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Provider: Northern Lincolnshire and Goole NHS Foundation Trust Requires improvement

Reports


Inspection carried out on 24 september to 27 september 2019

During a routine inspection

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

  • We rated safe as inadequate. We rated effective, responsive and well led as requires improvement. We rated caring as good.
  • Our rating of Diana Prince of Wales Hospital stayed the same. We rated it as requires improvement. Of the nine services we inspected, we rated three as inadequate and we rated six services as requires improvement.
  • Our rating of Scunthorpe General Hospital stayed the same. We rated it as requires improvement. Of the nine services we inspected, we rated three as inadequate, five as requires improvement and one as good.
  • Our rating of Goole and District Hospital stayed the same. We rated it as requires improvement. Of the five services we inspected, we rated two as inadequate and three as good. Our decisions on overall ratings take into account the relative size of services. We have used our professional judgement to reach fair and balanced ratings.
  • Our rating of the trust’s community services stayed the same. We rated community health services as requires improvement. We rated one of the three services as requires improvement and two as good.
  • Our rating for well-led at the trust overall improved. We rated well led as required improvement.
  • We rated the trust’s use of resources as requires improvement.


CQC inspections of services

Service reports published 7 February 2020
Inspection carried out on 24 september to 27 september 2019 During an inspection of Community dental services Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 24 september to 27 september 2019 During an inspection of Community health services for adults Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 24 september to 27 september 2019 During an inspection of Community end of life care Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
See more service reports published 7 February 2020
Service reports published 12 September 2018
Inspection carried out on 8 May 2018 During an inspection of Community end of life care Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 8 May 2018 During an inspection of Community health services for adults Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 8 May 2018 During an inspection of Community dental services Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 8 May 2018 During an inspection of Reference: not found Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
See more service reports published 12 September 2018
Service reports published 6 April 2017
Inspection carried out on 22 - 25 November 2016 and 8 December 2016 During an inspection of Community health services for adults Download report PDF (opens in a new tab)
Inspection carried out on 22 - 25 November 2016 and 8 December 2016 During an inspection of Community health services for children, young people and families Download report PDF (opens in a new tab)
Inspection carried out on 22 - 25 November 2016 and 8 December 2016 During an inspection of Community end of life care Download report PDF (opens in a new tab)
See more service reports published 6 April 2017
Service reports published 15 April 2016
Inspection carried out on 13, 14, 15 October 2015 During an inspection of Community health services for adults Download report PDF (opens in a new tab)
Inspection carried out on 13, 14, 15 October 2015 During an inspection of Community end of life care Download report PDF (opens in a new tab)
Inspection carried out on 13, 14, 15 October 2015 During an inspection of Community health services for children, young people and families Download report PDF (opens in a new tab)
Inspection carried out on 13,14, 15 October 2015 During an inspection of Community dental services Download report PDF (opens in a new tab)
See more service reports published 15 April 2016
Inspection carried out on 8 May 2018

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

We rated well-led as inadequate. We rated safe, effective and responsive as requires improvement. We rated caring as good.

Our rating of Diana Prince of Wales Hospital stayed the same. We rated it as requires improvement. We rated two of the hospital’s nine services as good, six as requires improvement and one as inadequate.

Our rating of Goole and District Hospital went down. We rated it as requires improvement. We rated three of the hospital’s five services as good, one as requires improvement and one as inadequate.

Our rating of Scunthorpe General Hospital improved. We rated it as requires improvement. We rated two of the hospital’s nine services as good, six as requires improvement and one as inadequate.

Our rating of the trust’s community services went down. We rated community health services as requires improvement. We rated two of the three services as requires improvement and one as good.

  • We rated well-led for the trust overall as inadequate. This was not an aggregation of the core service ratings.

Inspection carried out on 17 October, 22 - 25 November 2016 and 8 December 2016

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

We carried out a follow-up inspection of Northern Lincolnshire and Goole NHS Foundation Trust from 22 to 25 November 2016 to confirm whether the trust had made improvements to its services since our last inspection, in October 2015. We also undertook unannounced inspections on 17 October and 8 December 2016.

To get to the heart of patients’ experiences of care and treatment we always ask the same five questions of all services: are they safe, effective, caring, responsive to people’s needs, and well-led? Where we have a legal duty to do so, we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

When we last inspected this trust, in October 2015, we rated the trust overall as ’requires improvement’. We rated safe, effective, responsive, and well-led as ‘requires improvement’. We rated caring as ‘good’. Scunthorpe General Hospital was rated as ‘inadequate’ overall, Diana Princess of Wales Hospital was rated as ‘requires improvement’ overall and Goole District Hospital was rated ‘good’ overall. In community services community adult services was rated as ‘requires improvement’ overall, end of life care was rated as ‘requires improvement’ overall, children’s and young people’s services was rated as ‘good’ overall with safe rated as ‘requires improvement’ and dental services was rated as ‘good’ overall.

