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Provider: The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust Inadequate

On 13 September 2018, we published a report on how well The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust uses its resources. The ratings from this report are:

  • Use of resources: Requires improvement  
  • Combined rating: Inadequate  

Read more about use of resources ratings

Inspection Summary


Overall summary & rating

Inadequate

Updated 16 December 2020

Our rating of the trust stayed the same. We rated it as inadequate because:

When we complete focused inspection, we do not rate at trust level. Therefore, the overall rating for the trust remains inadequate despite improvements in the core services inspected. We rated urgent and emergency care, medicine, surgery, end of life care, maternity and diagnostic imaging services as requires improvement. 

Our inspection of the core services covered The Queen Elizabeth Hospital Kings’ Lynn only.

  • We found that there were regulatory breaches resulting in requirement notices and found that the organisation was preforming at a level which led to the overall rating of requires improvement at core service level.

Urgent and Emergency Care

  • The urgent and emergency service were rated as inadequate at the July 2019 inspection, with safe, effective and well led rated as inadequate and caring and responsive rated as requires improvement. We inspected all key questions at this inspection and rated the service as requires improvement overall. We rated the service as good for caring, and requires improvement for safe, effective, responsive and well led at this inspection. Across all key questions we saw that there had been a number of improvements which were focused on patient safety and improving the patients journey. There had been changes to local leadership and governance processes had been strengthened, however, leaders had not been in post for sufficient time to demonstrate a sustained improvement in performance. The service was not meeting national targets and the recruitment to substantive posts had been challenging. However, staff ensured that patients were assessed and escalated if necessary. There were processes in place to support a team approach to care and the multidisciplinary team worked cohesively to a common goal. Staff felt supported by the local, divisional and senior leadership teams. Robust governance structures aligned to the trust board was clear accountability across the division.

Medicine

  • The medicine service was rated as inadequate at the July 2019 inspection, with safe, effective and well led rated as inadequate and caring and responsive rated as requires improvement. We inspected safe, effective, caring and well led at this inspection and rated the services as requires improvement overall. Safe and caring were rated as good and effective and well led were rated as requires improvement. We found that there had been improvements across the service, however, leaders had not been in post for a sufficient time to demonstrate a continued and sustained improvement. Patient records were complete and detailed, although not always stored securely. Staffing levels were regularly reviewed and adjusted to manage peaks in activity on wards, although this sometimes left clinical areas short staffed. There were equipment checks in place, although these were not always completed (in one clinical area). Performance with national audits varied. However, there had been a number of changes in response to COVID -19, and staff had been trained to manage patients with different conditions to their usual speciality. Risk assessments were completed, and staff acted on findings. Patients and their families were considered when planning care and included where possible. Staff demonstrated compassionate care and were supportive to patients, relatives and each other in perceived difficult circumstances. There were robust processes underpinning the divisions functioning with regular risk assessments and meetings to review performance and share learning across medicine specialities.

Surgery

  • Surgical services were rated as requires improvement at the July 2019 inspection, with effective, caring and well led rated as good and safe and responsive as requires improvement. We inspected safe and well led at this inspection, and rated safe as good and well led as requires improvement. Since our last inspection the service had made a number of changes. Patients admitted to surgical area, were assessed and monitored for risks, any deterioration was escalated quickly and there was enough staff to manage patient care and treatment. Incidents were recognised and shared locally and across the wider team. Staff were aware of and had learnt from incidents that impacted on their services. The World Health Organisation (WHO) five steps to safer surgery process had been embedded, and there were robust processes in place to monitor performance and risk. Staff were largely positive about their jobs and the teams in which they worked. However, the service had been affected by the COVID- 19 outbreak and referral to treatment times had been impacted negatively. The service had robust recovery plans and service development plans in place to ensure protected activity. Mandatory training compliance was also lower than the trust target.

