The Queen Elizabeth Hospital Kings Lynn maternity service is operated by The Queen Elizabeth Hospital Kings Lynn NHS Foundation Trust . The hospital has 25 maternity beds within the antenatal/postnatal Castleacre ward, there is also a central delivery suite with eight birthing rooms and Waterlily birth centre which is a midwife led centre for low risk women and has three birthing rooms. The bereavement suite for the service is located in one room on the Waterlily birth centre.

The trust provides maternity services to the populations of West Norfolk, East Cambridgeshire and South Lincolnshire. Services are provided in the maternity unit and at clinics at a neighbouring hospital at Wisbech. Community midwifery teams provide care to low risk women choosing a home birth and outreach clinics are held across the three counties.

The maternity service includes an antenatal day assessment unit at the Queen Elizabeth Hospital and antenatal clinics at both the Queen Elizabeth Hospital and the neighbouring hospital at Wisbech; Waterlily Birth Centre, the delivery suite and a combined antenatal and post-natal ward at the Queen Elizabeth Hospital site.

The last inspection of maternity services took place on the 1 and 2 of May 2018. During the inspection we found several areas of concern including lack of leadership, dysfunctional culture and concerns around the safe care and treatment of high risk women and vulnerable women.

Following the inspection CQC undertook enforcement action and served a warning notice on 17 May 2018 under section 29A of the Health and Social Care Act 2009 in respect of Regulation 12 and Regulation 17.

We carried out an unannounced inspection at The Queen Elizabeth Hospital Kings Lynn on 4 December 2018. We carried out an unannounced inspection at North Cambridgeshire Hospital on 5 December to follow up specifically on compliance with the 10 points of concern within the Section 29A warning notice.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate. As this was a focussed follow up there are no ratings attached to this inspection.

We found the following areas of improvement:

• The premises at North Cambridgeshire Hospital had been risk assessed and improvements had been made to mitigate the risk to service users and staff.

• Care planning for high risk and vulnerable women had improved. There were consultant leads in place and response times to see high risk women and consultant attendance at antenatal clinics were clinics were monitored.

• The management of incidents had improved. Staff recognised incidents and reported them appropriately. Managers and clinicians investigated incidents and shared lessons learned with the whole team and the wider service.

• The service took account of women’s individual needs. Changes had been made to ensure women who miscarried before 16 weeks were cared for in a dedicated side room on the surgical ward. Alternative waiting areas were available for women on the Brancaster antenatal and gynaecology clinic outpatient unit should they require it.

• An electronic antenatal booking system was in place for women accessing maternity services. This had improved the process for the management of antenatal referrals.

• Leaders had been appointed to the service with the right skills and abilities to lead the service and deliver high quality care.

• The culture in the service had improved. There was evidence of improved communication, engagement and multidisciplinary team working between midwives and obstetricians.

• There were improved governance processes in place to identify and manage risk. Some consultants were involved in the governance process. Risks were identified and monitored on the risk register.

However, we also found the following issues that the service provider needs to improve:

• The number of consultant vacancies meant that high risk and vulnerable women did not see the same consultant at each appointment to provide continuity of care.

• Although the leadership of the service had improved key leaders were interim appointments and we were concerned about the sustainability of improvements when they left the service.

• Staff felt that there was not effective, timely communication keeping them updated with plans and changes within the service.

• Staff reported that some consultants were still not on board with the cultural change and still displayed inappropriate and unprofessional behaviour.

• The service’s audit programme was not fully embedded.

• There were 32 out of 64 guidelines still outstanding that required review and update.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve. We also issued the provider with one requirement notice. Details are at the end of the report.

Amanda Stanford

Deputy Chief Inspector of Hospitals.

• Staff in the cardiorespiratory department and the ultrasound department did not routinely offer chaperones or observe consultants during intimate patient imaging procedures.
• Consulting staff in the breast unit did not secure patient identifiable information on computer screens when they left the room. This was a breach of the Health and Social Care Act 2008 regulated activities regulations 2014 regulation 17: Governance.
• Radiology staff did not meet the trust wide target of 95% compliance for adults and children safeguarding training. Radiology medical staff achieved 64% and allied health professional staff achieved 66%.
• Breast care staff achieved 75% compliance for children safeguarding training, this did not meet the trust wide target of 95%.
• Radiology medical staff did not meet the trust wide target for mandatory training compliance (95%) in nine out of ten modules Including resuscitation training where only 50% of staff had completed the training.
• Allied health professional staff did not meet the trust wide target for mandatory training compliance (95%) in six out of ten modules including resuscitation training where only 67% of staff had received the training.
• Allied health professional staff did not meet the trust wide target for appraisal (90%) with only 61% of staff receiving an appraisal.
• Staff In the computerised tomography (CT) department referred to out of date protocols and protocols which applied to a decommissioned piece of equipment.

• Staff members in the radiology department did not consistently complete cleaning records. This meant that cleaning procedures were not followed appropriately and there was a potential infection prevention control risk.