Following the inspection in October 2015 there were six breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations. These were in relation to staffing, safe care and treatment, dignity and respect, premises and equipment, good governance and need for consent.

The trust sent us an action plan telling us how it would ensure that it had made improvements required in relation to these breaches of regulation. At this inspection we checked whether these actions had been completed.

In November 2016 we inspected:

  • Diana Princess of Wales Hospital
  • Scunthorpe General Hospital
  • Community Adult Services – safe and well led domains
  • Community end of life care services – effective, responsive and well led domains
  • Community children and young people’s services – safe domain

We did not inspect Goole District Hospital as the services provided at this hospital were rated as good in October 2015. We carried out a follow up inspection of community services and looked specifically at the domains that were rated as ‘requires improvement’ following the October 2015 inspection.

We rated Northern Lincolnshire and Goole NHS Foundation Trust as ‘inadequate’ overall. Safe and well led were rated as ‘inadequate’, effective and responsive were rated as ‘requires improvement’ and caring was rated as ‘good’. We rated Scunthorpe General Hospital as ‘inadequate’ overall. We rated Diana Princess of Wales Hospital as ‘requires improvement’ overall. We rated community services as ‘good’.

Key Findings:

  • There was insufficient management oversight and governance at Board, senior and middle management levels, of the identified risks and performance of the trust that has resulted in reoccurrence of patient backlogs and a deteriorating overall position with regard to referral to treatment times and patients waiting for follow up outpatient appointments and diagnostic tests in endoscopy.
  • The trust had a Board Assurance Framework (BAF) and a corporate risk register in place, there were concerns that the risks recorded remained on the BAF for prolonged periods of time even after mitigations had been put into place. There were 24 risks recorded on the BAF of which many were rated as amber. There were concerns that the right assurances were not in place.
  • There were concerns regarding the capacity and capability of the divisional management teams specifically with regard to the recognition, recording and mitigation of risks within the core services and ensuring timely action to address risks.
  • We found poor leadership and oversight in a number of services, notably maternity services and urgent care. In these services leaders had not led and managed required service improvements robustly or effectively. In addition service leads had tolerated high levels of risks to quality and safety without taking appropriate and timely action to address them.
  • There was some improvement in strengthening of governance processes across the trust. However, there were gaps in how outcomes and actions from audit of clinical practice were used to monitor quality in some services.
  • Nursing and medical staffing had improved in some areas since the last inspection. However, there were still a number of nursing and medical staffing vacancies throughout the trust, staff turnover in some areas were particularly high especially in medical care, emergency departments, surgical services, and services for children and young people.
  • The trust had systems in place to manage staffing shortfall as well as escalation processes to maintain safe patient care. However, a number of registered nurse shifts remained unfilled despite these escalation processes and we saw examples of wards not meeting planned staffing levels and high patient acuity not identified appropriately.
  • There had been a lack of improvement since the inspection in 2015, areas of concern had not been fully addressed in a sustained way and there had been deterioration in a number of services. Safety processes were not always adhered to in some services.
  • Assessing and responding to patient was risk was inconsistent and did not support early identification of deterioration. This was particularly evident in the Emergency Department (ED) at Scunthorpe General Hospital (SGH), where the national early warning scores (NEWS) were not recorded in the majority of records we reviewed and in maternity services.
  • Paediatric Early Warning Score (PEWS) was not in use in the ED at SGH and although used at DPoW, had not been consistently completed, following a review of records. We were not assured that the identification and escalation of deterioration in a child’s condition would be recognised.
  • The standard of documentation was variable, for example in ED across both sites we reviewed a total of 56 sets of patients’ records (37 adults and 19 children) fully and found completion of documentation was variable and at times inadequate to ensure delivery of safe care.
  • We found poor infection prevention and control processes and standards of cleanliness in the ED at SGH. Mandatory training rates in infection control were variable across the trust with low rates in the area where concerns were identified.
  • In 2015, we said that the trust must ensure there is an effective process for providing consistent feedback and learning from incidents. During this inspection learning from incidents remained inconsistent and variable between directorates. Staff we spoke to, reported a varying standard of feedback and learning from incidents.
  • We found inconsistent practice with regard to resuscitation trolley checks, fridge temperature checks and medication checks, across the trust.
  • The trust had significant access and flow issues which had not changed since the inspection in 2015. The trust performance with referral to treatment times and management of capacity and demand had shown either no or minimal improvement since 2015. The trust was not meeting the 4-hour waiting tome target in ED.
  • Patient flow through the hospital remained an issue with a significant number of patients cared for on non-medical or non-speciality wards. A ‘buddy ward’ system was in place, however there was still confusion regarding which consultant should review which patient. Patients who were moved more than once could be under the care of different consultants during their stay in hospital.
  • Not all management teams had a detailed understanding of the performance data, an ability to plan capacity to meet demands on services or credible recovery plans that would address the areas of concern.
  • In 2015, we raised concerns regarding the numbers and reporting processes of mixed sex breaches. The trust had updated the policy for eliminating mixed sex accommodation, which was in line with Department of Health guidance (November 2010). However, the trust has continued to report mixed sex breaches in a number of core services. For example in medicine at Scunthorpe 14 mixed sex breaches had been reported.
  • The trust participated in national and local audit programmes however trust performance was mixed across most of the core services with many showing performance that was worse than England averages. There was also variation in patient outcomes between the two hospital sites.
  • The endoscopy unit had lost their Joint Accreditation Group (JAG) accreditation in August 2016 due to an audit that was not submitted within the necessary timescales and communication issues.
  • In maternity services we had concerns regarding the completion of the K2 training package (an interactive computer based training system that covered CTG interpretation and fetal monitoring) for midwives and medical staff in maternity.
  • Concerns remained regarding the organisational culture. There were a number of themes that emerged from discussions with staff relating to there still being a disconnection between the executive team and staff, there was a sense of fear amongst some staff groups regarding repercussions of raising concerns and bullying and harassment. Feedback from management teams had a more positive focus.

