The Care Quality Commission
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  • SERVICE PROVIDER

The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust

This is an organisation that runs the health and social care services we inspect

Overall: Requires improvement read more about inspection ratings

All Inspections

7th & 8th December 2021 and 11th & 12thJanuary 2022

During a routine inspection

We carried out an unannounced inspection of three of the acute core services provided by this trust because the trust was in special measures. We carried out a comprehensive inspection of critical care and medical care and a focused inspection of urgent and emergency care services.

We also inspected the well-led key question for the trust overall.

We did not inspect several core services that had previously been rated as requires improvement because this inspection was focused on services where we had concerns. We are monitoring the progress of improvements to these services and will re-inspect them as appropriate. As we inspected three out of nine core services, this meant due to aggregation, the rating of requires improvement at location level would not have changed. Services previously rated as requires improvement and not inspected this time include:

  • Surgery
  • Maternity
  • Gynaecology
  • End of life care
  • Outpatients
  • Diagnostic Imaging

Our rating of this trust improved. We rated it as requires improvement and the chief inspector of hospitals has recommended to NHS England and NHS Improvement (NHSEI) that it be removed from the Recovery Support Programme.

  • The trust has made marked improvement on those issues that led to it being placed in the Recovery Support Programme (which was then called Special Measures).
  • We rated effective, caring and well-led as good, and safe and responsive as requires improvement. Well-led is the overall trust-wide rating, not an aggregation of services ratings.
  • We rated all three of the services we inspected as good overall. In rating the trust, we took into account the current ratings of the seven services we did not inspect this time.
  • Mandatory training, including safeguarding training compliance for medical staff was below the trust target. Staff did not consistently complete daily and weekly safety checks on resuscitation equipment. Critical care did not have a dedicated pharmacist to support the service. Patient records were not always stored securely. The service did not always use systems and processes to safely prescribe, administer, record and store medicines.
  • People could not always access the services when they needed it. Waiting times from referral to treatment were not always in line with national standards.

However:

  • Most services had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. The service managed safety incidents well and learned lessons from them.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

How we carried out the inspection

We carried out this inspection on various days throughout December 2021 and January 2022. We visited areas relevant to each of the core services inspected and spoke with a number of patients and staff, as well as holding focus groups. During the inspection we visited critical care, all ward areas for medical services except Stanhoe ward as patients with COVID-19 were being treated on this ward, and all areas of the adult and children’s emergency department, except those restricted due to COVID-19 for urgent and emergency care. We spoke with 76 staff members of various specialty and profession including, consultants, doctors, nurses, healthcare support workers, pharmacists, domestic staff, therapists, support staff, governance and educational staff and senior managers. We spoke with 13 patients throughout the departments and reviewed 36 patient records.

You can find further information about how we carry out our inspections on our website: www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

14 September to 23 September 2020

During a routine inspection

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.

