments at the team, directorate or organisation levels.

  • Generally, there were effective procedures in place for managing complaints.

  • There was a strong culture of local team working across most areas we visited.

We saw several areas of outstanding practice including:

  • The trust’s diabetes team won a prestigious national “Quality in Care Diabetes” award in the best inpatient care initiative category.

  • The trust had developed an outreach team to deliver seven day, proactive ward rounds specifically targeting high-risk patients. This included the delivery of a comprehensive set of interventions which included smoking cessation and structured education programmes.

  • We saw patients with learning disabilities and their relatives receiving high levels of outstanding care.

  • The ophthalmology department had implemented a minor injuries service. Patients could be referred directly from accident and emergency, their GP or opticians to be seen on the same day.

  • The Lister Robotic Urological Fellowship is an accredited and recognised robotic urological training fellowship programme in the UK by the Royal College of Surgeons of England and British Association of Urological Surgeons. This technique is thought to have significantly reduced positive margin rate during robotic prostatectomy and improved patient functional outcome.

  • We saw some examples of excellence within the maternity service. The foetal medicine service run by three consultants as well as a specialist sonographer and screening coordinator is one example; the unit offers some services above the requirements of a typical district general hospital such as invasive procedures and diagnostic tests. The unit has its own counselling room away from the main clinic and continues to offer counselling postnatally.

  • Another example being urogynaecology services, the Lister is expected to become an accredited provider for tertiary care in Hertfordshire.

  • The service also offered management of hyperemesis on the day ward in maternity to minimise admission.

However, there were also areas of poor practice where the trust needs to make improvements. The trust took immediate actions to address areas of concern regarding the emergency department and a medical care ward.

  • Staff did not always report incidents appropriately, and learning from incidents was not always shared effectively.

  • Some of the staff we spoke with did not know what duty of candour meant for them in practice.

  • The triage system within the emergency department was not sufficient to protect patients from harm or allow staff to identify those with the highest acuity. Urgent action was taken to address this following it being brought to the trust’s attention.

  • The emergency department did not consistently meet the four hour target for referral, discharge or admission of patients in the emergency department.

  • Infection control practices were not always followed in the emergency department.

  • In the emergency department, patient records lacked sufficient detail to ensure all aspects of their care were clear.

  • Medicines were not always stored and handled safely.

  • The medical care services required improvement in some aspects of patient safety, such as nursing staffing levels, infection control procedures, medicine management and the documentation within patient records.

  • Some patients were cared for on medical speciality wards, where nursing staff did not always feel they had the appropriate skills to care for non specialist patients. Patients whose condition deteriorated were not always appropriately escalated. This was brought to the attention of the trust and we saw action was taken to ensure harm free care which included the review of all patient records.

  • We found poor medicines’ management within the medical service which was brought to the attention of the trust who took immediate action to address our concerns. This resulted in the review of all medicine management procedures within the service with timely action plans.

  • Issues relating to high vacancies, poor staffing levels and the lack of skills and competencies to care for poorly children, along with the high level of clinical activity on Bluebell Ward were not being addressed in a timely way to ensure children were protected from avoidable harm. Following our inspection, the trust took urgent actions to address this.

  • Mandatory training attendance in some areas was not sufficient to meet the trust’s target, and did not ensure that all staff were trained appropriately.

  • Leaders in some services were not always visible in the department and it was the perception of some staff that they did not feel adequately supported as a result of this.

  • Some nursing staff we spoke lacked an understanding of the Mental Capacity Act (MCA) and how to assess whether a patient had capacity to consent to or decline treatment.

  • Medical records were stored centrally off-site and were not always available for outpatient clinics.

  • The management of risks within some services needed to be more robust and addressed in a timelier manner.

  • Not all services had effective leadership and staff engagement in place.

Importantly, the trust must:

  • Ensure all required records are completed in accordance with trust policy, including assessments, nutritional and hydration charts and observation records.

  • Ensure there are effective governance systems in place to assess, monitor and mitigate the risks relating to the health, safety and welfare of patients including the timely investigation of incidents and sharing any lessons to be learned.

  • Ensure effective systems are in place to ensure that the triage process accurately measures patient need and priority in the emergency department.

  • Ensure that the triage process in maternity operates consistently and effectively in prioritising patients’ needs and that this is monitored.

  • Ensure that all staff in all services complete their mandatory training in line with trust requirements.

In addition the trust should:

  • Ensure that the temperature of all fridges are monitored and where temperatures are consistently outside of the agreed settings that this is escalated and action taken.

  • Ensure staffing levels and competency of staff in all services meet patients’ needs.

  • Ensure that only competent and qualified staff are conducting patient triage in line with guidance in the emergency department.

  • Ensure that risk assessments, including in relation to pressure ulcers and falls, are completed for all patients and regularly reassessed.

  • Regularly monitor and improve infection control practices and all staff follow trust procedures.

  • Ensure that patient information is kept confidential at all times.

  • Ensure that all patient records are accurate to ensure a full chronology of their care has been recorded.

  • Review clinical pathways to ensure they are up to date with relevant guidance.

  • Ensure there are effective mechanisms to feedback lessons learnt from complaints to prevent future similar incidents.

  • Review staff competencies in relation to

    Patient Group Directives (

    PDGs) to ensure staff are competent to administer medications under these.

