The Care Quality Commission was contacted by the Bruce Keogh Rapid Response Team as they had concerns about the staffing levels at the hospital, particularly at night and weekends. We undertook three unannounced inspections to the hospital, one on a Friday night. In addition, we visited the hospital to speak to specific members of staff including specialist nurses, matrons and senior managers. We spoke with staff side union representatives and we contacted the Occupational Health Department to gain an understanding of sickness levels and the nature of referrals and the Chaplaincy Department.We looked at staffing levels and care practices across a number of wards and clinical areas. We were assisted by a number of professionals including professional advisors experienced in Trust Board Governance and workforce planning; a medical professional and a practicing professional who works in a care of the elderly service. We had received concerning information about how the trust was dealing with controlled drugs (controlled drugs are medicines which are subject to special storage and recording requirements). Therefore, a pharmacy inspector undertook a focussed inspection of the trust's arrangements for managing controlled drugs. We also contacted Health Education East Midlands to obtain information on post-graduate medical education in the hospital.
We spoke with patients, their families and representatives. We were assisted by an Expert by Experience (a person who has received services or has cared for someone in receipt of services). We contacted Lincolnshire's Local Healthwatch to see if members of the public had raised any concerns or given feedback on services relevant to this inspection. We also looked at information given to the Bruce Keogh Rapid Response Review about the views of members of the public about services at the hospital.
Overall, we found a mixed picture. We found staffing levels were low and this impacted on a range of activities across the hospital including care and treatment of patients, communication between clinical staff, the maintenance of patient records and staff access to training and appraisal. This meant the hospital staff were not always responsive to patients' needs, at times due to inconsistent care and recording practices so patients were not always kept safe. Not all staff had attended the necessary training to ensure they had up to date knowledge and skills to perform their duties appropriately.
We found staff to be caring and dedicated across all staff groups. When we asked patients about their care we received positive feedback. A patient told us, 'The staff are good I don't know how they keep going when they are busy.' When we asked patients about being consulted about their treatment patients reported they were informed about what was happening. One patient said, 'My treatment was explained to me.' Another said, 'I understand what they are going to do.' However, patients noticed staff were rushed and that this impacted on their care. We found that some care practices were poor, one patient told us, 'I am not pleased about just being given a booklet to read. I want someone to sit with me.'
We found staff could not always respond to the needs of patients. We found not all care needs were assessed, planned for or delivered in a timely manner. We found that some care records were not updated appropriately such as care plans, risk assessments and hourly observation charts. This meant patients were at risk of not receiving consistent or appropriate care.
We found a confusing picture when we looked at how patients, their families and representatives were involved in the decision whether to resuscitate a patient or not. When we looked in the documents used for 'do not attempt cardio pulmonary resuscitation' we found some poor recording practices, not all records were clear who had been involved in the decision and why, and there were some medical records without details of discussions held.
Staff reported they could not give the care they would wish to do and also keep up with the necessary paperwork. This was causing increased levels of stress, particularly when registered nurses had to undertake additional duties and procedures to cover for newly registered nurses and agency staff.
We found communication at times ineffective between different staff groups including medical and nursing as well as between clinical staff and senior managers at Trust Board level. We found leadership was variable across wards and between ward/department level and senior management. We found some very positive practice taking place, but this was not necessarily shared across the hospital. Staff were not confident in the reporting system and told us that feedback was inconsistent between managers. One doctor said, 'I do complete incident forms but what's the point I don't get any feedback.'
The trust had introduced some quality monitoring systems and these were indicating that improvements across care and practice were improving. However, we found some poor performance and high levels of risk had been identified over several months and action taken was ineffective. It was not clear for some performance information that any action had been taken to address issues or drive improvement or that timescales were appropriate. The Trust Board had recently agreed a revised board assurance framework, which contained robust reporting and management systems. However, this was not yet fully introduced and embedded in the trust. There was a drive to improve staff morale and relationships with clinicians. New strategies had been introduced to improve communication and consultation, including 'Listening Events', whereby senior managers including the Chief Executive were meeting with staff groups.
Staff reported over the last few months, there had been improvements in staffing in some areas. The trust had initiated recruitment strategies, with some success. There had been an increase in the number of consultants and newly registered nurses. There had been advertising campaigns taking place, including internationally and the trust was working with local universities. However, recruitment was proving a challenge.