• Waiting times from referral to treatment were worse than the England average and the trust was reporting 47% of images within 24 hours. This was not meeting the reporting turnaround time target of 90% of images within 24 hours.

• We had some concerns around the secure storage, prescription and administration of medicines. In the breast care unit staff stored personal medicines in the secure medicines cupboard. Staff in the magnetic resonance imaging unit (MRI) administered saline without the presence of a patient group directive (PGD) for its administration.

• There was no evidence of sharing the learning from complaints with staff.

• We were not assured the service had robust structures, processes and systems in place to support the delivery of high quality person centred care especially in the radiology department.

However,

• The service managed patient safety incidents well. There had been no reported never events in the service between April 2017 and March 2018.
• Staff could access appropriate records of patients’ care at the point of providing care and treatment. Staff provided care based on national guidance and monitored the effectiveness through audit.
• Staff of different specialisms worked together as a team to benefit patients and always had access to up-to-date, accurate and comprehensive information on patients’ care and treatment.
• Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005 and involved patients and those close to them in decisions about their care and treatment where appropriate.
• Staff cared for patients with compassion and kindness and provided emotional support to patients when required. Staff greeted patients by their name, asked patients what they prefer to be called, enquired after their comfort and protected their dignity.
• The service took account of patients’ individual needs and staff knew how to access a wide range of services to improve patient experience. For example, interpreters for those patients whose first language was not English, hearing loops, bariatric equipment, play specialists and dementia champions to meet the needs of patients.
• The service had a vision for what it wanted to achieve and workable strategy to turn it into action along with effective systems for identifying risks, planning to eliminate them or reduce them. Local leaders were visible, approachable and supportive to staff.
• The radiology department had a comprehensive audit programme to improve performance and safety and managers across the trust promoted a positive culture that supported and valued staff.

When we visited the trust in March 2012 and August 2012, we found that the trust was not meeting some of the essential standards.The trust wrote and told us about the action they planned to take. We completed this visit to check that action had been taken.

People who were receiving care told us that they were treated with respect and were kept informed about their care and treatment. We found that the wards were busy and saw that staff spoke with people in a polite and respectful manner, offered them choice when appropriate to do so and supported them to be independent.

We visited three wards and found the people that we spoke with were very complimentary about the quality of the food they received. One person told us,“The food here is good but I do not eat all of the things on the menu, such as pizza.” Most people told us they had a choice of meals they could order.

We found that members of staff provided appropriate levels of support to people who needed help to eat and drink Most of the records showed that nutritional risks were assessed and care plans to support people's needs were in place. However we found that a nutritional assessment for one person was not completed accurately and a care plan to address the person's nutrition needs was not up to date.

We found the trust had made some improvements to the quality of the care records. Regular checks were in place to monitor this improvement and actions was taken when standards fell below expectations.

People told us what it was like to be a patient in The Queen Elizabeth Hospital. They described how they were treated by staff and their involvement in making choices about their care. They also told us about the quality and choice of food and drink available. This was because this inspection was part of a themed inspection programme to assess whether older people in hospitals were treated with dignity and respect and whether their nutritional needs were met.

The inspection team was led by a Care Quality Commission (CQC) inspector joined by a practising professional and an Expert by Experience, who has personal experience of using or caring for someone who uses this type of service.

We visited the medical admissions unit (MAU) and an acute medical ward. We spoke with 12 people who used the service and one relative. Overall people were very complimentary about the care and treatment they had experienced. One person said,“I’ve no complaints about the care,” and another described staff as, "wonderful."

Most people seemed to have a good understanding of their condition and told us about their treatment in a way that suggested there had been good consultation with medical staff and some involvement with their treatment choices.

Two people we spoke with did not feel that their dignity had been respected. This was because one person had not been offered the opportunity to take a bath and the other felt staff had not respected their ability to walk to the bathroom.

In general people told us the food was sufficient and they could obtain additional food and drink on request if necessary. However we found the level of support to people at mealtimes varied and was not always person centred to meet their individual needs.

One person told us they thought there could be more staff as the call bells sometimes rang for a long time. We did not witness this during our visit to the two wards as call bells were answered within five minutes.

We looked at people's records in relation to their nutritional needs and found they did not always include accurate information about their needs. However we also saw some good records of detailed medical discussions with relatives and observed that staff were careful to ensure that personal information was not easily visible to people passing by.

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.

During our visit we spoke with patients on a number of wards and also with some visitors. Patients told us they were treated with respect and dignity at all times. They spoke positively about staff and described them as “pleasant” and “good”. Two relatives told us they had no concerns about the way staff treated patients.

Visitors were also complimentary about the staff and told us that they were well informed about the progress of patients they visited. One visitor said, “I can’t fault the care”. They told us that the patient was due to go home the following day and that appropriate arrangements had been made, following discussion with the patient’s family.

