United Lincolnshire Hospitals NHS Trust

The United Lincolnshire Hospitals NHS Trust has three main hospitals and provides a range of hospital-based medical, surgical, paediatric, obstetric and gynaecological services to the 700,000 people of Lincolnshire. The trust employs 7,500 staff.

We inspected United Lincolnshire Hospitals NHS Trust between the 10-14, 18-19 and 26-27 October 2016. We also carried out unannounced inspections to Lincoln County Hospital and Pilgrim Hospital on 24, 25 and 27 October 2016. On 19 December we carried out an unannounced inspection to Pilgrim Hospitals ED and medical wards in response to some information of concern we had received.

We included the following locations as part of the inspection:

• Lincoln County Hospital
• Pilgrim Hospital
• Grantham Hospital

We did not inspect County Hospital Louth, John Coupland Hospital in Gainsborough, Skegness and District General Hospital or the Johnson Community Hospital in Spalding.

We rated United Lincolnshire Hospitals NHS Trust as Inadequate overall.

We rated Pilgrim Hospital as Inadequate, Lincoln County Hospital as Requires Improvement, and Grantham Hospital as Good.

Our key findings were as follows:

Safety

• There were not robust arrangements in place to respond to emergencies and major incidents. A major incident plan and action cards were available but were not in date nor were they easily accessible to staff. Equipment for use in a major incident had not been checked and some was not in working order. The trust rectified these concerns following the inspection.
• Where patients had met the trust criteria for sepsis screening, not all patients were screened appropriately; this put patients at risk of harm because they did not receive the correct treatment in a timely manner and in line with national and local guidelines.
• The trust was not assured it was meeting the obligations of the Duty of Candour regulation.
• The trust was not assured it had adequate arrangements in place to meet its safeguarding responsibilities.
• We identified risks to patient safety. There were no clear arrangements for out of hours gastrointestinal bleed treatment at Pilgrim Hospital.
• We were not assured all incidents were reported; nor were we assured that they were investigated in a timely way.
• We received a mixed picture regarding staff receiving feedback from incidents. Some areas were able to tell us they received feedback and learning through email and staff meetings. In other areas, staff did not feel they received feedback.
• We were not assured actions identified from root cause analysis investigations were being implemented to improve the safety of care being provided.
• Medicines related incidents were the second highest number of incidents reported in the trust. Between July to September 2016, omitted medicines accounted for 36% of all incidents reported in the trust. Of these 84 omissions related to critical medicines where there was a significant risk of harm if these medicines were delayed or omitted. This corresponded with data collected during the inspection week.

• We found staff knew how to report incidents through the trusts electronic incident reporting system.
• The trust used a nationally recognised staffing tool for to determine nursing staffing levels alongside patient acuity and dependency. We were told this was also used in conjunction with professional judgement principles.
• The proportion of consultants reported to be working at the trust was about the same as the England average. The proportion of junior doctors (foundation years one and two) reported to be working at the trust was higher than the England average.

Effectiveness

• Whilst Information about patient’s care and treatment, and their outcomes, was routinely collected and monitored, outcomes for patients were sometimes below expectations when compared with similar services at a national level.
• There were no protocols in place for the management and manipulation of fractures or fractured neck of femur (a crack or break in the top of the thigh bone).
• The trust used a maternity dashboard but the data was not rated to enable themes and trends or benchmarking comparisons to be easily made.
• There was no policy for restraining patients. The trust did not consistently record the numbers of patients who had received rapid tranquilisation medication or recorded any episodes of restraint of patients.
• Procedures, policies and clinical guidelines were easily accessible through the trust’s intranet. Generally we found policies and procedures and clinical guidelines were up to date and reflected national guidance.
• Care pathways; multidisciplinary plans of anticipated care and timeframes were in place for specific conditions or sets of symptoms.
• Both of the hospitals endoscopy departments were Joint Advisory Group (JAG) accredited.
• Mortality Review Assurance Group (MoRAG) meetings were held monthly across all medical specialties to discuss patient deaths.
• Between April 2015 and March 2016, 60% of babies were born normally, which was the same as the England average. In the same period trust wide, caesarean section figures were the same as the England average at 26%.
• The trust submitted data to the sentinel stroke national audit programme (SSNAP). Lincoln County Hospital achieved grade B SSNAP level and Pilgrim hospital was rated as level C.
• Between February 2015 and January 2016, medical patients at the trust had a lower than expected risk of readmission for non-elective and elective admissions.