However,

  • The hospital-level mortality indicator (SHMI) statistics from July 2015 to June 2016 showed that the SHMI remains in the ‘as expected’ banding with a figure of 110.
  • The trust had taken action in some areas since the 2015 inspection, for example the trust had stopped using Band 4 nurses awaiting professional registration numbers within the registered nurse establishment.
  • Improvements had been made across the community services for adults, children and young people’s services and end of life care. There were robust safeguarding processes in place for both adults and children in community services.
  • We saw pathways in place that complied with the National Institute for Health and Care Excellence (NICE) guidelines, professional and local guidelines.
  • New roles had been developed including Assistant Nurse Practitioners and Acute Care Physicians.
  • There were improvements in critical care services, there was a clear vision and governance processes were effective.
  • There was a new management team in surgery that were able to demonstrate an understanding of the challenges and the areas that required further improvement. They had only recently come into post and had not had sufficient time to implement the changes required to address the ongoing concerns.
  • There were improvements in the ophthalmology service specifically with regard to the cancellation of clinics and clinical oversight of this process.
  • The trust was in the process of expanding the nursing teams for people living with dementia and who had learning disabilities.
  • Overall we observed staff treating patients with dignity and respect. Patients told us staff were caring, attentive and helpful. Staff responded compassionately to pain, discomfort and emotional distress in a timely and appropriate way.

We saw areas of good practice:

  • There was a new initiative called the virtual ward. Two health care assistants were available all day Sunday to Friday and half days on Saturdays. They were deployed to an elderly medical ward at the start of their shift, and then re-deployed to any area with short notice absence or where one to one patient care was required.
  • A online call service run by the infant feeding co-ordinator was being offered to support breast feeding mothers within the community setting.
  • The development of Advanced Midwifery Practitioners and Advanced Nurse Practitioners in gynaecology.
  • There was a dedicated member of staff to manage interpretation and translation services which also included British Sign Language based at the Diana Princess of Wales hospital (DPoW).
  • The trust had started to use “John’s campaign” which was being trialled on four wards.
  • A member of the speech and language therapy staff had received a Health Service Journal award for innovative work on voice banks.
  • Podiatry services had developed training sessions for patients to care for their own feet if this was considered appropriate. Patients were discharged if this was successful and waiting lists had fallen. We were told that there was to be a cross site review of podiatry services to improve patient access.