05 March to 11 April 2019

During a routine inspection

The Queen Elizabeth Hospital
Urgent and emergency care
  • The rating for Urgent and emergency care remained inadequate overall. The ratings for safe, responsive, and well-led remained the same, safe and well-led were rated inadequate and responsive was rated requires improvement. The rating for caring went down from good to requires improvement and the rating for effective went down from requires improvement to inadequate. The service did not always ensure that staff identified, monitored and responded appropriately to changing risks to people who used services, including deteriorating health and behaviour that challenges. There were concerns about staffing, incident investigation processes, the environment for patients with mental health concerns and documentation. The privacy and dignity of patients was not always maintained, and staff members did not always display an understanding and non-judgemental attitude when talking about patients and relatives. People could not access care and treatment in a timely way. Leaders either had not identified or had not acted to address some of the concerns that we identified during our current or last inspection. Leaders did not receive sufficient support or time to undertake their leadership roles effectively and maintain sufficient oversight over the department.
Medical care (including older people’s care)
  • The rating for Medical care remained inadequate overall. Safe and well led remained inadequate, effective had gone down from requires improvement to inadequate. Caring and responsive remained rated as requires improvement. The service did not manage patient safety incidents well. Staff recognised incidents, but the quality of investigations was not always robust. The service did not control infection risk well. The service did not ensure that premises was safe. Staff did not keep appropriate records of patients’ care and treatment. Staff did not understand how to protect patients from abuse. The service provided mandatory training in key skills to all staff but not all staff had completed it, particularly medical staff. The service did not have enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment. Staff did not always have access to up-to-date, accurate and comprehensive information on patients’ care and treatment. Staff did not understand their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. Staff did not always care for patients with compassion. Staff did not always involve patients and those close to them in decisions about their care and treatment. The service did not take account of patients’ individual needs. The trust did not have managers at all levels with the right skills and abilities to run a service. There was a significant lack of improvement since our last inspection and lack of capacity in divisional leadership to effect sustainable change. The trust did not have effective systems for identifying risks. We identified risks that the service had not addressed, and the service had failed to act on known past risks. However, the service planned for emergencies and staff understood their roles if one should happen. Staff of different kinds worked together as a team to benefit patients.
Surgery
  • Surgery services remained rated as requires improvement. Safe and responsive remained as requires improvement, effective had improved from requires improvement to good and caring and well led remained good. Staff did not always complete mandatory training in line with the trust’s target. Medical staff did not always complete training to recognise and safeguard patients from abuse. Staff within main theatres, did not always fully complete the debrief section of the World Health Organisation (WHO) and five steps to safer surgery checklist. The service did not always have enough nursing staff to keep people safe from avoidable harm and to provide the right care and treatment. Patients did not always receive their medication at the right time. People could not always access the service when they needed it. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were not always in line with good practice. The timeliness of complaint responses did not meet local policy targets. Main theatres did not always complete adequate assurance audits. However, the service controlled infection risk well, kept detailed records of patients’ care and managed patient safety incidents well. The service provided care and treatment based on national guidance and managers monitored the effectiveness of care and treatment. Staff of different kinds worked together as a team to benefit patients. Staff understood how and when to assess whether a patient had the capacity to make decisions about their care. Staff cared for patients with compassion, provided emotional support to patients and involved patients and those close to them in decisions about their care and treatment. The trust planned and provided services in a way that met the needs of local people and took account of patients’ individual needs. Managers had the right skills and abilities and promoted a positive culture. Surgery had a vision for what it wanted to achieve and workable plans to turn it into action. The service managed risks effectively. The service engaged well with patients, staff, the public and local organisations.
Maternity
  • The rating for maternity had improved to requires improvement overall. Safe and well led had improved from inadequate to requires improvement, responsive had improved from inadequate to good, effective had improved from requires improvement to good and caring remained good. Some mandatory training and safeguarding training rates did not meet trust targets. The department had midwifery vacancies which meant that some clinical areas were short staffed at times. Staff were not always aware of a procedure to ensure that agency midwives had received suitable training, were competent and that swipe card access to the unit was monitored. The number of midwives and doctors whom had received training to be competent in identifying small for gestational age babies was low. Several of the senior leadership roles were locum or interim posts. There was no formal vision or strategy in place. There was a lack of effective communication to staff about changes taking place or planned in the unit. Whilst there appeared to be a good culture in the unit, staff felt uncertain about their future direction due to changes in leaders. However, the service controlled infection risks well and had suitable premises and equipment. Staff completed appropriate records and risk assessments. The service managed medicines and safety incidents well. The service had taken action to update policies in line with national guidance however this remained ongoing at the time of inspection. The service carried out audits and evaluations to ensure the compliance and the effectiveness of care provision. Staff cared for women and their families with compassion, provided emotional support and involved women and those close to them in decisions about their care and treatment. The service planned and provided services to meet the needs and wishes of its service users and took account of peoples’ individual needs. Governance processes were improving.
