United Lincolnshire Hospitals NHS Trust was formed in April 2000 by the merger of the three former acute hospital trusts in Lincolnshire, creating one of the largest trusts in the country. The trust serves a population of approximately 700,000 people, situated in the county of Lincolnshire.

We carried out an unannounced focused inspection of the emergency department at Pilgrim Hospital on 25 February 2019. This was to follow up actions the trust had taken following our focussed inspections on 30 November and 18 December 2018.

We did not inspect any other core service or wards at this hospital or any other locations provided by United Lincolnshire Hospitals NHS Trust. During this inspection we inspected using our focussed inspection methodology. We did not cover all key lines of enquiry and we did not rate this service at this inspection.

Pilgrim Hospital, Boston is a large district general hospital located on the outskirts of Boston. At Pilgrim hospital the urgent and emergency services consists of the emergency department (ED), Integrated Assessment Centre (IAC) which included Ambulatory Emergency Care (AEC) and Acute Medical Short Stay Unit (AMSS).

The ED has one triage room, 10 major cubicles, three minor cubicles, one ‘fit to sit’ room, a see and treat room, a plaster room, a clean procedure room, four resus bays, three rapid assessment and treatment (RAT) cubicles, one waiting room and a quiet relatives room (which was also used as a mental health assessment room). The department also has one children's cubicle.

Pilgrim Hospital emergency department supports the treatment of patients presenting with minor, major and traumatic injuries. Serious traumatic injury patients receive stabilisation therapy before transfer to the major trauma centre at a neighbouring NHS trust.

Our key findings were as follows:

• The layout of ED was not suitable for the number of admissions the service received. During our inspection we saw significant overcrowding in the department. Throughout our inspection we saw patients being cared for on trolleys in the central area of the department and in the ambulance corridor as there were no free cubicles to use. This had not improved since our last inspection.

• Adults waited on average 81 minutes for treatment. This was against national standards of 60 minutes.

• Whilst the trust had a national early warning scoring system (NEWS) and paediatric early warning scoring system (PEWS) in place, these were not always used as part of the triage process.

• The Royal College of Paediatrics and Child Health (RCPCH) the initialassessment of children should be conducted by an appropriately trainednurse or doctor with paediatric competence. There was not always a paediatric competent nurse performing triage.

• We were not assured children would always be appropriately cared for in the department during 10pm and 10am. We asked the trust to provide us with evidence there was always a registered nurse with the appropriately level of competence to care for children during this time. We found not all shifts were appropriately covered.

• Flow concerns appeared to be ‘normalised’ and was considered to be a problem for the ED, not the wider trust.

• An ED risk tool gave an “at a glance” look at the number of patients in the department, time to triage and first assessment, number of patients in resus, number of ambulance crews waiting and the longest ambulance crew wait. Whilst we saw this updated on a regular basis, we did not see, despite an ‘extreme’ score, actions taken resulting in an improvement in this position.

• We saw there were significant issues in relation to patient flow which led to crowding and patients receiving care in corridors. Patients were experiencing unacceptable waits. Whilst staff in the department followed the escalation policy, actions taken by others in line with the policy did not prove effective at restoring flow. The lack of effective actions resulted in handover delays, overcrowding and poor patient experience.

However:

• At the time of this focussed inspection we observed part of one shift. There was good co-ordination between the doctor and nurse in charge.

• Staff at this inspection demonstrated a positive attitude towards their work and were working effectively together.

• Despite the challenges of the department, staff we spoke with were committed to doing the right thing for patients and wanted to deliver safe, effective and compassionate care.

• Since our last inspection the trust had implemented a dedicated frailty team based in the ED, which provided immediate review and care for patients who attended from care homes or where they needed input from older people specialists.

• At this inspection we found improvements in the management of patients who were at risk of deteriorating consciousness levels. We found staff were mostly monitoring these patients effectively. We also found improvements to triage times.

• There had been improvements in the provision of nursing staff for children at this inspection. Between 10am and 10pm there was at least one registered children’s nurse present in the department responsible for the care and treatment of children.