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

  • The trust must ensure that appropriate numbers of staff, both medical and nursing, are available in line with national guidance and patient acuity and dependency, specifically within surgery, medicine, maternity, and to meet the needs of children and young people being cared for, on both the paediatric wards and in ED.
  • The trust must improve the numbers of all staff receiving an annual appraisal and supervision, especially in children’s wards, surgical areas and the ED, and the actions identified in the appraisals are acted upon.
  • The trust must ensure that the service risk registers are regularly reviewed, updated and include all relevant risks to the service.
  • The trust must monitor and address mixed sex accommodation breaches.
  • The trust must continue to improve its paediatric early warning score (PEWS) system to ensure timely assessment and response for children and young people using services.
  • The trust must ensure that, following serious incidents or never events, root causes and lessons learned are identified and shared with staff, especially within maternity and surgery.
  • The trust must ensure that effective processes are in place to enable access to theatres out of hours, including obstetric theatres, and that all cases are clinically prioritised appropriately.
  • The trust must ensure that the five steps to safer surgery including the World Health Organisation (WHO) safety checklist is implemented consistently especially within maternity and surgery.
  • The trust must ensure there are effective planning, management oversight and governance processes in place, especially within maternity, ED and outpatients. This includes ensuring effective systems to implement, record and monitor the flow of patients through ED, outpatients and diagnostic services.
  • The trust must ensure the proper and safe management of medicines including: checking that fridge temperatures used for the storage of medication are checked on a daily basis in line with the trust’s policy.
  • The trust must ensure that there are effective processes in place to support staff and that staff are trained in the recognition of safeguarding concerns including all staff caring for children and young people receiving the appropriate level of safeguarding training and in outpatient services.
  • The trust must ensure that actions are taken so enable staff to raise concerns without fear of negative repercussions.
  • The trust must ensure that a patient’s capacity is clearly documented and where a patient is deemed to lack capacity this is assessed and managed appropriately in line with the Mental Capacity Act (2005).
  • The trust must ensure that policies and guidelines in use within clinical areas are compliant with NICE or other clinical bodies.

Emergency and Urgent Care

  • The trust must ensure that there are the appropriate systems in place to maintain the cleanliness of the ED at SGH to prevent the spread of infections.
  • The trust must ensure that effective timely assessment and/or escalation processes are in place, including the use of the National Early Warning Score (NEWS) system, so that patients’ safety and care is not put at risk, especially within ED.
  • The trust must ensure that timely initial assessment of patients arriving at the ED takes place and that the related nationally reported data is accurate.
  • The trust must ensure that ambulance staff are able to promptly register and handover patients on arrival at the ED.
  • The trust must ensure that patients are assessed for pain relief; appropriate action is taken and recorded within the patients’ notes.
  • The trust must ensure that patients in ED receive the appropriate nursing care to meet their basic needs, such as pressure area care and being offered adequate nutrition and hydration and, that this is audited.
  • The trust must ensure the checking of controlled drugs and the safe storage of medications used by the ‘streaming’ nurse in ED at DPoW hospital are in line with trust policy.

Critical Care

  • The trust must audit compliance with NICE CG83 rehabilitation after critical illness and act on the results.
  • The trust must review and reduce the number of non-clinical transfers from ICU.

Maternity

  • The trust must take steps to ensure that appropriate numbers of suitably qualified and experienced midwifery staff and medical staff are available to meet the needs of women being cared for by the service.
  • The trust must ensure that labour ward coordinators are supernumerary.
  • The trust must ensure that effective timely assessment and/or escalation processes are in place, including the use of the Modified Early Obstetric Warning Score (MEOWS).
  • The trust must continue to improve obstetric skills and drills training among medical staff working in obstetrics.
  • The trust must continue to improve midwifery and medical staff competencies in the recognition and timely response to abnormalities in cardiotocography (CTGs) including the use of ‘Fresh eyes’.

Children and Young People’s Service

  • The trust must ensure the number of staff who have received training in advanced paediatric life support, is in line with national guidance and the trust’s own target.

Outpatients and Diagnostic Imaging

  • The trust must complete the clinical validation of all outpatient backlogs and continue to address those backlogs, prioritised according to clinical need.
  • The trust must continue to take action to reduce the rates of patients who do not attend (DNA).
  • The trust must continue to take action to reduce the numbers of cancelled clinics.
  • The trust must continue to strengthen the oversight, monitoring and management of outpatient bookings and waiting lists to protect patients from the risks of delayed or inappropriate care and treatment.
  • The trust must continue to work with partners to address referral to treatment times and improve capacity and demand planning to ensure services meet the needs of the local population.

There were also areas of poor practice where the trust should make improvements, which are detailed at the end of this report.

On the basis of this inspection, I have recommended that the trust be placed into special measures.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 13 – 16 October 2015, 6 November 2015 and 5 January 2016

During a routine inspection

We inspected Northern Lincolnshire and Goole NHS Foundation Trust from 13 – 16 October 2015 and performed an unannounced inspection on 6 November 2015 and the 5 January 2016. This inspection was to review and rate the trust’s community services for the first time using the Care Quality Commission’s (CQC) new methodology for comprehensive inspections.

The acute hospitals had been inspected under the new methodology in April 2014, we therefore carried out a focussed inspection of the core services that had been previously been rated as “inadequate” or “requires improvement”. Due to additional information the inspection team also inspected maternity services and caring across the core services included this inspection.