Gynaecology
  • Gynaecology was rated as requires improvement overall. Safe, responsive and well led were rated as requires improvement. Effective and caring were rated as good. Mandatory training compliance rates were poor for both nursing and medical staff. Not all nurses had the appropriate competency based skills. There was a high use of locum medical staff, and not all had relevant skills to undertake ultrasound scanning. The service did not routinely audit the effectiveness of care and treatment and use the findings to improve. Timeliness of complaints needed to improve. Concerns raised by staff were not always acted upon in a timely manner. Staff felt there was limited action taken and were not empowered to improve the quality of care. However, there were systems in place to manage infection prevention and control and medicine management. Staff worked together to benefit patients and cared for patients with compassion. The service took account of individual patient needs.
Services for children and young people
  • The rating of children and young people’s services remained good. Safe, effective, caring and responsive remained good, well led had gone down from good to requires improvement. Nursing staff mandatory training compliance was close to the trust target. Staff had training on how to recognise and report abuse and knew how to protect patients. Staff kept detailed records of patients’ care and treatment which was based on national guidance, completed and updated risk assessments for each patient and followed best practice when prescribing, giving, recording and storing medicines. The service had enough nursing and medical staff with the right qualifications, skills, training and experience. Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005 and cared for patients with compassion; involving them in decisions about their care where appropriate. Managers appraised staff’s work and staff of different specialities worked together as a team. Waiting times from referral to treatment were in line with good practice. Managers at all levels in the service had the right skills and abilities to run a service and promoted a positive culture that supported and valued staff. The service had effective systems for identifying risks and engaged with patients and staff to plan and manage appropriate services. However, mandatory training compliance for medical staff did not meet trust target for any of the modules. Safeguarding children level three training compliance for nursing and medical staff did not meet trust target and the service did not have enough consultants to meet with royal college of paediatric and child health (RCPCH) guidance. Governance structures were not embedded, not robust and did not give enough consideration to children and young people’s services or monitor the progress of the service strategy which staff were unaware of.
End of life care
  • The rating for end of life care went down to inadequate overall. Safety remained requires improvement. Effective remained inadequate, responsive went down from good to inadequate and well led went down from requires improvement to inadequate. Caring remained good. Use of the individualised plan of care (IPOC) had not been embedded throughout the trust which meant patients did not always receive person-centred care that met their needs. Not all records reviewed contained documentation about ceilings of treatment. Palliative consultant staffing was not in line national guidance and senior leadership did not take ownership of end of life care or have sufficient oversight of performance within the service. We were not assured that risks were escalated appropriately. There had been a failure to address previous concerns. There remained a lack of ownership and oversight for the service, end of life care was not seen as a priority. There was no stable leadership team to support and promote end of life care. Data provided to demonstrate key performance metrics was inaccurate. There was no effective strategy in place for end of life care. There had been no improvement in the development or engagement of the strategy.
Outpatients
  • The rating for outpatients remained requires improvement. Safe had improved form requires improvement to good and caring remained good. Responsive and well led remained requires improvement, effective is not rated. Some outpatient areas did not meet the needs of the service and impacted on staff ability to protect patients’ privacy and dignity. Outpatient areas did not routinely audit the effectiveness of care and treatment and use the findings to improve them. Non-admitted referral to treatment pathway rates were below the trust’s operational standard and the England average. The trust did not routinely collect data on late starting clinics or patient waits in outpatients. The outpatient’s department had no local vision. We were not assured that local risk and performance was monitored appropriately. The trust did not have processes in place to engage with patients, the general public and local organisations. Processes and systems of accountability within clinical business units were not always effective. However, the service managed patient safety incidents and medicines well and kept appropriate records of patients’ care and treatment. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service made sure staff were competent for their roles. Staff of different kinds worked together as a team to benefit patients. Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. Staff cared for patients with compassion. The service treated concerns and complaints seriously. The service had managers at all levels with the right skills and abilities to run a service and they promoted a positive culture.
Diagnostic imaging
  • Diagnostic Imaging was rated as inadequate overall. Safe, and well led were rated as inadequate. Responsive was rated as requires improvement. Caring was rated as good. Effective was not rated. Staff did not recognise incidents or report them. Staff were unclear about their understanding and responsibility when administering contrast media. The service had not ensured that policies and procedures were in place across the diagnostic imaging department. Learning from incidents and complaints were not shared effectively with staff. There was not an effective management team in place, staff morale was low, and staff felt there was a disconnect between themselves and managers. The service did not have effective systems in place for identifying, escalating and acting to eliminate or reduce risk. However, staff worked together to benefit patients and cared for patients with compassion. The service took account of individual patient needs.