• Staff mostly carried out assessments and delivered treatment with privacy, dignity and compassion during all our observations, including during handovers.

• There was a positive regard for patients who were distressed and calling out, we saw nursing and medical staff respond in a timely and appropriate way.

• Patients and relatives, we spoke with were mostly happy with their care and treatment. They said staff were kind and caring and they were doing their best.

Amanda Stanford

Deputy Chief Inspector of Hospitals (Central Region)

United Lincolnshire Hospitals NHS Trust was formed in April 2000 by the merger of the three former acute hospital trusts in Lincolnshire, creating one of the largest trusts in the country. The trust serves a population of approximately 700,000 people, situated in the county of Lincolnshire.

We carried out an unannounced focused inspection of the emergency department at Pilgrim Hospital on 18 December 2018. This was to follow up actions the trust had taken following our focussed inspection on 30 November 2018.

We did not inspect any other core service or wards at this hospital or any other locations provided by United Lincolnshire Hospitals NHS Trust. During this inspection we inspected using our focussed inspection methodology. We did not cover all key lines of enquiry and we did not rate this service at this inspection.

Pilgrim Hospital, Boston is a large district general hospital located on the outskirts of Boston. At Pilgrim hospital the urgent and emergency services consists of the emergency department (ED),Integrated Assessment Centre (IAC) whichincluded Ambulatory Emergency Care (AEC) and Acute Medical Short Stay Unit (AMSS).

The ED has one triage room, 10 major cubicles, three minor cubicles, one ‘fit to sit’ room, a see and treat room, a plaster room, a clean procedure room, four resus bays, three rapid assessment and treatment (RAT) cubicles, one waiting room and a quiet relatives room (which was also used as a mental health assessment room). The department also has one children's cubicle.

Pilgrim Hospital emergency department supports the treatment of patients presenting with minor, major and traumatic injuries. Serious traumatic injury patients receive stabilisation therapy before transfer to the major trauma centre at a neighbouring NHS trust.

Our key findings were as follows:

• There was an unreliable and inconsistent system in place to identify critically ill patients who may present to the department. The triage process was not effective in the early detection of acutely unwell patients. We saw despite increased triage staffing levels, patients were not always assessed in a timely way. Once triaged patients were not always allocated a priority category and if they were, this did not correlate effectively with the patients condition.

• Patients did not always have an early warning score calculated at triage, despite their presenting condition, indicating they may be at risk of deterioration.

• Patients arriving by ambulance remained on ambulances for significant amounts of time, despite a presenting medical condition which had the potential to deteriorate. We saw a patient with a suspected gastro intestinal bleed (serious bleeding in the stomach) wait 25 minutes to be brought into the department, despite crews highlighting the nature of the presenting condition to the Pre- Hospital Practitioner (PHP).

• Patients at risk of deteriorating consciousness levels were not monitored effectively. We saw a number of patients who had presented to the department with head injuries. These patients did not have neurological observations performed initially or on an ongoing basis.

• Patients arriving by ambulance and brought into the department were not always clinically assessed by the PHP. The PHP was reliant on observations from the ambulance crew rather than performing their own and recorded this as an assessment time. This posed a risk to patients as the PHP did not have the most up to date information and the patients presenting condition may have worsened.

• Patients in the ambulance corridor did not always have observations performed in line with trust protocol. Patients went for long periods without observations. We saw a patient with a potential fractured neck of femur had not been offered any analgesia and, had been waiting more than two hours at the point we reviewed their notes, to be seen by a clinician.

• The Rapid Assessment and Treatment (RAT) process was ineffective at reducing ambulance handover times. We saw many patients held on ambulances and a long wait for a RAT assessment.

• Children in the department were placed at risk of harm as they were not cared for by nursing staff with the necessary competencies to provide safe and effective care. Whilst there was an identified registered childrens nurse in the department caring for some children, there was no oversight of new arrivals to the department, furthermore we observed children being triaged by nurses without additional pediatric competencies.

