Our rating of services stayed the same. We rated it them as requires improvement

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

We carried out this review to see if people were given information about the medicines prescribed for them, and received these medicines safely at the right times

We visited three wards, including one ward caring for elderly people. We talked to doctors, nurses and patients. We also went to the lounge where some patients wait for their medicines or for transport before leaving the hospital. We visited the pharmacy and met the trust’s chief pharmacist and other pharmacy staff.

One person said “The doctors and nurses were fantastic.” Another person told us “The drug rounds are usually on time. Staff check my wristband, name and date of birth and that I have taken the tablets.”

However, several people told us that no-one had discussed their ‘take home’ medicines with them. One person said, “I was just handed the bag (of medicines).” We found that one of this person’s medicines was incorrectly labelled and there was also a mistake in the discharge letter to their GP.

We found that people on one elderly care ward received their medicines at the right times. On the other two wards we visited medicines were sometimes ‘out of stock’. Also, nurses had not always signed medicine charts to show whether the medicine had been given or not.

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.

When we undertook a visit to Lincoln County Hospital patients told us they were happy with the care and support that they received.

Of the five wards we visited the care and welfare of patients was met in all but one ward, Clayton ward.

During our visit we spoke with patients, members of staff and senior managers as well as relatives and another professional who worked for the trust.

On one ward a patient we spoke with told us, “They couldn’t do enough for me when I came in”.

Another patient we spoke with stated that they felt that they were being treated as an older person and “not as a person in my own right”. They also added that they had been” treated very well” and had been included in their care and treatment.

A relative we spoke with stated that there were always “call bells going off” during evening visiting and felt there were insufficient staff to answer them. They told us that the bells were rung for attention to go to the toilet most of the time.

Another person who was visiting their relative told us, “Staffing has been good; they are always available when needed”.

A patient on another ward told us “The care is fantastic” and that they had been treated very well.

During our visit to the hospital, we observed interactions between patients and staff that demonstrated people were being treated with dignity and respect. Adults who had undergone surgery told us they had received clear explanations, including the risks and benefits of the intervention before being asked to sign a consent form. One person said, “it was very helpful to have everything explained because I was very apprehensive about the operation.” A child told us that they had seen several doctors during their stay in hospital and said “all the doctors have been nice and they have explained things to me so I understand them.”

Not all people were happy with the level of care they had received and we received positive and negative comments. For example, some people did not think they received enough information about what was happening whilst others felt their care had been good. All the patients’ that we talked to said that they felt safe whilst in hospital.

We observed lunch being served on two wards and found that all patients were given the appropriate assistance to eat their meals. People told us “the food is good and there is plenty of choice.” We observed that people appeared to enjoy their meals.

Some people did not feel that there was good communication between their GP and the hospital. Other agencies, such as the local doctors and some care home managers agreed with this and would like the hospital to improve.

People told us the hospital was clean. One patient said, “It is a nice hospital and it always looks clean.” With the exception of the women’s unit, we observed most areas of the hospital to be in a good state of repair and were clean and uncluttered. Some people had told us before our review that the facilities in the women’s unit needed upgrading. People in the other areas of the hospital said that they thought their ward was suitable for their needs and there was enough equipment for staff.

During our observations we found staff were competent in their role. One person told us “the staff appear very knowledgeable and suitably trained.” On the children’s ward, parents/guardians told us that the staff were too busy and they wanted to help them.

We found that not all people using the service were aware of how to make a complaint and during our observations we did not find it easy to locate information about how to raise a concern or a compliment about care and treatment. Some people also told us that the hospital did not always investigate their complaints thoroughly enough and in a timely way.

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 Lincoln County Hospital between the 10-14, 18-19 and 26-27 October 2016. We also carried out unannounced inspections on 24, 25 and 27 October 2016.

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 Lincoln County Hospital as requires improvement overall. Surgery and services for children and young people were rated as good, urgent and emergency care, medical care and maternity and gynaecology were rated as requires improvement.

Our key findings were as follows:

Safe

• There were not always effective systems in place to ensure ambulance handover times took place in line with the Department of Health target of 15 minutes, with no patients waiting more than 30 minutes and that the initial assessment of patients should take place within 15 minutes of presentation to the department.
• 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.
• Staff did not routinely raise patient safety incidents for those patients who had not been appropriately screened or treated for sepsis.
• In some areas, staff did not always recognise concerns, incidents or near misses. Where incidents had been raised some staff reported little or no feedback and could not give examples of where learning from incidents had taken place.
• Safety systems, processes and standard operating procedures were not always fit for purpose. We saw out of date resuscitation equipment and insufficient evidence to suggest resuscitation equipment had been checked in line with trust policy. Arrangements were not always in place to ensure the safe storage of medicines and arrangements for the disposal and storage of used sharps meant there was a risk of harm to staff, patients or members of the public.
• Records to demonstrate hourly rounding (checks on patients) were not always completed.
• There was no abduction of children policy available for any of the inpatient areas of the service.
• Health records were not always available for outpatient appointments.
• As of the week of our inspection, there were 8,108 patient appointment outcomes, which staff had not completed and closed on the electronic record system. Data supplied by the trust showed the current position was worse than the previous year. This presented a risk to patients in their ongoing treatment and care. Following our inspection the trust had forecast that the numbers of incomplete outcomes would fall by half in early 2017.
• Nurse staffing on the neonatal unit was in line with the British Association of Perinatal Medicine (BAPM) standards.
• Patients were protected from abuse; staff had an understanding of how to protect patients from abuse. Staff could describe what safeguarding was and the process to refer concerns.
• Staff used paediatric early warning scores (PEWS) and neonatal early warning scores (NEWS) to appropriately identify a deteriorating patient.