4 April 2018

During a routine inspection

Our rating of the trust went down. We rated it as inadequate because:

Safe and well led were rated as inadequate, effective, and responsive were rated as requires improvement and caring was rated as good.

Our inspection of the core services covered The Queen Elizabeth Hospital King’s Lynn only. Our decisions on overall ratings take into account, for example, the relative size of services and we use our professional judgement to reach a fair and balanced rating.

On the basis of this inspection, the Chief Inspector of Hospitals has recommended that the trust be placed into special measures.

The Queen Elizabeth Hospital

  • Urgent and Emergency care was rated as inadequate overall. The ratings for safe, effective, responsive and well-led all went down, whilst caring remained good. Effective and responsive went down from good to requires improvement. Safe went down from requires improvement to inadequate and well-led went down from good to inadequate. The service did not always have systems in place to ensure that staff were able to identify and respond appropriately to changing risks to people who used services. The design and use of facilities and premises in the emergency department did not always keep people safe. The numbers and skill mix of nursing and medical staff were not always suitable for the needs of the emergency department. Learning from serious incidents was not always robust. A significant number of clinical guidelines were out of date for review. Performance in national audits was mixed and there was limited evidence of learning and action when national audit results were in the lower UK quartile. We were not provided with evidence that urgent and emergency services were following a trust-wide process to ensure that compliance with new or updated National Institute of Health and Care Excellence (NICE) guidance was regularly reviewed. There were a number of factors impacting on flow through the department and policies in place to manage escalation and crowding lacked clarity. Leaders had not always taken action to address concerns and learning from external reviews was not effectively used to make improvements. There were not always robust arrangements for risk or information management. However, medicines storage and compliance with hand hygiene had improved since our last inspection. Staff were knowledgeable about the Mental Capacity Act and about how to respond if a patient complained. There was a positive culture and leaders were perceived to be visible and supportive.
  • Medical care was rated as inadequate overall. The question of safety went down from requires improvement to inadequate. Effective, caring and responsive all went down good to requires improvement. Well led went down from good to inadequate. Staff turnover, sickness and vacancy rates were higher that the trust targets. There was evidence that low nurse staffing levels were impacting on patient safety because staff did not have capacity to assess patient risk and meet basic food, drink and toileting needs promptly. Medicines management processes were not robust and patient records were poor in their completion and clarity. There was limited evidence that audit results were acted upon as a means of continuous quality improvement for the service. Staff knowledge of mental capacity assessments was poor and mental capacity assessments were not being completed appropriately and consistently. Although staff displayed a kind, compassionate and dedicated approach to patients and relatives, they did not have the time or capacity to provide the level of support they would like. Access and flow was not being effectively managed. Services were not always delivered in a way that was responsive to people’s individual needs. Poor support and communication from the trust senior team had led to a poor culture and morale, with staff feeling disengaged and under pressure. Arrangements for governance and risk management were not robust.
  • Surgery services went down from good to requires improvement overall. The questions of safety, effectiveness, responsive and well led went down from good to requires improvement. The question of caring remained rated as good. Mandatory training compliance was below target levels and some staff did not follow infection prevention and control procedures. Records were not stored securely on all wards and we had concerns relating to the safe management of medicines. We were not assured that incidents were always identified, reported and investigated in a timely way or that duty of candour requirements were consistently met. Staff did not always understand or correctly implement the Mental Capacity Act and Deprivation of Liberty Safeguards. Staff appraisal rates were below target and implementation of local clinical audit was variable. Access and flow was not always managed effectively, services were not always planned to meet patients’ needs, and the documentation of patients’ individual needs was not always completed in a timely way. There was no vision and strategy in place for the service and there were concerns around governance processes relating to sharing of information, risk management and performance reporting. Staff gave variable feedback on the response of leaders to their concerns. However, staff treated patients with kindness and compassion and there were improvements in relation to decontamination of cystoscopes and the consultant rota for gastric bleeds.