Caring

• We observed isolated instances at Pilgrim Hospital where staff had not treated patients with dignity, respect and compassion.
• At times, staff focused on the task instead of the patients as individuals. Staff were providing one to one support for some patients as they had been assessed as being at increased risk. However, when providing one to one support, staff did not always engage with patients meaningfully.
• However, in most of the areas we inspected staff responded compassionately when patients required help and supported patients emotionally.
• Generally staff interacted positively with patients and we observed that patients were treated with kindness, dignity, respect and compassion while they receive care and treatment. Feedback from patients was mostly positive about the care and treatment they had received.
• The trust had introduced a carer’s badge, which enabled any family members and trusted friends to be involved in the care of their loved ones. The carers badge encouraged carer involvement, particularly for patients with additional support needs.
• The trust’s Friends and Family Test performance was generally worse than the England Average between October 2015 and September 2016. In the latest period, September 2016, the trusts performance was worse than the England average (91% compared to an England average of 96%).
• In the Cancer Patient Experience Survey 2015 the trust was not in the top 20% of trusts for any of the 50 questions, was in the middle 60% for 40 questions and in the bottom 20% for 10 questions.

Responsive

• Patients had been unable to access services in a timely way for an initial assessment, diagnosis or treatment including when cancer was suspected. During 2016 the trust has failed to meet the majority of the national standards for the cancer referral to treatment targets.
• The trust had failed to meet the national standard for the referral to treatment time for incomplete pathways for the previous three consecutive months.
• There were significant delays in patients receiving their follow up outpatient appointment across several specialities with 3,772 appointments being overdue by more than six weeks.

• The trust’s referral to treatment time (RTT) for admitted pathways for medical services was worse than the England overall performance between October 2015 and October 2016.
• The trust reported a high number of bed moves (40%) over 11 months, 595 of which occurred after 10pm within a six-month reporting period.
• Systems were not robust to identify vulnerable patient groups which included patients living with dementia and patients with learning disabilities.
• Although there had been improvements in the management of complaints within the trust since our last inspection, the response times were still not in line with the trust's policy.
• The trust's bed occupancy rate was similar to the England average for Quarters 1 to 3 2015/2016 and below the England average for Q4 2015/2016.
• Site management meetings took place three times each day in the hospitals. These meetings were used to identify the number of available beds, patients who needed admission, were awaiting discharge or were on outlying wards.
• The chaplain teams represented a range of faiths and provided support across all beliefs. Bereavement services were also provided within the chaplaincy service. The team provided a range of specific services including hospital funerals, weddings, birth and death sacraments, memorial services, worship and Holy Communion.