Maternity

  • Maternity services were rated as requires improvement at the July 2019 inspection, with effective, caring and responsive rated as good and safe and well led as requires improvement. We inspected safe and well led at this inspection and rated both key questions as requires improvement. Maternity services had taken action to address concerns raised at the last inspection. There had been changes to staff training and competence and agency staff were fully inducted. Equipment was serviced regularly. Medicines were stored securely. Patient risks were identified and escalated appropriately, and staff shared learning from incidents. There had been changes to the leadership team and governance processes had been reviewed and embedded. However, staffing numbers were not within establishment which impacted on coordinators abilities to be supernumerary. There was minimal representation from midwifery staff at meetings and although work had been completed on improving engagement, there were some pockets where the culture was not as positive.

End of Life Care

  • End of Life Care services were rated as inadequate at the July 2019 inspection, with caring rated as good, safe rated as requires improvement and effective, responsive and well led rated inadequate. We inspected all key questions at this inspection and rated the service as requires improvement overall. We rated effective, responsive and well led as requires improvement and safe and caring as good. Since the outbreak of COVID- 19 there had been a trust wide focus on providing end of life care which resulted in significant improvements. The end of life team worked collaboratively across the health economy to manage patients, ensure their comfort and support families, although patients did not always receive timely care. There was an end of life care strategy which addressed concerns raised at the April 2019 inspection, and staff were engaged with the processes of embedding practical elements to ensure good quality end of life care. There was a governance process which included regular auditing which helped to identify areas of improvement and performance against targets. Improvements were being driven by the team and trust wide staff, despite the lack of palliative care consultants. Records sometimes lacked details, such as printed staff names and mental capacity assessments were not always completed, however, records were generally to a good standard detailing action taken. Performance against national and local standards were variable.

Diagnostic Imaging

  • Diagnostic Imaging services were rated as inadequate at the July 2019 inspection, with caring rated as good, responsive rated requires improvement and safe and well led rated inadequate. We currently do not rate effective. We inspected safe and well led at this inspection and rated both key questions as requires improvement. There were some gaps in team leadership and staffing numbers which sometimes impacted on out of hours cover and morale. Capacity issues also impacted on the trust wide performance in meeting referral to treatment times. New governance processes and risk management systems were not fully embedded, although there was recognition by leaders that further work was needed. We also found that there had been a number of improvements within diagnostic imaging, particularly around the safe administration of contrast media. Staff ensured there were processes in place to review the use of contrast media and ensure it was administered in line with guidance. Staff were familiar with their roles and responsibilities on ensuring patients safety using appropriate risk assessments as necessary. A new leadership team had developed systems for supporting staff to develop and staff were committed to improving. There was a positive team culture amongst staff.
Inspection areas

Safe

Inadequate

Updated 16 December 2020

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

The Queen Elizabeth Hospital

  • Due to the COVID- 19 pandemic, there had been a reduction in face to face mandatory training. This included life support training and safeguarding adults and children’s’ training. The trust had changed face to face training to eLearning modules where possible, however, mandatory training compliance was below the trust target across all core services. There was a trust wide delivery plan to improve compliance and face to face training had recommenced, although social distancing impacted on the size of classes.
  • Across the trust, staff prioritised infection control and prevention. Staff were observed wearing appropriate personal protective equipment and encouraging visitors to wash their hands and wear PPE when attending. Entrances displayed prompts for visitors. All areas were visibly clean and free from clutter.

Urgent and Emergency Care

  • The urgent and emergency service were rated as inadequate for safe, at the July 2019 inspection, with significant concerns around staffing skill mix, risks not being identified, non escalation of the deteriorating patient, lack of learning from incidents and poor patient records. At this inspection we rated the service as requires improvement for safe. Since our last inspection, there had been an increase in the nursing establishment by 46 whole time equivalent (WTE) nurses to 127 (WTE) staff. We saw that staffing levels were maintained, although there was a number of agency or locum staff used to achieve this due to a number of vacancies. Although there had been changes to the physical environment, some areas remained cramped which did not always facilitate safe distances between patients. We saw that there was a multidisciplinary team focus on patient safety, patients were assessed and treated appropriately and escalated to lead clinicians as necessary. The team had introduced additional steps to maintain safety, such as two hourly safety huddles. Patient records were maintained, risk assessments were timely, and medicines were stored and administered in line with policy. There was evidence that incidents were investigated fully, and any learning shared across the trust.