Effective

• The trust’s Hospital Standardised Mortality Ratio (HSMR) for March 2016 was 97.62. HSMRs are intended as an overall measure of deaths in hospital. High ratios of greater than 100 may suggest potential problems with quality of care.

• The latest published Summary Hospital level Mortality Indicator (SHMI) for January 2015 to December 2015 was 110.99 and within hospital SHMI deaths was a reported 105.4 for the same period. The Summary Hospital-level Mortality Indicator (SHMI) is the ratio between the actual number of patients who die following hospitalisation at the trust and the number that would be expected to die based on average England figures, given the characteristics of the patients treated there.

• Patient’s care and treatment was mostly planned and delivered in line with current evidence based guidance, standards, best practice and legislation. We saw good use of patient pathways aligned to the National Institute for Health and Care Excellence (NICE) quality standards. However, staff did not consistently adhere to local guidelines for sepsis screening.
• Where outcomes for patients were below expectations when compared with similar services we saw action plans had been put in place.
• Nursing staff were not always managed or developed effectively. Not all nursing staff had received an annual appraisal and appraisal completion rates had significantly declined since the previous year.
• Endoscopy services at this hospital were Joint Advisory Group (JAG) accredited.
• There was an effective multidisciplinary team (MDT) approach to planning and delivering patient care and treatment; with involvement from general nurses, medical staff, allied health professionals (AHPs) and specialist nurses. All staff we spoke with told us there were good lines of communication and working relationships between the different disciplines.
• Staff had some understanding of the Mental Capacity Act (MCA) 2005 and consent. We saw consent to care and treatment was mostly obtained in line with legislation and guidance, including the MCA and patients were supported to make decisions.

Caring

• Generally, feedback from patients who used the service and those close to them was mostly positive about the way they had been treated.

• We observed nursing and medical staff treating patients with dignity, respect and kindness. Staff spent time talking to patients and showed compassion when patients needed help. However, 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.

• Results of the CQC A&E Survey (2014) showed the trust performing ‘about the same’ as other trusts.

• The NHS Friends and Family Test (FFT) results were worse than the England average.

Responsive

• There were systems in place to support vulnerable patients and those patients who were medically fit for discharge, with good access to learning disability specialist nurses and the assertive in-reach team (AIR).

• Some patients were not able to access services for assessment, diagnosis or treatment when they needed to.
• 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. This included the referral standard for patients suspected of cancer who needed to be seen with two weeks. This standard had not been consistently met during 2016.
• 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. These did not include the patients identified as missing from the waiting lists.
• Stroke services provided timely access to initial assessment, diagnosis or urgent treatment of those patients who may be experiencing a stroke.

• Delays in obtaining to take out (TTO) prescriptions had been identified as delaying discharges and staff attributed this in part to a sporadic pharmacy service to the wards. In addition, pharmacy staff did not routinely access the electronic discharge documents and this resulted in discrepancies not being identified until medicines had been dispensed.

• There was insufficient consideration paid to meeting the information and communication needs of patients. The service had not taken steps to meet the requirements of the accessible information standard. However, staff could access interpreting services for patients who did not speak or understand English. The service was provided externally and included the provision of British Sign Language.

Well led

• Generally staff knew there were a vision and strategy in place for the trust.

• There was not always an effective governance framework which supported the delivery of safe, good quality care.
• We found some risks regarding the provision of services for patients had not been identified by senior nurses and service leads.
• We were not assured incidents were reported and acted upon appropriately. Staff did not routinely raise patient safety incidents for those patients who had not been appropriately screened or treated for sepsis. This meant there were missed opportunities to address poor compliance in order to minimise the risk of patients being exposed to avoidable harm, when they met the trust criteria for sepsis screening.
• Staff satisfaction and morale varied across the hospital with some staff groups feeling more engaged than others.
• We found most staff were dedicated and committed to delivering high quality, safe care.

We saw several areas of outstanding practice including:

• 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.

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 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 patient’s’s 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 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.