Well led

• We found low levels of staff satisfaction coupled with high levels of stress and work overload. Some staff told us they did not feel respected, valued or appreciated.
• There was a theme in the focus groups and during our contacts with staff which centred on staff telling us they perceived they didn’t feel confident to raise concerns within their work environments. We met with some staff on a one to one basis and talked with other staff in focus groups. Some staff told us they perceived they were being bullied or intimidated.
• Whilst it was isolated to a small number of wards at Pilgrim Hospital, we were not assured that all staff understood the values because we saw care being delivered that was not respectful or compassionate.
• The Friends and Family test scores were lower on average when compared with other trusts. The trust was within the 10% of lowest performing trusts in terms of percentage of patients who would recommend the ward/clinic.
• The trust’s sickness levels between April 2015 and February 2016 were higher than the England average.
• There were weaknesses in the trust's governance framework to support the delivery of good quality care and the trust's vision and strategy.
• We were not assured the board were sufficiently sited on risk.
• The trust did not have systems in place to ensure the Fit and Proper Person regulation was met. We looked at the files of four directors and found the checks made were inconsistent so assurances that directors were fit and proper persons were not in place.
• The trust had failed to respond to the concerns we raised in the 2014 and 2015 CQC inspections in relation to the outpatient service at Lincoln County Hospital.
• The trust had a vision and a set of values and generally staff knew about these.
• In the past two years, the governance arrangements in the maternity service had been strengthened significantly.
• Generally staff knew who the executive team were and felt the Chief Executive was approachable.
• Each hospital had a patient forum which was led by a non-executive director. Patient representatives attended the forums. In addition to this the trust worked with the local Healthwatch to obtain patient feedback.

We saw several areas of outstanding practice including:

Lincoln County Hospital

• The emergency department (ED) inputted hourly data into a specific risk tool which had been created, to give an internal escalation level within ED separate to the site operational escalation level. This tool gave an “at a glance” look at the number of patients in ED, time to triage and first assessment, number of patients in resus, number of ambulance crews waiting and the longest ambulance crew wait. This gave a focus across the trust on where pressure was building and there were local actions for easing pressure.
• The ED had designed and were using a discharge tool ‘TRACKS’ (T-transport, R-relatives/ residential home, A-attire, C-cannula, K-keys, S-safe) to facilitate the safe discharge of older and/or vulnerable patients.
• The trust had introduced a carer’s badge, which enabled any family members and trusted friends to be involved in the care of their loved ones. The carer's badge encouraged carer involvement, particularly for patients with additional needs. Being signed up to the carer's badge also gave carers free parking whilst they were in attendance at the hospital.

• Ashby Ward had just introduced visits from pets called a therapy (PAT) dog. PAT is a charity and volunteers from PAT, along with their own pets, visit care organisations to enable patients to interact with them.
• On the care of the elderly wards a red, amber, green system was used to identify patients who required more assistance than others. Red signified those patients who required the most help, whilst green identified those patients who required the least. This system was also applied to each patient’s menu card to signify the amount of support a patient required with eating. Patients with a green sticker were given their meals first. Staff who took meals to patients with a red sticker then stayed to support the patient to eat their meal.
• Staff on Nocton Ward had introduced sibling activity bags for any siblings of the infants admitted on the ward. This demonstrated a positive approach to involving the whole of the family in the service experience.

Pilgrim Hospital

• The emergency department (ED) was trialling the introduction of a hot meal for those patients who were able to eat at lunchtime.
• The ED inputted hourly data into a specific risk tool, which had been created, to give an internal escalation level within ED separate to the site operational escalation level. This tool gave an ‘at a glance’ look at the number of patients in ED, time to triage and first assessment, number of patients in resus, number of ambulance crews waiting and the longest ambulance crew wait. This gave a focus across the trust on where pressure was building and there were local actions for easing pressure.
• In response to an identified need for early patient rehabilitation, a physiotherapy assistant had been employed to work within the critical care unit. Under the direction of a chartered physiotherapist, the assistant carried out a program of exercises with individual patients to support the rehabilitation process. This included a variety of exercises including the use of cycle peddles to aid the maintenance of muscle tone. Staff spoke positively about this service and of the benefits to patient recovery.
• Staff on the children’s ward had learnt sign language to enhance their communication skills with children who had hearing difficulties.
• The trust had direct access to electronic information held by community services, including GPs. This meant that hospital staff could access up-to-date information about patients, for example, details of their current medicine.