However:

• Since our last inspection the trust had implemented a process for transfering patients to wards and other clinical areas, which did not impact on nurse staff to patient ratios.

• Two hourly safety huddles had been introduced into the department.

• Nurse and medical staffing levels and skill mix were sufficient to meet the needs of patients during the period of our inspection.

• We saw the trust had taken some action to ensure the ‘fit to sit’ room was not overcrowded and patients were not cared for along a throughfare corridor in the department. They also tried to ensure patients being cared for in the main area of the department were of the same sex.

Amanda Stanford

Deputy Chief Inspector of Hospitals (Central Region)

United Lincolnshire Hospitals NHS Trust was formed in April 2000 by the merger of the three former acute hospital trusts in Lincolnshire, creating one of the largest trusts in the country. The trust serves a population of approximately 700,000 people, situated in the county of Lincolnshire.

We carried out an unannounced focused inspection of the emergency department at Pilgrim Hospital on 30 November 2018, in response to concerning information we had received in relation to care of patients in this department. At the time of our inspection the department was under adverse pressure.

We did not inspect any other core service or wards at this hospital or any other locations provided by United Lincolnshire Hospitals NHS Trust, however we did visit the admissions areas Integrated Assessment Centre (IAC) which included Ambulatory Emergency Care (AEC) and Acute Medical Short Stay Unit (AMSS) to discuss patient flow from the emergency department. During this inspection we inspected using our focussed inspection methodology. We did not cover all key lines of enquiry and we did not rate this service at this inspection.

Pilgrim Hospital, Boston is a large district general hospital located on the outskirts of Boston. At Pilgrim hospital the urgent and emergency services consists of the emergency department (ED),Integrated Assessment Centre (IAC) which included Ambulatory Emergency Care (AEC) and Acute Medical Short Stay Unit (AMSS). At the time of this visit the AMSS was operating 24 of the 48 beds in which it had allocated.

The ED has one triage room, 10 major cubicles, three minor cubicles, one ‘fit to sit’ room, a see and treat room, a plaster room, a clean procedure room, four resus bays, three rapid assessment and treatment (RAT) cubicles, one waiting room and a quiet relatives room (which was also used as a mental health assessment room). The department also has one children's cubicle.

Pilgrim Hospital emergency department supports the treatment of patients presenting with minor, major and traumatic injuries. Serious traumatic injury patients receive stabilisation therapy before transfer to the major trauma centre at a neighbouring NHS trust.

Our key findings were as follows:

• There were unsafe, unvalidated and unreliable systems in place to identify critically ill patients who may present to the department. The triage process was not effective in early detection of acutely unwell patients. Staff used a categorisation scale of one to five (one being immediate priority and five least priority). We saw patients such as a patient with a diabetic ketoacidosis (DKA) categorised as a category three when they should have been categorised as category one (immediate priority). We also saw a child with potential sepsis was also categorised as a category three when they should have been categorised as category one (immediate priority).

• We saw delays more than three hours for patients to be assessed by the medical team.

• We saw patients arriving by ambulance remained on the ambulance between 20-65 minutes waiting to enter the department. Whilst the patients remained under the care of the ambulance crew, there was no system in place to prioritise the patient who may have a high early warning score, indicating they may be sick.

• Whilst there was a “track and trigger” tool in place to monitor those patients who had been admitted to the department, staff did not always carry out observations in line with trust protocol and in a timely way. We saw critical observations go overdue for significant time periods. Patients who were at risk of deteriorating consciousness levels were not monitored effectively.

• There was no oversight of patients pre- and post-triage in the main waiting room and routine observations were not performed on these patients following triage.

• Staff did not always commence interventions or treatment in a timely way. We saw a patient had waited two and a half hours following a senior review to be commenced on a diabetic ketoacidosis pathway, despite presenting to the department three hours and 42 minutes earlier.

• Patients were not always getting their medicines in a timely manner and when they needed them. Doctors did not always communicate effectively with nursing staff when they had created a plan, prescribed a treatment or wanted an intervention for a patient. We saw four patients who required medication administering,however, doctors had not alerted this to the nursing team.