  • We rated maternity as inadequate overall. We rated safe, responsive and well led as inadequate, we rated effective as requires improvement and caring remained rated as good. There were concerns relating to the safety of the service in respect of risk assessment procedures for the environment, care planning for high-risk women, equipment and emergency medicines monitoring and mandatory and safeguarding training compliance rates. We found that leadership within the service had broken down and that the service’s leaders did not have oversight of risk or quality improvement within the service.
  • End of life care remained rated as requires improvement overall. Safe went down from good to requires improvement, effective went down from good to inadequate, well-led stayed requires improvement, responsive improved from requires improvement to good and caring remained good. The trust's ‘do not attempt cardio-pulmonary resuscitation’ (DNACPR) forms did not meet national standards and were not always completed correctly. There was lack of assurances that the Mental Capacity Act and Deprivation of Liberty Safeguards were always being implemented for people who had DNACPR documentation. The end of life care strategy was ratified in February 2018 and therefore had not been embedded fully. Implementation of the end of life care strategy and various initiatives such as the amber care bundle and the IPOC have been very slow due to lack of engagement from the medical team. In addition, due to staff shortage on the wards, training had to be cancelled, which meant the IPOC had not been fully rolled out or effectively used.
  • Outpatient services were rated as requires improvement overall. Safe, responsive and well led were rated as requires improvement and caring was rated as good, effective is not rated. We previously inspected outpatients jointly with diagnostic imaging so we cannot compare our new ratings directly with previous ratings There were concerns related to the performance in areas such as infection prevention and control, mandatory training, safety checks prior to minor procedures and resuscitation equipment. There was a lack of performance and patient outcome audit, and processes to improve the service. Leadership was not robust with a lack of oversight of governance and risk to the service and poor senior leadership engagement. However, the service had a better than England average percentage for two-week cancer referrals and feedback from patients was positive.
  • Diagnostic imaging was rated as requires improvement overall. The question of safety, responsive and well led were rated as requires improvement. Caring was rated good, effective is not rated. We previously inspected diagnostic imaging jointly with outpatients so we cannot compare our new ratings directly with previous ratings. There was a potential risk of abuse to patients and staff as chaperones were not routinely offered or provided during intimate imaging procedures. Services did not meet the needs of local people as patients were unable to access diagnostic imaging services in a timely manner and we were not assured the service had robust structures, processes and systems in place to support the delivery of high quality person centred care especially in the radiology department. However, the service held Imaging Services Accreditation, (ISAS), provided care and treatment based on national guidance and carried out audit to monitor the effectiveness. Feedback from patients confirmed that staff treated them well and with kindness.
  • On this inspection we did not inspect critical care and children and young people services. The ratings we gave to these services on the previous inspection in the comprehensive inspection in June 2015 and focused inspection in June 2016 are part of the overall rating awarded to the trust this time.

9-11 June 2015

During an inspection looking at part of the service

The Care Quality Commission (CQC) carried out a scheduled focused inspection at The Queen Elizabeth Hospital Kings Lynn between the 9 and 11 June 2015. The trust had been placed into special measures in October 2013 due to serious failings and had undergone a full comprehensive inspection in July 2014 where we rated the trust as requires improvement. We carried out the focused inspection in 2015 to review services that had been previously rated as requires improvement or inadequate and to consider the current status of the trust in relation to special measures. Critical care services had been previously rated as good throughout and therefore were not re-inspected. We did not formally reassess the key question relating to caring as this had been rated as good throughout in 2014

The trust had two outstanding warning notices in relation to safeguarding (safe and ethical restraint) and medicines management which were reviewed as part of this inspection. We judged that the trust was now meeting the requirements under the regulations and therefore we have removed the warning notices.