Grantham Hospital

• The emergency department (ED) inputted hourly data into a specific risk tool. The tool gave an “at a glance” look at the number of patients in ED, time to triage and first assessment, number of patients in resuscitation room, number of ambulance crews waiting and the longest ambulance crew wait. This gave a focus across the trust on where pressure was building and there were local actions for easing pressure.

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

Importantly, the trust must:

Lincoln County Hospital

• The trust must take action to ensure staff in the emergency department are appropriately trained and supported to provide the care and support needed by patients at risk of self-harm.
• The trust must take action to ensure all staff working in the emergency department receive appropriate supervision, appraisal and training to enable them to fulfil the requirements of their role.
• The trust must take action to ensure systems and processes are effective in identifying where safety is being compromised and in responding appropriately and without delay. Specifically, systems and processes to identify and respond to the assessment and treatment of sepsis in the emergency department.
• The trust must take action to ensure staff have the appropriate qualifications, competence, skills and experience, in addition to paediatric life support, to care for and treat children safely in the emergency department.
• The trust must continue to ensure systems and processes are effective and that staff respond appropriately in recognising and treating patients in line with the trust’s sepsis six care bundle.
• The trust must take action to ensure ligature risk assessments are undertaken and that ligature cutters are available in all required areas.
• The trust must take action to ensure staff in maternity are appropriately trained and supported to provide recovery care for patient’s post operatively.
• The trust must take action to ensure all staff working in the termination of pregnancy service receive formal counselling training.
• The trust must take action to ensure that the handover process on Nettleham Ward does not compromise patients’ privacy.
• The trust must take action to ensure that sensitive patient groups are not mixed within gynaecology and maternity outpatient areas.
• The trust must ensure the environment within Clinic 6 is reviewed and actions taken to prevent or control the potential risk to patients from infections. The trust must comply with the Health and Social Care Act 2008, Code of Practice on the prevention and control of infections and related guidance.
• The trust must ensure that the drinking water dispensers are cleaned and maintained in accordance with the manufacturer’s instructions including completion of scheduled electrical safety testing, a water hygiene maintenance programme and cleaning schedule.
• The trust must ensure that equipment is appropriately maintained. It must ensure any checks carried out by staff are recorded and done with sufficient frequency and with sufficient knowledge to minimise the risk of potential harm to patients.
• The trust must ensure that patients who are referred to the trust have their referrals reviewed in a timely manner to assess the degree of urgency of the referral.
• The trust must ensure that the patients who require follow up appointments are placed on the waiting list.

Pilgrim Hospital

• The trust must ensure systems and processes are effective in identifying and treating those patients at risk of sepsis.
• The trust must ensure that there are processes in place to ensure that patients whose condition deteriorates are escalated appropriately.