Focused inspections do not look across a whole service; they focus on the areas defined by the information that triggers the need for the focused inspection. We therefore did not inspect children and young people’s services or end of life services within the hospitals at the follow up inspection. Additionally not all of the five domains: safe, effective, caring, responsive and well led were reviewed for each of the core services we inspected. We inspected the effective domain in A&E and the minor injuries unit as it had not been rated in the previous inspection. We inspected diagnostic imaging services across all three sites as these had not been previously inspected in 2014.

At the inspection in April 2014 we found the trust was in breach of regulations relating to patient care and welfare, staffing, premises, staff support and governance.

Overall at the October 2015 inspection we rated the trust as "required improvement" overall. The trust was rated as “good” for being caring. The trust was rated “required improvement” in the domains of safe, effective, responsive and well-led. The core service of outpatients was rated inadequate at Scunthorpe General Hospital (SGH) and Diana Princess of Wales (DPoW) hospital. There was evidence of harm to patients within the outpatient services because of poor management of the follow up appointment system. There were no significant concerns identified within the diagnostic services we inspected where we found patients were protected from avoidable harm and received effective care.

The community services we rated as good for dentistry and children’s services with community health services for adults and end of life care, rated as required improvement. Scunthorpe General Hospital was rated inadequate overall, Diana Princess of Wales Hospital was rated as required improvement overall and Goole Hospital was rated as good overall.

Our key findings were as follows:

  • We were assured by the quality of the governance arrangements in place. However, we were significantly concerned that these governance arrangements were not either widely understood, applied or embedded to ensure the delivery of high quality care.

  • We found within the trust there had been improvements in some of the services and this had meant a positive change in some of the ratings from the previous CQC inspection notably within critical care at Diana Princess of Wales hospital. However we found that the services in A&E at Scunthorpe, outpatients and surgical services had either not improved or had deteriorated since our last inspection.

  • There were significant gaps in the medical rotas for some specialities: both A&E and critical care services were not staffed in line with nationally recommended levels of consultants and A&E was not staffed to the trust’s own recommended levels. The medical cover overnight at Scunthorpe was delaying care and treatment of some patients.

  • Whilst the trust was actively recruiting to nursing posts, there remained a high number of nursing posts vacant on a significant number of wards and other services. Shift co-ordinators on each ward also had a cohort of patients to care for. On most wards there were two registered nurses overnight; frequently one of these would be bank or agency. We saw examples of delayed care and staff who were not familiar with ward environments and specialities. This was raised at the time of inspection and the trust are undertaking a review of nurse staffing and developing the shift co-ordinator role.

  • There was a backlog of patients requiring outpatient follow up and high levels of clinic cancellations resulting in patients being cancelled on multiple occasions. There was a lack of clinical involvement in the cancellation process and a lack of clinical validation of the patients who were waiting for follow up appointments.

  • There was lack of oversight and accountability of the outpatient processes and associated backlogs with actions slow and lacking sufficient senior managerial involvement at core service level. The issues regarding outpatient backlogs was raised at the inspection. The trust took immediate action and provided monitoring information which indicated that all 30,000 patients in the backlog had been reviewed and validated by 31 December 2015. 

  • There were gaps in learning from incidents in almost all acute and community services. There were systems and processes in place to support the dissemination of learning. However staff told us that they did not receive or access feedback/learning from incidents. We were therefore not assured that learning from incidents was effective.

  • At the time of the inspection the trust was a mortality outlier for deaths from acute bronchitis and cardiac dysrhythmias.

  • The Summary Hospital-level Mortality Indicator (SHMI) for the trust was 111 which was higher than the England average (100) in June 2014. For the period July 2014 – June 2015 the SHMI was 109.7 which was within the ‘as expected range’ nationally. The SHMI is the ratio between the actual numbers of patients who die following hospitalisation at the trust and the number that would be expected to die on the basis of average England figures, given the characteristics of the patients treated there.

  • The Hospital Standardised Mortality Ratio (HSMR) was 99.2 which was similar to the England ratio (100) of observed deaths and expected deaths.

  • Staff were not aware of how to record minimum and maximum temperatures for medication fridges; what the recommended range was or that this was necessary for safety and efficacy of medicines. We saw several examples where a temperature had been recorded outside of recommended range but no action had been taken.

  • There was not sufficient resource identified including specialist staff, training and systems in place to care for vulnerable people, specifically those with learning disabilities and dementia. However, there was a highly motivated and compassionate quality matron who had the lead for dementia and also learning disabilities.