During this inspection we inspected those areas rated as requiring improvement or inadequate at our previous inspection in 2014. We also reassessed the leadership capacity and capability of the senior management team. The senior leaders had recently been appointed and the trust board consisted of a new chief executive, new director of nursing and a new medical director. The chair had been appointed the day of our previous inspection and the chief operating officer was an interim appointment. Governance systems had been reviewed and strengthened and the culture of the trust had become more open and quality focused.

Our key findings were as follows:

  • In all areas staff were kind, caring and compassionate towards patients.
  • Overall the trust leadership is strong and cohesive with a clear vision and strategy, the exceptions to this being some local leadership issues within maternity and end of life services.
  • There is good direction and leadership from the chief executive which resonates down through the leadership team.
  • There is good communication throughout the organisation and the morale and culture of the organisation has improved since our comprehensive inspection in 2014.
  • Increased stability of the board has improved the pace of change at the trust and the confidence in the ability to drive improvements throughout the trust.
  • Significant improvements had been made throughout many specialties including the emergency department, medicine and surgery.
  • Evidence was not consistently recorded in the emergency department due to the combined use of paper and electronic systems.
  • Patient assessments and records were not consistent or updated to reflect changes in a patient’s condition within medicine
  • The total number of cancelled operations remained high however a downward trend was beginning to emerge in the number of cancelled operations alongside an improving performance on patients rebooked within 28 days.
  • The previous concerns regarding privacy and dignity for patients within the breast unit remained in place however the service was due to relocate to new premises which would eradicate the issues.
  • Patient outcomes were not being reviewed due to a lack of clinical outcome information within the maternity service.
  • Nurse staffing was insufficient in both the neonatal and paediatric unit.
  • Complaints and significant events were not being appropriately coded for end of life care so information was not being used to improve services
  • The hospital used a prescription and medication administration record chart for patients which facilitated the safe administration of medicines. Medicines interventions by a pharmacist were recorded on the prescription charts to help guide staff in the safe administration of medicines.

Management of medicines had improved across the trust with the exception of some storage concerns within outpatients and storage of intravenous fluids within the emergency department

In summary urgent and emergency care, medical care and surgery which had previously been rated as requires improvement have now been rated as good, alongside critical care and children and young people’s services which had been rated as Good in 2014. Maternity and gynaecology services, end of life care services and outpatients services still require improvement.

We saw several areas of outstanding practice including:

  • The waiting area for children within the emergency department, whilst small, was designed in an outstanding way which responsive to all children who visit the service.
  • The commitment of midwifery staff to develop effective midwifery services for women from the King’s Lynn area. Midwifery staff rotated throughout the service to maintain their knowledge and skills.
  • Relatives and staff told us the paediatric team were a well organised and effective team who provided a good service for the children and families of the Kings Lynn area.

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

Importantly, the trust must:

  • Ensure that medicines are stored securely at all times including those within the outpatients department, and IV fluids in the emergency department.
  • Ensure that resuscitation trolleys are checked in accordance with the trust policy and resuscitation council guidelines.
  • Ensure that an accurate record of each patients care is recorded.
  • Ensure that the staffing is in line with national guidance. Examples include but are not exclusive to: registered children’s nurses in the emergency department, patients requiring non-invasive ventilation, paediatric staff on the children’s ward, endoscopy medical staffing, midwives in maternity and staffing on the neonatal intensive care unit.
  • Ensure that there is a robust governance system to assess monitor and improve the quality of services especially in respect of decontamination of flexible cystoscopes, clinical outcome data within maternity services and the management of ASIs (Appointment Slot Issues) within outpatients.