• There was an unstructured approach to patient flow. All components of the patient flow system were not managed or escalated appropriately.

• The Rapid Assessment and Treatment (RAT) process was ineffective at reducing ambulance handover times. At the time of our inspection the average time patients were waiting for RAT was two hours and nine minutes. We saw many patients held on ambulances.

• Whilst beds had been identified for some patients, patients were not always moved from the ED in a timely manner.

• We saw there were significant issues in relation to patient flow which led to crowding and patients receiving care in corridors. Patients were experiencing unacceptable waits. Staff did not follow the escalation policy in use to ease and manage patient flow effectively.

• The nurse staffing levels and skill mix were not sufficient to meet the needs of patients. The department was under extreme pressure at the time of our inspection and we saw no action taken to assess nursing staffing levels were sufficient to meet the increasing capacity, demand or patient acuity issues.

• Children in the department were placed at risk of harm as they were not cared for by nursing staff with the necessary competencies to provide safe and effective care.

• Medical staffing was a mixture of junior, middle grade and registrar doctors, 80% of the medical workforce were locum. Despite the department being under extreme pressure at the time of our inspection we saw no action taken to assess medical staffing levels were sufficient to meet the increasing capacity, demand or patient acuity issues. We heard how some doctors had not had a break for the entire 12-hour shift.

• Leadership within the department was not effective. There was a lack of co-ordination between the consultant in charge, nurse in charge and site management team. The consultant in charge had no awareness of the increasing wait for senior review, rapid assessment and treatment area or ambulance handover delays.

• We found a culture of blaming overcrowding and low staffing levels / recruitment and use of agency staff for poor compliance with safety measures and poor practice. Nursing and medical staff used overcrowding as a rationale for lapses in care we identified during our unannounced inspection.

• The shift by shift management of risks, issues and performance in the Emergency Department (ED) was not robust. Our inspection team had to escalate several immediate patient safety concerns to medical and nursing staff to keep patients protected from avoidable harm. We also saw insufficient action to manage handover delays, overcrowding and poor staffing levels, this lead to poor patient experience.

Amanda Stanford

Deputy Chief Inspector of Hospitals (Central Region)

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

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

We carried out this review to see if people were given medicines safely and at the right times. We asked people whether staff explained why their medicines had been prescribed.

We visited six wards, where we talked to doctors, nurses, patients and the parents of a child. We also met three of the pharmacists who work in the hospital.

People told us they were very happy with the way doctors and nurses looked after them. One person said, “Everyone has been fantastic.” Another said, “I would give it 10 out of 10 for care. Any questions I have asked have been answered.”

One person was being given a continuous injection of fluid and did not know why they needed this.

We talked to a mum and dad on the children’s ward: They said that the plan for treating their child’s illness and the medicine prescribed had not been fully explained to them. The parents said that the ward was busy and noisy; this was difficult for them as their child was very poorly.

We met two people when we visited the discharge ward. Both people told us no-one had explained their ‘take home’ medicines to them. The nurses said that they had not talked to these people about their medicines as both of them were going to care homes where carers and other nurses would look after them.

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.

There is evidence of improved outcomes for people at this hospital. We also carried out an investigation in 2011 which was published in November 2011 and the trust has demonstrated that it has implemented actions designed to address the recommendations made in the report.

Since the report, the trust has provided a very comprehensive action plan to ensure that the quality of the care delivered is being assessed and monitored on a regular basis at all levels of management. The trust has put a new system in place to ensure that complaints and incidents are reported, tracked and investigated in a more timely way.

Patients said they were happy with the care they were getting and said that staff could not be more helpful. One patient who had been in hospital for five weeks said that she had not seen a miserable face from the staff and that they had been absolutely marvellous.

One member of staff said; “I am proud to work at this hospital and I think people get good care.” Another person said; “we have worked hard to improve. Things were not right here at the start of the year, but we have really moved on and have turned things around.” Another member of staff said; “I like my job and I like working here.”