• The trust must take action to ensure safety systems, processes and standard operating procedures are in place to ensure there is an on-call gastrointestinal bleed rota to protect patients from preventable harm.
• The trust must ensure that all staff have an appraisal and are up to date with mandatory training, and ensure staff in the emergency department have received appropriate safeguarding training.
• The trust must ensure staff have the appropriate qualifications, competence, skills and experience, in addition to paediatric life support, to care for and treat children safely in the emergency department.
• The trust must ensure there is an adequate standard of cleaning in the emergency department.
• The trust must ensure staff comply with hand decontamination in the emergency department.
• The trust must ensure that patient records in the emergency department are complete; specifically that risk assessments, pain scores and peripheral cannula care are documented.
• The trust must ensure patient records are kept securely in the ambulatory emergency care unit (AEC).
• The trust must ensure governance and risk management arrangements are robust and are suitable to protect patients from harm.
• The trust must take action to ensure there is a robust process in place to report incidents appropriately and investigate incidents in a timely manner and staff receive feedback, lessons are learnt and shared learning occurs.
• The trust must take action to ensure safety systems, processes and standard operating procedures are in place to ensure there is an on-call gastrointestinal bleed rota to protect patients from preventable harm.
• The trust must take action to ensure systems and processes are effective staff respond appropriately in administering treatment in the recommended time frame in accordance to the sepsis six bundle of care.
• The trust must take action to ensure systems, processes are in place to reduce the significant number of omitted medication doses, and any omissions recorded in accordance with trust policy.
• The trust must take action to ensure ligature risk assessments are undertaken in all required areas.
• The trust must take action to ensure ligature cutters are accessible and available when needed to meet the needs of people using the service.
• The trust must take action to ensure there are sufficient numbers of suitably qualified competent, skilled and experienced staff to meet the identified needs of patients.
• The trust must take action to ensure the Care Quality Commission (CQC) is informed about any DoLS applications made in line with Regulation 18 of the Health and Social Care Act 2008 (Registrations) Regulations 2014.
• The trust must Include evidence of outcomes and learning from complaints within communication with staff.
• The trust must take action to ensure that people are told when something goes wrong.
• The trust must take action to ensure that emergency equipment in the antenatal day unit is checked when the unit is in use.
• The trust must take actions to ensure that staff within gynaecology have greater involvement in the reporting and monitoring of incidents. This would include sharing learning from historical incidents.
• The trust must take action to ensure staff in maternity are appropriately trained and supported to provide recovery care for patients post operatively.
• The trust must take action to ensure that all staff receive basic life support and infection prevention and control training.
• The trust must take action to ensure all staff working in the termination of pregnancy service receive formal counselling training.
• The trust must take action to ensure that all paperwork is correctly completed to ensure Human Tissue Authority guidance is followed in the disposal of fetal remains.
• The trust must take action to ensure that when gynaecology patients are admitted the inpatient records are found as soon as possible. Where temporary patient notes are created, these must be combined with inpatient records as quickly as possible.
• The trust must take action to ensure that the area designated as the labour ward recovery area is ready for use with privacy maintained at all times.
• The trust must complete a ligature risk assessment of the children’s ward where Child and Adolescent Mental Health Services (CAMHS) patients are admitted.
• The trust must ensure paediatric medical staffing is compliant with the Royal College of Paediatrics and Child Health (RCPCH) standards.
• The trust must ensure nurse staffing on the children’s ward is in accordance with Royal College of Nursing (RCN) (2013) staffing guidance.
• The trust must ensure there is at least one nurse per shift in all children's clinical areas trained in either advanced paediatric life support (APLS) or European paediatric life support (EPLS) as identified in the RCN (2013) staffing guidance.
• The trust must ensure staff adhere to the trust’s screening guidelines for screening for sepsis.
• The trust must ensure the management of health records enables the safe care and treatment of patients, compliance with information governance requirements and ensures patient confidentiality is maintained. This includes the availability, the condition and storage of medical records.
• The trust must ensure that equipment is appropriately maintained. Ensure any checks carried out by staff are recorded and done with sufficient frequency and with sufficient knowledge to minimise the risk of potential harm to patients.
• The trust must ensure that patients who are referred to the trust have their referrals reviewed in a timely manner to assess the degree of urgency of the referral.
• The trust must ensure that the patients who require follow up appointments do not suffer unnecessary delays and are placed on the waiting list.
• The trust must ensure patients have complete and recorded outcomes to ensure there are documented decisions and actions in relation to their treatment and care.

Grantham Hospital

• The trust must take action to ensure that the environment in the emergency department is fit for purpose.
• The trust must take action to ensure staff have the appropriate qualifications, competence, skills and experience, in addition to paediatric life support, to care for and treat children safely in the emergency department.
• The trust must ensure there are sufficient numbers of medical and nursing staff working in the emergency department who have up to date and appropriate adult and children resuscitation qualifications.

Provider wide

• The trust must take action to ensure they are compliant with the Fit and Proper Person requirement.
• The trust must ensure they are compliant with the requirements of the Duty of Candour.
• The trust must ensure there is good governance within the organisation.

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