Our rating of services stayed the same. We rated it them as good because:

A summary of this hospital appears in the overall summary above.

The inspection of Grantham and District Hospital was carried out on 30 April 2014 as part of the wider inspection of United Lincolnshire Hospitals NHS Trust. The trust was chosen for inspection because it was an example of a high risk trust. In 2013, the Keogh Mortality Review found significant concerns, and the trust was placed in ‘special measures’ as a result.

The hospital was rated as ‘requires improvement’ overall. Core services for accident and emergency (A&E) and medical care were found overall to require improvement.

Our key findings were as follows:

• There was a shortage of consultants and paediatric staff in A&E.
• Poor completion of patient records in surgery.
• Poor dissemination of learning from incidents within maternity outpatients.
• The hospital was advertising a midwifery-led birthing service, despite this closing in February 2014.
• There was a lack of a dedicated resuscitation emergency call number, paediatric team or paediatric bleep system. However, there is a system in place to summon assistance.
• Although the policies and procedures for children and young people’s services were in line with national guidance, they did not reflect the service that was being provided at the time of the inspection.
• The time taken for patients to be handed over from ambulance crews to the A&E department was in excess of targets set.
• The hospital did not meet the needs of the large Eastern European population in the county.
• There was a lack of electronic profiling beds and other equipment in the Critical Care Unit.
• Maintenance issues were not always attended to promptly.
• Staff throughout the hospital were observed to be kind, caring and compassionate.
• The hospital was clean, hand washing facilities and alcohol gel was available in all areas. Staff used gloves and aprons when providing care to patients.
• Patients were supported to have appropriate nutrition and hydration in most areas of the hospital, although on one medical ward the protected meal time was not observed by all staff.

•  [PP(1]The system that exists is that ED staff have resuscitation skills and fast bleep the anaesthetist. (See CEO letter for more context)

We saw several areas of outstanding practice including:

• The A&E department had a robust system for reporting incidents, known as IR1s. These were discussed and staff had changed their practices as a result of them.
• A designated and suitably decorated cubicle for children in A&E.
• Patients stated they were cared for with compassion and were very supportive of staff.
• Staff were using an assessment tool for pain specifically designed for patients with dementia, where this was applicable.

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

Importantly, the trust must:

• Ensure that systems are in place to improve waiting times in A&E as the department was regularly missing waiting-time targets.
• Ensure there are sufficient numbers of suitably qualified, skilled and experienced staff in the A&E and paediatric departments.
• Ensure the availability of suitable equipment: there were insufficient infusion pumps available in medical wards and A&E; the manual beds in critical care and in EAU did not ensure patients’ needs were met; there was insufficient suitable pressure-relieving equipment in EAU; and suitable equipment was not available in the maternity department.
• Ensure that information is available to demonstrate that staff had received training and development.
• Maintain records relating to the management of venous thromboembolism, catheter care and cannula care.

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

In addition the trust should:

• Fully implement its dementia strategy and ensure that staff are routinely using dementia care-specific documentation.
• Ensure a formal safety and quality dashboard is in place in A&E.
• Ensure greater cross-trust working to ensure that staff whose directorates are pan-trust are supported by the directorate management.
• Consider improving the signage and notices in A&E and in EAU in order to support the large Eastern European population they serve.
• Ensure that the bed in the maternity-led unit to provide antenatal care is fit for purpose.
• Ensure that learning from incidents, complaints and the monthly quality report is cascaded to community midwives.
• Ensure that the cleaning service to the maternity-led unit is adequate.
• Consider the appointment of specialist midwives for bereavement, substance misuse or safeguarding.
• Consider making the governance meetings more accessible to staff working on the Grantham site.
• Ensure information available to the public, student midwives and the university in the form of the trust website and signage in and outside of the hospital, reflects the maternity services available.
• Ensure there is equity in the scanning facilities offered to women.
• Improve communication from the board regarding the sustainability review.
• Ensure there is a dedicated resuscitation emergency call number.
• Ensure the paediatric service’s policies reflect the service provided.

On the basis of this inspection, I have recommended that the trust remain in special measures.

Professor Sir Mike Richards

Chief Inspector of Hospitals

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

In March 2011, we visited two medical wards at the hospital and spoke with many patients. During our time on the wards we observed interactions between staff and patients and saw that staff were behaving in a way that was respectful to people. All patients told us that they had been treated with dignity and respect and many patients were very complimentary about the care they had received. For example, one person said, “the staff are so caring, they look after everyone extremely well in here.”

Patients told us that their needs were always met by the staff. Without exception all of the patients and relatives that we talked to were very happy with their care. For example, one patient said “you can’t fault anything.” Another said “it’s like a holiday home here, we are treated so well.” Patients also said that they felt the staff listened to them. We observed all patients had access to their call bell and these were not left ringing.

Patients told us that meal times were very clam and the food was always warm enough and they always got the help they needed to eat their meal. The majority of the patients said they enjoyed the food. We saw staff encouraging people to eat their meal but were respectful of patient’s wishes if they did not want to eat. We observed one patient not wanting to eat and heard the staff offer them of a pudding instead as they knew they preferred puddings.

Throughout the visits to the wards we observed patients had access to drinks and they were placed within reach. Hot drinks were served regularly and we heard one patient asking for a cup of tea outside of the drinks round and saw that the healthcare support worker went to fetch them one.

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 Grantham Hospital between the 18 and 19 October 2016. We did not carry out an unannounced inspection to this hospital.

We inspected Urgent and Emergency care at Grantham Hospital; we did not inspect any of the other core services that were offered at this hospital.