When we spoke to a doctor they said that patients who could take food and drink by mouth were generally supported to do so by the nursing staff. They said that occasionally they had to help a patient to have a drink because the glass or beaker was out of reach or they were unable to drink independently.

In one ward a member of nursing staff said that they do what they can to organise a timely discharge but that sometimes it “doesn’t always work.” However, on another ward we were told by a patient that their discharge arrangements were already in place and that “everything is going according to plan”.

The patients we spoke with said that they felt safe in the hospital. When we asked what they would do if they didn’t, they told us that they would tell one of the nurses or the sister in charge of the ward. All of them said they felt confident that the staff would do something about it.

The majority of the communal areas and the wards we visited were clean and patients said that the wards were cleaned regularly. One lady described how her bed was washed down every day and her bed area was always clean and tidy.

One patient said, “They are always rushing around and are very busy all of the time.” Another patient said, “I don’t always get the help I need when I call them, I have to wait because they are really busy.” On another ward a patient said that “staff have always come when I have called.”

Two of the nurses we spoke with told us that they wished they had time to undertake more training to develop themselves but realised that patient care would always come first. Other nurses told us that they had attended a lot more training in recent months which had been very useful.

During this visit nursing staff told us that they felt they were more able to raise concerns through their line management system and they used incident reports to ensure that issues were properly looked at and actions taken to minimise the risk of them happening again.

We were informed by members of nursing staff and a doctor that notes were easy to use, with everything in one place and they were aware of the need to keep notes secure and confidential.

Most of the patients and relatives that we talked to during our visits were satisfied with their care and many patients were very complimentary, particularly about the nursing staff. One person said, “the nurses are very good.” A small number of people raised some concerns with us which often related to poor communication between staff and the patient and or relative. Some patients and relatives made comments to us about the attitude of staff in that they had been rude to them or were pushing them too hard with rehabilitation. No patient, carers or relatives raised any concerns that they did not think that staff were competent to carry out their role but many people have been in touch with us outside of our visits to the hospital. People have told us about instances where they felt the care provided by the hospital fell short. We have referred these people to either the trusts own complaints process or to the local authority safeguarding team for further investigation.

On ward 6a, a care of the elderly ward for female patients, we observed a patient being helped to have a bath and the staff washed, cut and set her hair for her. We did not hear the call bells ringing on this ward and patients told us “we don’t need to ring, they (the nurses) are around us all the time.”

Patients told us they could tell the nurses if they were in any pain and they would be given pain killers. We observed staff asking patients if they were in pain and also saw evidence in care records that staff had reviewed pain during their hourly care rounds.

Several patients told us they did not find the clinical decisions unit (CDU) to be a pleasant environment, one person said, “the lights are too bright on there, they need to turn them down.” Another patient said, “it was too noisy on CDU.”

On one of the wards we saw twelve staff, including allied health professionals all taking part in the lunch service. We observed all of the patients during this meal time getting the help they needed to either sit comfortably to eat their own meal, or get help with feeding. We observed the staff checking on the patients that required no assistance to eat their meal to ensure they were actually managing and did not need any help. One patient told us they always saw the nurses giving patients help with their meals if they needed it. During all our visits to different wards we saw patients being offered drinks and we often saw staff helping patients to have a drink. We also observed drinks were in reach of patients that had restricted mobility.

Patients told us they knew what any new medications they had been prescribed were for and they could tell the nurses if they were in pain and would be given pain killers. We observed the care of one patient who could not communicate verbally but was displaying non verbal signs of pain. This had not been identified by the staff caring for him until it was highlighted by the inspector. Once identified, the patient was given pain relief.

We carried out a focused inspection to United Lincolshire Hospitals NHS Trust so we could follow up on improvements that had been made since our last inspection. This was our third inspection to the trust since the introduction of our new inspection methodology. The announced inspection took place between the 10-14, 18-19 and 26-27 October 2016. We also carried out unannounced inspections to Pilgrim Hospital on 24, 25 and 27 October 2016. We carried out a further unannounced inspection on 19 December 2016 in respone to information we had received from members of the public/relatives of patients.