Medicine

  • Medicine services were rated as inadequate for safe, at the July 2019 inspection, with concerns around the safe management of infection control, patients records, staff knowledge of safeguarding and vacancy rates for nursing and medical staffing. At this inspection we rated the service as good for safe. We saw that infection control and prevention was managed well, all areas were visibly clean, and staff promoted good hand hygiene and the use of protective equipment. Although there was some variation in the storing of patients records, they were of a good quality and detailed treatment plans and care given. Staff were aware of their roles in escalating concerns, and managed deteriorating patients well. Patients were treated respectfully and with compassion. Staff were positive about their work, felt respected, valued and supported by their local, divisional and senior leaders. Staffing was managed to ensure safe staffing levels, however, there were some gaps in establishment and some equipment checks were not always completed in isolated areas.

Surgery

  • The Surgery services were rated as requires improvement at the July 2019 inspection, with concerns around mandatory training compliance, the completion of the World Health Organisation (WHO) and five steps to safer surgery checklist, staffing levels and the timely administration of medicines. At this inspection we rated the services as good because, we saw that the WHO checklist was embedded and there were processes in place to ensure compliance was maintained. Patients were assessed and monitored for risks and deterioration and staff escalated any concerns appropriately. Medicines were stored, and administered in line with guidance and there were processes in place to ensure that incidents were reported, investigated and shared across the team. Staffing numbers were appropriate for the clinical needs. However, mandatory training compliance was lower than the trust target although the COVID- 19 outbreak had impacted this there was a recovery plan in place.

Maternity

  • Maternity services were rated as requires improvement at the July 2019 inspection, with concerns around mandatory and safeguarding training compliance, midwifery vacancies, and staff competency particularly the interpretation of cardiotocography (CTG) traces. At this inspection we rated the service as requires improvement because although there had been work completed to address concerns previously highlighted, there remained a number of vacancies and staff relied on agency midwives to support numbers. CTG meetings were held, but midwife representation was not always robust and training compliance had been impacted by COVID- 19. However, staff were able to identify risks and escalated concerns appropriately. Incident were reported and staff shared learning within the team and across the organisation. Anaesthetists compliance for PROMPT (Practical Obstetric Multi-Professional Training) was significantly below the trust target.

End of Life Care

  • At the July 2019 inspection, end of life care was rated requires improvement for safety. There were concerns with mandatory training compliance, patient records were not always clear, and not secure, individualised plans of care were not always completed, palliative care consultant numbers were not in line with national guidance and safety incidents were not being captured or managed appropriately. At this inspection we rated the service as good because we saw that the majority of these issues had been addressed. Patients records were detailed, although missed printed names next to signatures. Individualised plans of care were completed, and detailed conversations with patients and their relatives about treatment plans or wishes. There continued to be a lack of palliative care consultant, however, there had been a trust wide, multidisciplinary focus on caring for patient nearing the end of their lives in response to COVID- 19.

Diagnostic Imaging

  • Diagnostic imaging services were rated as inadequate for safety at the July 2019 inspection, due to staffs lack recognition of incidents and consequential lack of reporting, poor infection control management, lack of understanding of roles and responsibilities for administering contrast media, and lack of staff with the relevant training and competence to ensure patients received timely care and treatment. At this inspection, we rated the service as requires improvement because, we found that there had been a number of improvements around safety. Staff were clear about their roles and responsibilities, and supported each other to develop. There was a robust process in place to manage medicines used within the department, including contrast media. There were some concerns regarding staffing out of hours, as there were a few vacancies which were being recruited to.

Effective

Inadequate

Updated 16 December 2020

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

Urgent and Emergency Care

  • In July 2019, we rated the urgent and emergency services as requires improvement for effectiveness. This was because we saw that guidance was not always followed, there were limited numbers of audits to monitor performance, national audit results were varied and there was limited evidence of learning in response to audit results. At this inspection we rated the service as requires improvement because, we saw that patients outcomes were not always in line with national targets. Performance was variable in audits, although there was evidence that learning was taken from results. We also saw that there were processes in place to ensure that national guidance and local policies were updated and followed. Staff managed patients nutritional, hydration and pain relief well and were competent to complete their roles. Staff worked collaboratively with each other for the benefit of patients and ensured patient consent was considered.