We rated the urgent and Emergency Care service overall as Good, with safety requiring improvement.

Our key findings were as follows:

Safe

• There was not a robust system in place for checking availability of life saving equipment.
• We found staff had not checked resuscitation equipment in line with trust policy. Several single-use items in the paediatric resuscitation trolley were out of date.
• There were not sufficient numbers of children’s nurses in the department and four out a possible 20 (20%) adult nurses had completed paediatric competencies
• The environment in the department was visibly aged; we saw exposed plaster in a number of areas for example in the children’s cubicle and dirty utility room.
• Nurses and doctors told us the department was not big enough for the number of patients now accessing the department, one nurse said they had “outgrown” the department. We saw doctors bringing patients into the department to cubicles, which were already in use. There was no dedicated receiving area for patients arriving by ambulance. Staff allocated ambulance stretchers to the corridor until a cubicle was available. There was a risk to safety as it would be difficult to evacuate the area in an emergency or to assess and treat a patient who became unwell.
• There were insufficient numbers of nurses and doctors trained in paediatric resuscitation.
• We saw effective and reliable systems and processes in place for medicines management, patient records and assessing and responding to patient risk.
• We saw an effective system in place to ensure patients received appropriate initial assessment by appropriately qualified clinical staff within 15 minutes of arrival to the emergency department (ED) in line with best practice.
• Emergency preparedness plans were in place and staff knew of these.
• Openness and transparency about safety was encouraged.
• When staff reported incidents, these were investigated and learning was shared.
• Staff gave sufficient priority to safeguarding vulnerable adults and children.
• The environment posed a risk to patients’ privacy and dignity. There were no “in use” signs on treatment room doors, the surgical procedures room was not closed off from a storage area and adjacent resuscitation room and staff did not always seek permission to enter closed cubicle curtains.
• It was not always possible to maintain patients’ confidentiality due to the position of the waiting room and the glass partition at the reception desk.

Effective

• Care and treatment was mostly planned in line with current evidence based guidance, standards and best practice. Patient needs were mostly assessed throughout their care pathway in line with National Institute of Health and Care Excellence (NICE) quality standards and Royal College of Emergency Medicine (RCEM) guidelines.
• Information about patients’ care and treatment, and their outcomes was routinely collected and monitored. This information was used to improve patient care.
• Staff could access information they needed to assess, plan and deliver care to people in a timely way.
• Staff were supported to deliver effective care and treatment through meaningful and timely supervision and appraisal.
• Staff demonstrated understanding of the issues around consent and capacity for adults and children attending the department.

• The department did not audit the number of patients who were recalled to the department with a missed fracture.

Caring

• Patients were treated with dignity, respect and kindness during all interactions with staff.
• Staff helped people and those close to them cope emotionally with their care and treatment.
• Staff respected patients’ rights to make choices about their care.
• We saw staff providing specialist support to patients and those close to them in relation to their psychological needs.
• The results of the CQC A&E Survey (2014) showed the trust scored ‘about the same’ as other trusts for most questions.

• The environment posed a risk to patients’ privacy and dignity. There were no “in use” signs on treatment room doors, the surgical procedures room was not closed off from a storage area and adjacent resuscitation room. Staff did not always seek permission to enter closed cubicle curtains.
• It was not always possible to maintain patients’ confidentiality due to the position of the waiting room and the glass partition at the reception desk.

Responsive

• Waiting times and delays were minimal and managed appropriately.
• Care and treatment was coordinated with other services and providers.
• There were systems in place to support vulnerable patients.
• There were arrangements in place to avoid unnecessary admissions to the hospital.
• Complaints about the service were shared with staff to aid learning.
• Patients could not always access the right care at the right time especially those with urgent care needs.

Well led

• There was an effective governance framework in place. Quality, risks and performance issues for the department were monitored through monthly clinical governance meetings and there was a good feedback loop.
• Department leaders had the experience and capability to lead the services and were committed. They prioritised safe, high quality and compassionate care.
• Nursing and medical staff said the department manager, matron, interim head of nursing and consultants were approachable, visible and provided them with good support.
• We saw effective team working across the department and an obvious mutual respect amongst staff.
• Morale in the department was mixed; some staff described the overnight closure as worrying and wondered if the department would ever re-open overnight. However, some said they liked it as there were more staff on duty in the day. Consultants said morale was low; they felt that they were unable to provide the service they wanted to the local population of Grantham.
• The risks and issues described by some leaders did not correspond to those that were currently on the department risk register.

We saw several areas of outstanding practice including:

• The department inputted hourly data into an ED 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:

• 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 excess of 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.

The trust should:

• The trust should take action to ensure there are effective and consistent systems for learning from deaths to be shared across the emergency department.
• The trust should ensure there is a robust system in place for checking safety and suitability of life saving equipment in the emergency department.
• The trust should ensure ligature cutters are immediately available in the emergency department.
• The trust should ensure there is a protocol in place for management and manipulation of fractures.
• The trust should review the process for patients presenting to the ED reception at Grantham to maintain patient’s privacy and dignity.
• The trust should ensure the emergency department risk register is reflective of the risks identified by senior leaders.
• The trust should ensure there is a hearing loop system in the emergency department at Grantham.
• The trust should ensure there are adequate processes in place to ensure handovers between the ambulance and the emergency department take place within 15 minutes with no patients waiting more than 30 minutes.
• The trust should consider the process in place for children awaiting triage in order to meet the 2012 Intercollegiate Committee Standards for Children and Young People in Emergency Care Settings.
• The trust should consider how the emergency department can comply with the accessible standard for information.

Professor Sir Mike Richards

Chief Inspector of Hospitals