Overall we observed marked improvement in the quality of care being delivered by the trust and we commend the new leadership for the steps that they have taken.There is no doubt that leadership of the trust is much stronger than in the past. This has helped to drive very considerable improvements in the quality and safety of patient care in a relatively short period of time. Importantly more of the core services are now rated as ‘good’ than when we inspected in 2014. I am therefore recommending that the trust should now come out of special measures

Professor Sir Mike Richards

Chief Inspector of Hospitals

1-3 July 2014

During a routine inspection

The Queen Elizabeth Hospital is an established 488 bed general hospital which, together with 12 cots in the newly-refurbished neonatal intensive care unit (NICU), provides healthcare services to West and North Norfolk, in addition to parts of Breckland, Cambridgeshire and South Lincolnshire. The trust provides a comprehensive range of specialist, acute, obstetrics and community-based services. The Macmillan Centre provides palliative care for patients with cancer and other chronic illnesses, and the radiology department is one of only five units to have achieved the Imaging Standards Accreditation Scheme status. The trust also works in partnership with Bourne Hall, to bring IVF and fertility treatment locally. The trust achieved Foundation Trust status in 2011.

The Care Quality Commission (CQC) carried out a comprehensive inspection between the 1 and 3 July 2014. We carried out this comprehensive inspection because the Queen Elizabeth Hospital King's Lynn NHS Foundation Trust had been identified as potentially high risk on the Care Quality Commission’s (CQC) Intelligent Monitoring system. The trust was inspected by CQC in August 2013, and was subsequently placed into ‘special measures’ in October 2013 due to the serious failings identified. We also received some whistleblowing accounts that gave us concerns.

The trust had four outstanding warning notices and eight compliance actions, which were reviewed as part of this inspection. We noted that improvements had been made around consent to care and treatment, care and welfare of patients, nutrition and hydration, incident reporting, respecting and involving service users, complaints, records, and co-operating with other providers. However, the service remained non-compliant with the regulations on staffing, support for workers, safeguarding and medicines management. The risk around medicines management has increased since our last inspection, and was having a moderate impact on the service and patients.

The trust remains non-compliant with the warning notice issued on safeguarding. This is because the trust has failed to improve the training and procedures for undertaking safe and ethical restraint of patients, and therefore patients and staff remained at significant risk.

The comprehensive inspections result in a trust being assigned a rating of ‘outstanding’, ‘good’, ‘requires improvement’ or ‘inadequate’. Each section of the service receives an individual rating, which, in turn, informs an overall trust rating. The inspection found that overall, the trust has a rating of requires improvement.

Our key findings were as follows:

  • In all areas, we found that staff were kind, caring and compassionate towards patients.
  • Good progress had been made in strengthening the executive capacity of the board and establishing a pace of change towards improving quality.
  • Evident support for the interim CEO’s style and influence across the trust, engendering a commitment to change and improvement.
  • Staff were proud to work in the trust.
  • Patients received adequate nutrition and hydration; however, medical wards, including Pentney, Necton and Oxborough, were reminded of their responsibility around nutrition and hydration needs during the inspection.
  • There was a ‘disconnect’ between the local leadership and the trust board leadership styles, particularly in A&E and in surgery. This meant that communication messages across all areas were mixed and not consistent.
  • While risks were robustly identified and placed on the risk register, there was little evidence of any action taken following this identification and recording.
  • Resuscitation support, equipment, training and compliance with Resuscitation Council guidance were not consistent in practice or implementation throughout the trust.
  • Management of medicines, including storage and recording of temperatures, was not always in accordance with national guidelines.
  • Medical staffing levels across the medicine directorate were not sufficient.
  • Skill mix across nursing staff required review to ensure that the skill mix was appropriate and to ensure the safety of patients.
  • Nurse staffing was insufficient in both the neonatal and the paediatric unit.
  • Environmentally, there were concerns with the outpatients department, which required refurbishment improvement.
  • The mortuary environment required refurbishment.
  • The A&E environment for paediatric care was not in line with national requirements.
  • There were insufficient side rooms in which to isolate high risk patients across the trust.
  • Outpatients clinics were overbooked and cancellations frequently occurred.
  • The elective surgery cancellation rates were significantly higher than expected, and therefore the service was not able to meet the needs of the local people.
  • Infection control standards and practices around cleaning and equipment were not consistent.