Overall, we rated Pilgrim Hospital as inadequate. The medical service and the outpatients and diagnostic imaging service were rated as inadequate, urgent and emergency services and maternity and gynaecology services were rated as requires improvement and surgery, critical care and services for children and young people were rated as good.

Our key findings were:

Safe

• The approach to reviewing and investigating incidents in some services was insufficient and too slow and led to unacceptable delays. However, there was a positive approach to reporting and learning from incidents in the critical care unit.
• We were not always assured incidents were reported appropriately, investigated, that lessons were learnt and shared in a timely way. However, some staff told us they had received feedback following raised incidents and could give examples of where learning from incidents had taken place.
• Where patients had met the criteria for treatment of sepsis, staff were not always responding appropriately in administering treatment in the recommended time frame and in line with the “sepsis six” care bundle.

• We were not assured patients were receiving their medication as prescribed.

• Individual care records were not always written and managed in a way that kept people safe. Some records were incomplete and not up-dated to reflect patients care needs.

• Fluid balance charts in some areas were not always updated appropriately to minimise risks to patients.
• Staff training compliance for safeguarding adults and children did not meet the trusts mandatory target of 95% completion. We were therefore not assured all staff would be able to respond appropriately.
• Not all areas met the trust target of 95% for a majority of their mandatory training and compliance was variable across the hospital.

• Nurse and medical staffing levels and skill mix were not always appropriate to keep patients protected from avoidable harm at all times. However, there were the appropriate numbers of staff on duty in the critical care unit.

• The hospital participated in the national safety thermometer scheme but it was not always displayed in the ward areas.

• The poor condition of and unavailability of health records was having a negative impact on all clinic areas, resulting in appointment delays, additional anxieties and work for clinic staff and causing difficulties and delays in medical information being located.

• The hospital did not secure records in a way, which protected patient confidentiality. We saw numerous occasions where staff left confidential records in public areas. The environment was hazardous for administrative staff in areas where boxes of medical records had been inappropriately stored.

• Data from the trust showed 18,636 patients had been missing on the electronic patient administration system. Of these, 1,119 patients required a further appointment meaning they had been missing from the waiting list. There was an ongoing process to continue to identify further patients missing from waiting lists. This presented a risk to patients’ ongoing treatment and care.

Effective

• The trust’s ‘rolling 12 month’ Hospital Standardised Mortality Ratio (HSMR) for April 2015 to March 2016 was 101.5.
• The latest published Summary Hospital-level Mortality Indicator (SHMI) for July 2015 to June 2016 was 1.101 which was as expected.
• Outcomes for patients were sometimes below expectations when compared with similar services at a national level.
• Generally, care and treatment was planned and delivered in line with current evidence based guidance but there were times when care and treatment didn’t followed evidence based guidance.
• Patient outcomes were variable compared to similar services and some standards were not measured or audited.
• Not all staff had the right qualifications, skills, knowledge and experience to do their job. Not all staff had the training or completed competences recommended by the trust to care for patients with a tracheostomy or to care for patients receiving non-invasive ventilation.

• There was no policy for restraining patients but we found evidence that patients had received tranquilisation drugs in order to sedate them.
• Generally there was good multidisciplinary working across the service. This included support from community staff who attended meetings to discuss patient care.
• There was a colour coded system to signify assistance required for patients to maintain dietary and fluid requirements.
• Endoscopy services at this hospital were Joint Advisory Group (JAG) accredited.
• A dementia care practitioner was available to support patients living with dementia.

• The maternity service used a maternity dashboard but they did not use this to set local goals for each of the parameters monitored, as well as upper and lower thresholds

Caring

• Generally patients and relatives spoke positively about the care they received. Staff treated patients with kindness and compassion and provided emotional support. Staff were friendly and professional in their interactions with patients and relatives and patients felt involved in their care and informed about the care they received.
• However, we observed some instances within the medical service of the hospital where patients were not treated with compassion, dignity and respect. We also received concerns from members of the public/relatives about the care being delivered.
• We observed some instances where patients basic care needs were not always met.