  • There had been managerial change within critical care which was beginning to have a positive impact with regard to development of the service. There had been significant improvements in the delivery and location of high dependency services at the DPoW hospital since the initial comprehensive inspection of 2014.

  • At our inspection in April 2014 we found that not all clinical staff who required level 3 safeguarding of children training had received it. At this inspection, we found that clinical staff were now in the process of being trained up to level three in safeguarding children. However, the numbers of staff who had received the level three training was below the trust’s 95% target. The records provided to us by the trust showed that no medical staff in the emergency department had undertaken level three safeguarding children training.

  • Community nurses were not aware of policies and procedures in relation to the management and disposal of controlled drugs in patients’ own homes. Staff we spoke with used different methods to dispose of drugs that were no longer required by a patient.

  • There appeared to be a disconnect between acute and community services. Staff told us that the community services staff voice was not heard at board level and many did not feel they were part of the trust.

  • There was no trust specific end of life strategy or related performance indicators to measure the success of the end of life care services. We saw that national guidelines were used by staff however it was not possible to tell if patients’ preferences at end of life were met, as outcomes such as preferred place of care, were not measured. However, the trust were part of the wider health economies’ strategic groups for end of life care.

  • Community dental services were effective and focused on the needs of patients and their oral healthcare.

  • There was a lack of evidence that an acuity tool was used to allocate caseloads to health visitors and staff were not aware that there was not a designated doctor for the looked after children’s team. Additionally three-monthly safeguarding supervision had not been taking place for health visitors, which did not meet guidance.

We saw several areas of outstanding practice including:

  • The dental health education team developed a package of resources offering oral health promotion support and training to dental practices in the North Lincolnshire region. This online learning package enabled dental professionals to earn continuing professional development hours as part of the General Dental Council requirements to maintain their registration. They could also use the resources to take part in a strategy called ‘making every contact count’, aimed at improving the community’s oral health.

  • There was a highly motivated and compassionate quality matron who had the lead for dementia and also learning disabilities.

  • The development of a pressure sore assessment tool known as a ‘pug wheel’ to support staff in the accurate identification of pressure damage. This had been developed by the tissue viability team.

  • The Frail Elderly Assessment and Support Team gave elderly patients, immediate access to physiotherapy / occupational therapy assessment as well as nursing and medical assessment. Social services would also be involved in assessment with the aim of providing immediate treatment / assessment and initiation of community based care or services. The aim of this service was that patients should be able to return to their usual place of residence with the support of community services.

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

Action the trust MUST take to improve acute services:

  • The trust must ensure that there are sufficient numbers of suitably skilled, qualified and experienced staff in line with best practice and national guidance, taking into account patients’ dependency levels. This must include but not be limited to: medical staff within the emergency department (ED) and critical care, nursing staff within ED, medicine and surgery. It must also include a review of dedicated management time allocated to ward co-ordinators and managers. It must ensure adequate out of hours anaesthetic staffing to avoid delays in treatment. The trust must ensure there are always sufficient numbers of radiologists to meet the needs of people using the radiology service.

  • The trust must ensure that the significant outpatient backlog is promptly addressed and prioritised according to clinical need. It must ensure that the governance and monitoring of outpatients’ appointment bookings are operated effectively, reducing the numbers of cancelled clinics and patients who did not attend, and ensuring identification, assessment and action is taken to prevent any potential system failures, thus protecting patients from the risks of inappropriate or unsafe care and treatment.

  • The trust must ensure that all risks to the health and safety of patients with a mental health condition are removed in Scunthorpe emergency department (ED). This must include the removal of all ligature risks, although must not be limited to the removal of such risks. The trust must undertake a risk assessment of the facilities (including the clinical room and trolley areas, but not be limited to those areas), with advice from a suitably qualified mental health professional.

  • The trust must ensure that the recently constructed treatment rooms at Scunthorpe ED that were previously used as doctors’ offices are suitable for the treatment of patients on trolleys. This must include ensuring that such patients can be quickly taken out of the room in the event of an emergency.

  • The trust must ensure that staff at core service/divisional level understand and are able to communicate the key priorities, strategies and implementation plans for their areas.

  • The trust must improve its engagement with staff to ensure that staff are aware, understand and are involved in improvements to services and receive appropriate support to carry out the duties they are employed to perform.

  • The trust must ensure there are timely and effective governance processes in place to identify and actively manage risks throughout the organisation, especially in relation to critical care and ensuring the equipment is included in the trust replacement plan.

  • The trust must ensure it acts on its own gap analysis of maternity services across the trust to deliver effective management of clinical risk and practice development.