We saw several areas of outstanding practice, including:

  • The use and implementation of guideline-specific simplified care bundles through the acute medical unit (AMU) into the hospital, which have improved patient care and patient outcomes.
  • The use of ‘Project Search’, which supports people in the community with a learning disability, to gain work experience and employment, in the community, and within the hospital.
  • The endoscopy service, operating a single sex patient list for elective cases.
  • The expert support available to babies transferred home with breathing or feeding requirement.
  • The initiative of the director of nursing to bring together all nursing leaders across the locality to review issues affecting the quality of services to patients transferring to the independent sector.
  • Daily surgical consultant ward rounds.
  • The establishment of dementia coaches to supplement the dementia team in supporting patients and families.

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

Importantly, the trust must:

  • Ensure that resuscitation support, equipment and training is consistent throughout the trust and compliance with Resuscitation Council guidance is achieved.
  • Ensure that the management of medicines, including storage and recording of temperatures, is done in accordance with national guidelines.
  • Ensure that patients are protected from the risks associated with the unsafe use and management of medicines, by means of ensuring that appropriate arrangements for the recording and use of medicines are in place.
  • Review and improve medical staffing levels across the medicine directorate to ensure the safety of patients.
  • Embed skill mix assessments for nursing staff to ensure skill mix is appropriate and ensures the safety of patients.
  • Review nurse staffing levels in both the neonatal and the paediatric unit.
  • Improve the environment in the emergency department, including paediatric A&E, and outpatients; the mortuary also required improvement.
  • Improve access to training for both mandatory training requirements, and for staff 'required to undertake the role'.
  • Review the elective surgery cancellation rates, and review the elective surgery service demand.
  • Review and improve cancellation rates within outpatients.
  • Ensure that patients are protected from infections by appropriate infection prevention and control practices.
  • Ensure that there are sufficient numbers of staff on duty who are trained to restrain patients.
  • Ensure that its governance systems, including committee structures, divisional structures, shared learning and incident investigation, are improved and embedded.
  • Ensure that there are clear reporting processes and risk monitoring in place for the emergency planning and local security work, including the testing of resilience plans.
  • Ensure that frontline staff are trained appropriately in breakaway techniques.

In addition, the trust should:

  • Ensure that equipment storage within A&E resuscitation areas is improved.
  • Ensure that the environment and storage of equipment in the neonatal unit is more organised.
  • Ensure that patients are discharged in a timely manner across all wards and, in particular, at the end of their life.
  • Ensure that outpatient clinics are not overbooked, and cancellations are minimised.
  • Review the equipment used to transport the deceased from the wards to the mortuary to ensure it respects people’s privacy and dignity.
  • Ensure that there are sufficient numbers of staff CBRN trained. (CBRN refers to chemical, biological, radiological and nuclear equipment and policies.)
  • Ensure that plans to strategically move over to NEWS are agreed and implemented. (The NEWS system relates to the management of deteriorating patients.)
  • Review the availability of hydration on Pentney, Oxborough and Necton Wards.
  • Ensure that patients are discharged in a timely manner.
  • Ensure that all serious incident investigations are undertaken by trained investigators.
  • Ensure that all board members have revised training on emergency planning, business continuity and local security specialists.

We would normally take enforcement action in these instances; however, as the trust is already in special measures we have informed the regulator, Monitor, of these breaches, who will make sure they are appropriately addressed and that progress is monitored through the special measures action plan.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Use of resources

These reports look at how NHS hospital trusts use resources, and give recommendations for improvement where needed. They are based on assessments carried out by NHS Improvement, alongside scheduled inspections led by CQC. We’re currently piloting how we work together to confirm the findings of these assessments and present the reports and ratings alongside our other inspection information. The Use of Resources reports include a ‘shadow’ (indicative) rating for the trust’s use of resources.

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.