Medicine

  • At our last inspection, in July 2019, we rated medicine as inadequate for effective. There were concerns that care and treatment was not based on national guidance, and the service did not monitor the effectiveness of care and treatment to improve care. Audit results were poor, staff did not have access to up to date information and gave inconsistent information about the Mental Capacity Act 2005 (MCA). At this inspection we rated the service as requires improvement because performance in national and local audits was not always in line with targets and staff did not always receive appraisals. However, staff were competent and received targeted training according to their roles. Staff understood how to assess mental capacity and could access support and guidance when necessary. Patients nutritional and hydration needs were met. Staff worked well together.

End of Life Care

  • End of life care services were rated as inadequate for effective at the July 2019 inspection. We found that the individualised plan of care (IPoC) was not fully implemented or consistently used, additional work was required to embed the completion of the do not attempt resuscitation forms (DNACPR), and audits were not used to improve practice. At this inspection we rated the service as requires improvement because we found that patient outcomes were variable and the IPoC was not fully embedded. However, there was clear guidance for staff to follow and audits were completed to monitor performance. Staff ensured that patients received adequate nutrition, hydration and pain relief. There had been a focus on ensuring staffs abilities and understanding of the needs of a dying patient and staff were assessed for competence. Staff worked collaboratively for a common goal across the trust and external partners.

Caring

Requires improvement

Updated 16 December 2020

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

We did not inspect this key question in all core services.

Urgent and Emergency Care

  • The urgent and emergency service were rated as requires improvement for caring, at the July 2019 inspection. Privacy and dignity were not always maintained, staff were not always understanding of the patients’ needs and there was mixed feedback about staff from patients. At this inspection, we rated the service as good because we saw that patients were treated with respect, kindness and dignity was maintained. We saw good examples of effective communication, where staff would explain conditions and treatment options. Families were included in conversations and feedback from patients was largely positive.

Medicine

  • Medicine services were rated as requires improvement for caring, at the July 2019 inspection, with concerns around some staff lacking compassion, not including patients in decisions about care and poor communication with relatives. At this inspection we rated medicine as good, because we saw that staff were caring and considerate. They included patients in decision making, treated them with kindness and considered their individual needs. Patients were included in conversations during their care and feedback from patients was positive.

End of Life Care

  • We rated end of life care as good at our July 2019 inspection. Feedback was positive and staff treated patients with compassion. At this inspection, we rated the service as good because we saw that staff took patients wishes into consideration and ensured their comfort in the last few days of their lives. There were processes in place to support relatives and loved ones throughout the patients admission and following their death.

Responsive

Requires improvement

Updated 16 December 2020

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

We did not inspect this key question in all core services.

Urgent and Emergency Care

  • At the July 2019 inspection, urgent and emergency care was rated as requires improvement because people could not access care and treatment in a timely way. Flow had not been addressed and there were no systems in place to meet patients individual needs. At this inspection we rated the services as requires improvement because although performance was reviewed regularly, there remained some delays in accessing treatment or admission to hospital. Due to COVID- 19 changes had occurred within the department to ensure staff and patient safety which had impacted on space.

End of Life Care

  • We rated end of life care inadequate for responsiveness at our July 2019 inspection. Data collected was not accurate. The service had failed to monitor the number of patient referrals to the palliative care team, and could not provide data about referral to treatment times. At this inspection we rated the service as requires improvement because performance against key indicators was not always positive. Patients did not always die in their preferred location. However, staff ensured that patients needs were met whilst in hospital and there were additional facilities which could be offered to relatives to ensure their comfort.

Well-led

Inadequate

Updated 16 December 2020

Our rating of well-led improved. We rated it as requires improvement because:

Urgent and Emergency Care

  • The urgent and emergency service was rated as inadequate for well led, at the July 2019 inspection, with significant concerns around risk management, lack of support to leaders, lack of oversight of department, there was no strategy and staff felt unable to raise concerns with leads. At this inspection we rated the service as requires improvement because leadership had not demonstrated a sustained improvement and the team were not meeting performance targets. However, we saw that there was a positive culture within the department with a shared vision for what the team wanted to achieve. There were robust processes in place to ensure good governance and all staff were aware of the risks and what actions needed to be taken to mitigate them. Staff were engaged with the development of the department and felt included, supported and valued. There was strong visible leadership within the team and staff displayed mutual respect for their colleagues.