  • The trust must have a process in place to obtain and record consent from patients and/or their families for the use of the baby monitors in critical care and for the use of CCTV in coronary care.

  • The trust must ensure the safe storage and administration of medicines including the storage of oxygen cylinders on the intensive care unit at DPoW hospital. The trust must ensure staff check drug fridge temperatures daily and record minimum and maximum temperatures. Additionally it must ensure staff know that the correct fridge temperatures to preserve the safety and efficacy of drugs and what action they need to take if the temperature recording goes outside of this range. Patient group directions for medications within ED must be reviewed and in date.

  • The trust must ensure equipment is checked, in date and fit for purpose, including checking maternity resuscitation equipment and critical care equipment is reviewed and where required, included in the trust replacement plan.

  • The trust must ensure that action is taken to address the mortality outliers and improve patient outcomes in these areas.

  • The trust must ensure there is a robust process for providing consistent feedback and learning from incidents.

  • The trust must review the validation of mixed sex accommodation occurrences, ensure patients are cared for in an appropriate environment and report any breaches.

  • The trust must ensure the reasons for Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR) are recorded and is implemented in line with best practice within surgical services.

  • The trust must ensure the Five Steps for Safer Surgery including the WHO check list is consistently applied and practice is audited.

  • The trust must review the effectiveness of the patient pathway from pre-assessment through to timeliness of going to theatre, and the number of on the day cancellations for patients awaiting operations.

  • The trust must ensure policies and guidelines in use within clinical areas are compliant with NICE or other similar bodies.

  • The trust must ensure there are adequate specialist staff, training and systems in place to care for vulnerable people specifically those with learning disabilities and dementia.

  • The trust must stop including newly qualified nurses awaiting professional registration (band 4 nurses) within the numbers for registered nurses on duty.

  • The trust must ensure it continues to improve on the number of fractured neck of femur patients who receive surgery within 48 hours The trust must ensure that staff, especially within surgery, have appraisals and supervision, and that actions identified in the appraisals are acted upon.

Action the trust MUST take to improve community services:

  • The trust must ensure three-monthly safeguarding supervision takes place for health visitors.

  • The trust must ensure all staff are up to date with appraisal and mandatory training.

  • The trust must ensure it has an end of life care vision and strategy in place supported by key performance indicators that reflects national guidance and ensure staff are included in the development of these.

  • The trust must have effective systems in place to assess, monitor and improve the quality of the end of life care services, including auditing preferred place of care and other patient outcomes.

  • The trust must ensure that all community equipment is tested for electrical safety and evidence is available to show that equipment is serviced in line with manufacturers recommendations.

  • The trust must ensure that all substances which could be harmful are stored appropriately, specifically within the Ironstone Centre.

  • The trust must ensure that procedures for managing controlled drugs in patients’ homes are standardised and all staff follow guidelines for the safe management and documentation in relation to controlled drugs.

  • The trust must ensure that record keeping meets all appropriate registered body standards.

Additionally there were other areas of action identified where the trust should take action and these are listed at the end of each report.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 23-25 April and 6 and 8 May 2014

During a routine inspection

Northern Lincolnshire and Goole NHS Foundation Trust serves a population of more than 350,000 people living in North and North East Lincolnshire and East Riding of Yorkshire. In total the trust employs around 6,500 staff and has 850 beds across three hospitals, Diana Princess of Wales, Scunthorpe General Hospital and Goole and District Hospital. Other locations registered with the Care Quality Commission include Monarch House and Community Equipment Store.

We carried out this comprehensive inspection because the Northern Lincolnshire and Goole NHS Foundation Trust was placed in a high risk band 1 in CQC’s intelligent monitoring system. The trust was also one of 14 trusts, which were subject to a Sir Bruce Keogh (the Medical Director for NHS England) investigation in June 2013, as part of the review of high mortality figures across trusts in England. At that time, there were concerns around a lack of senior clinical leadership in relation to clinical issues, the approach to medical handovers, patient flow management, standards of clinical documentation, a lack of trust wide sharing of lessons learnt from clinical incidents including serious untoward incidents and Never Events. In addition, the review found low levels of mandatory training in some areas, issues regarding hydration, nutrition and promoting hand hygiene, as well as the process of responding to complaints being seen by patients as inaccessible and slow.

We completed an announced inspection of the trust between 23 and 25 April and on 8 May 2014, and an unannounced visit took place on 6 May 2014. We did not inspect the community service provision at the trust as part of this inspection.

Overall, this trust was found to require improvement, although we rated it as good in terms of having caring staff.