Patients told us that staff explained their care, treatment and progress in a way they could understand. They said that they were happy with the care they received and that, on the whole, they were having their needs met. However, a few patients said that some staff were not very helpful and they didn’t feel able to ask them for help when they needed it because staff were so busy.

Patients also told us that they were given a choice of food and that they received appropriate support to eat and drink. They said that staff knew which people required help with their meals. One patient said, “They always reposition tables and cut up food for patients.”

All of the patients we spoke with were very complimentary about how their medicines were managed. They told us that they received their medicines on time, and were not kept waiting for pain relieving medicines or waiting for medicines at night. They told us that staff had explained to them the purpose of any new medicines they had been prescribed.

During our visit on 18 August 2011 we visited four clinical areas and spoke with a number of people and their visitors.

Most people told us that when they were admitted to hospital they were involved in the decisions made in respect of their treatment and care. One person said that staff had told them what was happening, had discussed their medication and were making arrangements for this to be dispensed, with a letter to the person’s doctor, so they could go home. Conversely another person said that staff “Didn’t tell me anything.” They said they felt as if they were kept in the dark and, “That’s the way it is really.”

On the maternity ward people were very complimentary about the care and information they had received. They made comments like "Fantastic, couldn't fault them."

People told us that they had found the staff to be discreet when talking to them and asking intimate questions, always pulling the curtains around when being examined. They told us that as far as possible privacy and dignity were respected, for example if feeding the baby the staff asked whether they wanted the curtains drawn.

On the older persons’ wards people who could express their views were very positive about how they were cared for. One person who was receiving care on the medical admissions unit was very complimentary about their experience. They said they felt well informed and had already been given the results of tests carried out that morning. One person was waiting to go home and said that they knew what was going to happen following their discharge from hospital. They said “My tablets have been sorted out, the staff are very good indeed.”

People with whom we spoke mostly told us that they were very happy with the way in which they had been treated and cared for during their stay in hospital. One person said staff were very good and they had no complaints. Another said the staff were “kind and caring.”A visitor also told us that they thought the care and treatment had been “alright”. They said their relative appeared to be well cared for and that “staff do a good job”. However, another visitor told us that the standard of care had not been good. They said staff did not know how to meet the needs of their relative and they had made a complaint about their concerns.

One person said that staff had been very efficient in supporting them. They said that a pharmacist had made sure that their medicines were explained to them and discussed with the consultant so they were clear about the arrangements for these before they left the hospital. However another person did not feel their ongoing care needs had been discussed.

People who were receiving maternity services told us that they had received good quality care and felt their needs were being met. One person told us that the staff were careful about infections, they were very clean, always wiping round and checking under beds.

One visitor with whom we spoke was critical of the care their relative had received in the medical assessment unit. They told us that staff had been abrupt and unfriendly (“No smile, no touching”) and had declined help to take their relative to the toilet when asked, responding “well he pulled his catheter out.” Conversely this person was very happy with the care they had received on the older person ward and said that staff were helpful and could communicate well with the people on the ward.

A number of people we spoke with gave us a good account of the choices offered at meal times. We were told the meals were good and that the choices were made on a menu tick chart the day before. They told us the food was hot and the options were healthy. One person with whom we spoke was able to give us a good example of how the hospital had improved over the past few years as they had been admitted several times. We were told that the choice and quality of food was better. Another person told us that when they were admitted they were not asked about their dietary needs. This person said they were a diabetic and able to manage their diet themselves. One visitor told us that they visited every day to ensure that their relative had a meal at lunch time. They did not feel confident that their relative would have a meal otherwise. They told us that on occasions they had visited to find that food and drink had been left out of reach. They also told us that they had observed several people on the wards who needed support with their meals and did not get it.

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

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

Our key findings were as follows:

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

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

We saw several areas of outstanding practice including:

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

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

Importantly, the trust must:

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

In addition the trust should:

• Review the clinical pathways especially for fractured neck of femur between the ED and the orthopaedic service and within the maternity and gynaecology services as highlighted in this report.
• Ensure a system of clinical leadership developed for all areas of the maternity service with clarity about the role, responsibilities and reporting relationships. A strategic vision should be developed.
• Should ensure that infection control practices are adhered to at all times in the emergency department.
• The hospital should develop a joint clinical and managerial response to the review carried out by the royal college of obstetricians which provides a clear strategic vision for the service
• Ensure staff training for patients living with dementia is effective in practice, and that staff can recognise the need and complete the patient passport where necessary.
• Ensure the operational management structure is established and known to all staff within each service
• Access to medical staff on call should be improved across obstetrics and gynaecology to ensure patients have timely access to medical advice
• Develop the role of the PAU in response to the needs of the population
• Ensure incidents and complaints relating to end of life care are easily identified and a process is in place to ensure learning is identified and used to influence the development of the service.
• Ensure the cancellation rates and specialty clinic waiting times in the outpatients department are reviewed and improved.

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

Professor Sir Mike Richards

Chief Inspector of Hospitals