Medicine

  • Medicine services were rated as inadequate for well led, at the July 2019 inspection, with concerns around the skills of divisional leads to effect change, there was no vision or strategy, a mixed culture with poor communication and low staff morale. There were no robust systems in place to identify or manage risks and information was not collected or used to drive improvements. At this inspection we rated the service as requires improvement because we divisional leaders were relatively new to post and had not evidenced sustained improvements. However, we saw that there had been a number of improvements. Divisional leads and matrons were enthusiastic and passionate about ensuring patients received good quality care and had processes in place to monitor performance and challenge any variances. Staff were aware of their roles and were held to account. There was a clear vision which was aligned to the trusts vision and strategy and staff had been included in its development. Ward managers were encouraged to develop their teams and staff felt supported. There was an eagerness to improve services across all clinical areas and teams.

Surgery

  • Surgery services were rated as good at the July 2019 inspection although there were concerns that there was not a robust audit plan within theatres and the World Health Organisation (WHO) and five steps to safer surgery checklist were not embedded. At this inspection, we rated the service as requires improvement because they were not meetings targets and people were waiting longer than they should for treatments. COVID- 19 had impacted negatively on the surgical division, although there were plans in place to move provide a protected area for elective cases. The division had a plan for what it wanted to achieve although this had not been formalised. However, we saw that there was a robust audit plan across the division. Information was gathered and analysed to monitor performance and if necessary, improve. The WHO and five steps to safer surgery were embedded and regular monitoring ensured compliance. Risks were identified and actions taken to monitor them. Staff were largely positive about their team and roles.

Maternity

  • Maternity services were rated as requires improvement at the July 2019 inspection. There had been improvements, but these were not embedded. There was no established leadership and a reliance on interim positions, risk and quality processes were not fully embedded, there was no formal vision and a lack of communications about changes. At this inspection we rated the service as requires improvement because although there was an established leadership team in place, although some staff were in interim posts. There was a robust governance process although midwifery staff did not always attend meetings which meant that midwifery staff may not always be kept informed of service activity, plans or changes. However, there was a strategy in place which was aligned to the trust strategy and vision. Staff were largely positive about their jobs and the service. They felt respected, valued and able to contribute to the development of the service. Risks were identified and there were plans in place to address them.

End of Life Care

  • At the July 2019 inspection, end of life care was rated inadequate for well led. There were concerns with the lack of ownership from senior leaders, there was no plans to implement the strategy, individualised plans of care were not embedded, and staff were unfamiliar with the documents, there were no effective systems in place to identify risks. At this inspection we rated the service as requires improvement, because there was limited leadership with insufficient numbers of palliative care specialists in post and patients needs and wishes were not always facilitated. Internal and external resources did not always facilitate rapid discharge. However, since our last inspection, most of the issues previously identified had been addressed. Individualised plans of care we saw were completed, and detailed conversations with patients and their relatives about treatment plans or wishes. Staff were familiar with the document and kept records up to date. Staff were focused on providing good end of life care and had completed a lot of their plans quickly in response to COVID- 19. Although there continued to be a lack of palliative care consultants, there had been a trust wide, multidisciplinary focus on caring for patient nearing the end of their lives in response to COVID- 19.

Diagnostic Imaging

  • Diagnostic imaging services were rated as inadequate for well led at the July 2019 inspection, as a result of a lack of managers with the right skills, low morale, a disconnect between staff and their managers, poor systems to identify risks and the lack of escalation of any risks identified. At this inspection, we rated the service as requires improvement because we saw that governance processes were in place but not fully embedded. Capacity and staffing numbers impacted on the key deliverables across the trust with regards to meeting referral to treatment times. The service vision was not formalised and there were pockets where staff did not feel as supported. However, leadership had changed, and they recognised that further work was needed to improve the service. Staff were clear about their roles/ accountabilities. Performance was monitored and discussed regularly, and divisional leads engaged with staff and partner organisations to help improve the service.

Assessment of the use of resources

Use of resources summary

Requires improvement

Updated 13 September 2018

Combined rating