Responsive

• 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 had 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.
• 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.
• 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.

• Maternal choice for a midwife led unit delivery was limited and there were no designated bereavement areas for families who had lost a baby.

Well led

• Not all staff were aware of the vision and strategy for the trust and some staff felt uncertain about the future of the hospital.
• There was not always an effective governance framework which supported the delivery of safe, good quality care.
• Risks were not always dealt with appropriately or in a timely way.
• We received mixed feedback from staff about morale and feeling they could raise concerns and were listened to. Some staff reported morale as good in their clinical area, where as others were less engaged with the hospital and did not feel as comfortable to raise concerns.
• We were not assured that all of the local leaders had the necessary knowledge and capability to lead effectively because in some areas they were out of touch with the clinical care being delivered on the front line. In some areas, there was a lack of clarity about how staff were held to account.

We saw several areas of outstanding practice including:

• The emergency department was trialling the introduction of a hot meal for those patients who were able to eat at lunchtime.
• The department inputted hourly data into an emergency department (ED) 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 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 needs. Being signed up to the carers badge also gave carers free parking whilst they were in attendance at the hospital.
• 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.

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

Importantly, the trust must:

• 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 avoidable 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 excess of 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 avoidable 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 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 actions 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 actions 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 actions 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 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 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.

In addition the trust should:

• The trust should ensure there are robust systems in place to ensure all incidents are reported, investigations occur in a timely manner, staff receive feedback and processes are in place to ensure learning occurs.
• The trust should ensure that governance procedures are robust, risks are clearly identified and that there is a comprehensive assurance system.
• The trust should ensure ligature cutters are immediately available in the ED.