Our key findings were as follows:

  • There were arrangements in place to manage and monitor the prevention and control of infection, with a dedicated team to support staff and ensure policies and procedures were implemented. We found all areas visited clean. Methicillin-Resistant Staphylococcus Aureus (MRSA) and Clostridium difficile (C.difficile) rates were within an acceptable range for the size of the trust.
  • There were significant vacancies with nursing and medical staff in some areas. The trust was actively recruiting into these posts. In the meantime, staff were able to work additional hours and bank, agency and locum staff were used to fill any deficits in staff numbers.
  • Patients were able to access suitable nutrition and hydration including special diets. Patients reported that on the whole they were content with the quality and quantity of food provided.
  • Best practice and national guidance was not consistently applied across some specialities.
  • Mortality rates are improving for this trust. There had been a reduction in the summary hospital level mortality indicator (SHMI) rate and the trust was now at 109, which is within the ‘as expected’ range.
  • Work was in progress to improve the patient experience, including initiatives to engage with patients, increase feedback responses and improve the handling of complaints.

We saw some areas of outstanding practice including:

  • The maternity service at Scunthorpe General Hospital had won a national award for promoting a normal birth experience. A midwifery-led vaginal birth after caesarean section clinic had been introduced which worked with women who had a previous caesarean section. This meant that women were given increased opportunities to have a natural birth.
  • The facilities team received the National Annual Hospital Estates and Facilities Management Association Team of the Year Award, with the Hotel Services Manager being awarded Project Manager of the Year for improving patient and staff experience. This included the creation of a multi-skilled role – ward caterer, ward domestic and nursing support.

Importantly, to improve quality and safety of care, the trust must:

  • Ensure that there are sufficient qualified, skilled and experienced staff, particularly in the A&E department, and medical and surgical wards. This is to include provision of staff out of hours, bank holidays and weekends at Scunthorpe General Hospital and Diana, Princess of Wales Hospital.
  • Review the skills and experience of staff working with children in the A&E departments to meet national recommendations at Scunthorpe General Hospital and Diana, Princess of Wales Hospital.
  • Review the consistency of care and level of consultant input, particularly out of hours and at weekends in the High Dependency Unit at Diana Princess of Wales Hospital.
  • Review care and treatment to ensure that it is keeping pace with National Institute of Clinical Excellence guidance and best practice recommendations, particularly within the intensive therapy units and the high dependency unit at Scunthorpe General Hospital and Diana, Princess of Wales Hospital.
  • Ensure that the intensive therapy unit uses nationally-recognised best-practice guidance in terms of consultant wards rounds and reviewing admissions to the unit.
  • Review delayed discharges from intensive therapy unit in terms of the negative impact this can have on patients.
  • Review the environment and lay out of the accident and emergency department at Scunthorpe General Hospital so that it can meet the needs of children and patients with mental health needs.
  • Ensure that the designation of the specialty of some medical wards reflect the actual type of patients treated at Scunthorpe General Hospital and Diana, Princess of Wales Hospital .
  • Review the on-call medical rota covering patients admitted with gastrointestinal bleeding (GI bleed).
  • Ensure that the availability of emergency theatre lists at Scunthorpe General Hospital is improved.
  • Ensure that there is an improvement in the number of Fractured Neck of Femur patients who had surgery within 48 hours at Scunthorpe General Hospital and Diana, Princess of Wales Hospital.
  • Ensure there is appropriate care planning and a paediatric early warning scoring system on the neonatal intensive care unit and that there is consistent nutritional and tissue viability screening and assessment on paediatric wards.
  • Ensure that all staff attend and complete mandatory training, particularly for safeguarding children and resuscitation at Scunthorpe General Hospital and Diana, Princess of Wales Hospital.
  • Ensure that staff have appropriate appraisal and supervision at Scunthorpe General Hospital and Diana, Princess of Wales Hospital.
  • Review the effectiveness of handovers, particularly in the medical services at Scunthorpe General Hospital and Diana, Princess of Wales Hospital.
  • Ensure that all patient documentation is appropriately updated and maintained including documentation for mental capacity assessments and risk assessments at Scunthorpe General Hospital and Diana, Princess of Wales Hospital.
  • Ensure that reasons for Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) are recorded and are in line with good practice and Guideline at Scunthorpe General Hospital and Diana, Princess of Wales Hospital.
  • Ensure that DNACPR orders confirm discussion with patients or family members and whether multidisciplinary teams are involved before an order is put in place at Scunthorpe General Hospital and Diana, Princess of Wales Hospital.
  • Review access to soft diets outside of meal-times at Scunthorpe General Hospital and Diana, Princess of Wales Hospital.
  • Review the ‘did not attend’ and waiting times in outpatients’ clinics and put in steps to address issues identified.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up.

Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.


Joint inspection reports with Ofsted

We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.