  • Ensure that all staff understand the level of MCA, DoLS and best interests’ assessment required for their role and how this is delivered.

  • Ensure that defined cleaning schedules and standards are in place to comply with the Department of Health 2014 documents ‘Specification for the planning application, measurement and review cleanliness services in hospitals’.

  • Ensure that patients’ medical records are available at all clinics to prevent delays in appointment or appointments being rescheduled.

  • Review the process of bed allocation for surgical patients to prevent patients’ surgery being cancelled on the day of surgery due to lack of available beds.

  • Ensure that information leaflets and signs are available in other languages and in easy-to-read formats

  • Ensure learning from localised incidents and complaints is shared across all staff groups.

  • Ensure patients always have identity bands in place.

  • Ensure that agency staff receive a timely induction to areas they work.

  • Ensure CCU mortality and morbidity meetings minutes include action plans when needed.

  • Ensure all nursing staff receive annual appraisals in accordance with trust policy.

  • Reduce delays experienced by patients in transferring to a ward bed when they no longer require critical care.

  • Ensure that outpatient appointments for gynaecology and maternity patients are arranged at separate times.

  • Ensure that the vision for maternity is consistent in all documents.

  • Produce a viable strategy for children and young people’s services.

  • Ensure that children and young people have an appropriate child-friendly waiting area in the outpatient clinics.

  • Review the lack of equipment across the C&YP service and a more timely response to procuring equipment when necessary. Where there is a wait for replacement equipment risk assessments should be carried out and documented

  • Review readmission rates for paediatric care.

  • Review the tools used to monitor the deteriorating child.

  • Ensure that care and treatment complies with the mental capacity act. There was no evidence of mental capacity assessments being used in the decision making process to decide if a person had capacity to make a decision about DNACPR. Patients’ mental capacity must be assessed and recorded when making decisions about DNACPR.

  • Ensure that all end of life documentation is completed fully in accordance with trust policy.

  • Review the DNACPR forms to ensure they reflect all aspects of national guidance, especially with reference to mental capacity.

  • Ensure systems are in place to collect information of the percentage of patients achieving discharge to their preferred place within 24 hours to enable them to monitor the effectiveness of the service in line with national guidance.

  • Ensure that patient records are available for all clinic appointments.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 5, 6 September 2013

During a routine inspection

During our inspection, we visited two care of the elderly wards, three surgical wards and the stroke unit. Our findings and observations are drawn mainly from these areas with the exception of the trust’s governance processes for which the focus was trust-wide.

Overall, we found that people were happy with their care and treatment and spoke highly of the staff. The trust has a strong patient experience focus and people told us they felt involved and respected. We found that staff gained consent before carrying out care and treatment, although best interest and capacity assessments were not always documented.

People were assessed and their care was regularly reviewed to ensure their safety and welfare. We found that 66% of staff had received an annual appraisal and that training figures needed to be reviewed, but that staff felt supported to carry out their roles. Whilst staffing levels were a challenge, particularly in nursing, the trust had effective systems in place to ensure adequate levels were in place.

The trust has a good and clear governance framework, and a pro-active approach to dealing with areas for improvement. There was an open culture of incident reporting, and learning was shared across the trust to ensure continuous improvement in patient care.

Inspection carried out on 6 December 2012

During a routine inspection

People spoken with told us they had experienced care and treatment that met their needs at the Lister hospital and had been involved, where possible, in decisions about this. One person told us they had seen a consultant or a doctor everyday during their stay and who explained clearly to them before and after any procedure or treatment. They said, “They speak to me, they always explained what was to happen, why, the risks and the expected outcomes, I cannot fault that.”

We found people’s health, safety and welfare was protected when more than one provider was involved in their care and treatment, or when they moved between different services. This was because the provider worked in co-operation with others. People who use the service were also protected from the risk of abuse because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening.

We spent time on three wards during our visit and spoke with five patients about staffing levels. Most of the people we spoke with told us that there were adequate staff in place to meeting people’s needs on a day to day basis.

During our inspection visits on 6 and 7 December 2012 we saw records that showed that staff at the trust worked to continuously improve the quality of all aspects of their services through the review of progress against organisational performance priorities and strategies.

Inspection carried out on 21 March and 12 June 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.

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

We did not speak directly to people using the service as part of this review. However, feedback gathered by the Local Involvement Network and the trust's safety walk about visits showed that people did not have any concerns.

Inspection carried out on 5 October 2011

During an inspection in response to concerns

People we spoke with during our visit on 5 October 2011 spoke highly of the staff looking after them. People told us that staff were respectful, polite and treated them with dignity. People told us that staff gave them choice in their care and that they felt involved in their care and treatment plans. People told us they felt safe on the ward and didn't raise any concerns over the way in which they were being treated. Most people told us they

received their medicines in a timely fashion and some people commented that although the staff are very good, they are too busy.

Inspection carried out on 5 January 2011

During an inspection in response to concerns

People told us they were happy with the care and treatment they received within the A&E department. Generally people felt well informed, although some people would have liked to have known how long the wait was likely to be.

People using the service felt confident with the staff's ability to look after them, one person stated they were "very good, can't complain", another felt she had been given "very clear instructions" on her treatment before leaving the department. People using the service had been told whether they could eat or drink and generally felt involved in their treatment.