• 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 implement the difficult airway trolley in the emergency department at the earliest opportunity.
• The trust should ensure the proper and safe management of medicines, including storage at the correct temperature in the emergency department.
• The trust should ensure it continues to work to response to the increased capacity and improve flow through the emergency department in order to ensure patients are seen by a registered healthcare practitioner in 15 minutes, do not have to wait longer than four hours and that ambulance handovers happen within 15 minutes.
• The trust should ensure there is 16 hours of consultant presence each day.
• The trust should ensure there is a suitable room in ED to treat those patient with mental health needs.
• The trust should consider if mental capacity assessments and best interest decisions for patients attending the emergency department are recorded in line with the Mental Capacity Act.
• 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 consider how the emergency department can comply with the accessible standard for information and also how facilities for the hard of hearing can be improved at the reception area of the emergency department.
• The trust should consider how the environment in the emergency department could be more dementia friendly.
• The trust should ensure mandatory training is completed in line with trust policy.
• The trust should ensure safeguarding adults and children’s training is completed in line with trust policy.
• The trust should ensure standards of hygiene and cleanliness at all times to prevent and protect people from healthcare-associated infection.
• The trust should ensure that timely care planning takes place to ensure the health, safety and welfare of the service users.
• The trust should ensure observation charts for monitoring fluid balance of patients are completed to ensure the health, safety and welfare of the service users.
• The trust should ensure systems, processes, standard operating procedures are in place to ensure documentation, and checklists for the safe delivery of care for patients with a tracheostomy are completed and displayed in accordance with trust policy.
• The trust should ensure evidence based guidance is followed. The trust did not follow national guidance for the administration of rapid tranquilisation medication.
• The trust should ensure staff training on Consent, Mental Capacity Act and Deprivation of Liberty Safeguards is completed in line with trust policy.
• The trust should ensure staff appraisal rates are completed in line with trust policy.
• The trust should ensure patient records are kept securely.
• The trust should ensure all fridge temperatures for the storage of medication are recorded in line with trust policy.
• The trust should ensure staff training on Consent, Mental Capacity Act and Deprivation of Liberty Safeguards is completed in line with the trust target of 95%.
• The trust should ensure do not attempt cardio pulmonary resuscitation (DNACPR) orders are completed and mental capacity assessment for those deemed to lack capacity are completed in line with trust policy and national guidance.
• The trust must ensure pain assessments tool are completed for patients in line with evidence based guidance and staff are clear about the specialist pain team referral pathway.
• The trust should ensure systems are robust to identify vulnerable patient groups including, but not exclusive to, patients living with dementia and patients with learning disabilities.
• The trust should ensure there are robust systems in place to manage quality and safety issues in the absence of the Quality and Safety Officer (QSO) for the medicine directorate.
• The trust should ensure patient records are kept securely.
• The trust should ensure all fridge temperatures for the storage of medication are recorded in line with trust policy.
• The trust should ensure that staff vacancies are recruited into to meet the patient acuity within this service.
• The trust should ensure that the emergency call bells on the risk register since 2014 are installed.
• The trust should ensure they review the consultant rota to ensure that the rota is sustainable, and that consultants receive 11 hours rest in line with the European working time directive.
• The trust should ensure there is an allocated physiotherapist to surgical ward areas.
• The trust should ensure that a Psychologist or Counsellor are available to support vascular amputation patients.
• The trust should ensure that the measures are addressed for the National Emergency Laparotomy Audit.
• The trust should ensure that the safety thermometer is displayed in all areas.
• The trust should ensure that all staff receive a yearly appraisal.
• The trust should ensure they address concerns regarding the clinical waste arrangements with disposal trolley bins permanently outside the theatre corridor.
• The critical care unit should display safety thermometer outcomes within the department so that staff and visitors are informed of safety outcomes for the unit.
• The critical care unit should establish a recorded program of equipment maintenance and capital replacement in line with standards for equipment in critical care.
• Critical care should consider improving links with speech and language therapists to ensure patients are able to swallow effectively following tracheostomy or long term intubation.
• The critical care department should consider increasing the number of staff able to access the post registration award in critical care nursing.
• The senior management team should consider incorporating CCOT into the critical care team to facilitate continuity of care between critical care and the wards.
• Critical care should consider integrating a named medical consultant when caring for emergency medical patients, to ensure continual and consistent treatment for these patients on discharge from the unit.
• Critical care should review the service in line with intensive care standards.
• Critical care should consider collecting data to reflect their delayed discharges by speciality and reason to support this topic on the risk register.
• The trust should take actions to ensure that NICE guidance is followed in the provision of care for patients with hypertensive disorders in pregnancy.
• 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 if recent NICE guidance is not followed then the current guidance includes an addendum to explain the current decision. (CG 190)
• The trust should audit the length of time patients attending for emergency gynaecology appointments are expected to wait.
• The trust should take action to improve the provision of multidisciplinary training.
• The trust should ensure that within maternity service users feedback is captured.
• The trust should ensure that action plans are made following audits, and a reaudit is performed, such as following the regular CTG audits.
• The trust should consider delivering more transition clinics for other long-term conditions other than diabetes and cystic fibrosis.
• The trust should ensure they devise an abduction policy for the neonatal unit and children’s ward, and test the policy regularly.
• The trust should ensure all staff follow best practice documentation guidance to ensure all entries into clinical notes is of a satisfactory level and in line with professional standards.
• The trust should ensure staff working in the children and young people’s service receive formal clinical supervision.
• The trust should ensure outpatient and diagnostic services are delivered in line with national targets.
• The trust should ensure staff report incidents in line with trust policy.
• The trust should ensure staff are reminded of the procedures regarding fridge temperatures falling outside expected range.
• 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.
• The trust should ensure all staff are supported and are not subject to any behaviour falling outside the trust code of conduct.
• The trust should ensure all staff know their responsibilities and expectations regarding screen breaks.
• The trust should continue to review the progress and effectiveness of the outpatient transformation programme and work undertaken to reduce diagnostic backlogs.
• The trust should ensure staff documented ultrasound probe cleaning.

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