In addition the trust should:

• The trust should ensure there are effective and consistent systems for learning from incidents to be shared across the emergency department.
• The trust should ensure the governance framework in the emergency department clearly identifies risks, responsibilities and actions required to ensure all staff raise patient safety incidents appropriately.
• The trust should ensure that the resuscitation trolleys and their equipment are checked, properly maintained and fit for purpose in the emergency department.
• 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 ensure there are adequate processes in place to ensure patients who self-present to the emergency department receive an initial clinical assessment by a registered healthcare practitioner within 15 minutes of the time of arrival.
• The trust should ensure that there is 16 hours of consultant presence available each day in the emergency department.
• The trust should ensure there are appropriate procedures in place for identifying seriously ill patients who self-present at the reception of the emergency department.
• The trust should ensure procedures are followed regarding the safe management of sharps boxes.
• The trust should ensure all staff have completed mandatory and role specific training.
• The trust should ensure the environment for children’s provision in the emergency department meets the 2012 Intercollegiate Committee Standards for Children and Young People in Emergency Care Settings.
• The trust should ensure staff are appropriately trained and supported to meet the requirements related to duty of candour.
• The trust should ensure an annual audit is carried out in line with the recommendations of The Royal College of Emergency Medicine (RCEM) guidelines; Management of Pain in Children (revised July 2013).
• The trust should ensure they take steps to address the accessible information standard in the reception area of the emergency department at Lincoln County Hospital.
• The trust should ensure mandatory training is completed in line with trust policy.
• The trust should ensure all staff are aware of the arrangements in place to respond to major incidents.
• The trust should ensure hourly rounding charts and charts used for monitoring fluid balance of patients are completed to ensure the health, safety and welfare of the service users.
• The trust should ensure medications are always handled safely, in line with legislation, the trust’s policies and best practice guidelines.
• The trust should ensure venous thromboembolism treatment is prescribed in a timely manner and re-assessed after 24 hours.
• The trust should ensure there are measures in place to ensure patient medical notes are stored securely.
• The trust should ensure continued engagement within the Oromaxillo facial service in order to further develop the service.
• The trust should consider 24 hour reception cover on the surgical emergency assessment unit.
• The trust should consider a discharge co-ordinator post within ward areas.
• The trust should consider how the role of the domestic assistants support the ward team in relation to food serving and cleaning.
• The trust should ensure that grading of incidents is consistent and follows trust guidance.
• The trust should ensure that the new IT system supports accurate documentation of safety thermometer data.
• The trust should ensure that notes for patients undergoing caesarean section are consistent including standardised documents.
• The trust should ensure that safeguarding supervision is provided regularly for all staff.
• The trust should ensure that accurate up to date maternal weights are performed on admission in order to prescribe weight dependant medication.
• The trust should ensure that the resuscitation trolleys on Bardney Ward are checked, and appropriate documentation completed.
• The trust should ensure that if recent NICE guidance is not followed then the current guidance includes an addendum to explain the decision (CG 190).
• The trust should ensure staff development programmes are supported and staff are encouraged to attend learning opportunities.
• The trust should audit the length of time patients attending for emergency gynaecology appointments are expected to wait.
• The trust should ensure that within maternity service users feedback is captured.
• The trust should ensure that they audit the number of patients whose elective caesarean sections are delayed to the next day.
• The trust should ensure that action plans are made following audits, and a re-audit is performed, such as following the regular CTG audits.
• The trust should ensure outpatient and diagnostic services are delivered in line with national targets.
• The trust should ensure that incidents are correctly graded and there are effective systems in place to ensure learning from incidents takes place.
• The trust should ensure that there are sufficient documented procedures and records in place to provide assurance that ultrasound probes are decontaminated after use in line with the manufacturer’s recommendations and in compliance with the Health and Social Care Act 2008, Code of Practice on the prevention and control of infections and related guidance.
• The trust should ensure that there is sufficient signage throughout the outpatient department to direct patients/visitors to the hand hygiene facilities that are provided to minimise the risk of spreading infection.
• The trust should ensure that the condition of health records enables the safe care and treatment of patients, compliance with information governance requirements and ensures patient confidentiality is maintained.
• The trust should ensure all staff working in the outpatient and diagnostic departments attend the trust's mandatory training programme as required by their role and professional responsibilities.
• The trust should consider reviewing the method by which MRI reports are transferred onto the Radiology Information System to ensure the risk of error during the transfer of data is minimised or removed.
• The trust should ensure that there are sufficient systems in place and utilised to minimise the risk of potential harm to patients. Sufficient time must be available to ensure comprehensive patient identity and procedure checks are completed prior to all diagnostic procedures being commenced.
• The trust should ensure that staff working in the radiology department have sufficient knowledge of the national diagnostic reference levels to be able to apply them appropriately when required.
• The trust should take action to ensure all staff working in the outpatient and diagnostic services receive an annual appraisal to ensure they are able to fulfil the requirements of their role.
• The trust should consider whether the action taken to reduce the back log of clinic letters waiting to be sent to GPs and patients following their appointment was effectively resolving the backlog of letters.

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