United Lincolnshire Hospitals NHS Trust
Review into the Quality of Care & Treatment provided by
14 Hospital Trusts in England
RAPID RESPONSIVE REVIEW REPORT FOR RISK SUMMIT
June 2013
Contents
1.
Introduction
3
2.
Background to the Trust
7
3.
Key Lines of Enquiry
16
4.
Findings
18
5.
Governance and leadership
22
Clinical and operational effectiveness
30
Patient experience
35
Workforce
40
Safety
48
General Medicine and Elderly Care
52
Urgent Care
56
Obstetrics
61
Critical Care and Surgery
65
Conclusions and support required
Appendices
Appendix I:
Appendix VI: Information available to the RRR panel
81
Appendix VII: Unannounced site visit
84
70
73
SHMI and HSMR definitions
74
Appendix II: Panel Composition
76
Appendix III:
77
Interviews held on announced visit
Appendix IV: Observations undertaken
78
Appendix V:
80
Focus groups held
2
1. Introduction
Overview of review process
On 6th February the Prime Minister asked Professor Sir Bruce Keogh, NHS England Medical Director, to review the quality of the care and treatment being provided by those
hospital trusts in England that have been persistent outliers on mortality statistics. The 14 NHS trusts which fall within the scope of this review were selected on the basis that
they have been outliers for the last two consecutive years on either the Summary Hospital level Mortality Indicator (SHMI) or the Hospital Standardised Mortality Ratio
(HSMR). Definitions of SHMI and HSMR are included at Appendix I.
These two measures are intended to be used in the context of this review as a ‘smoke alarm’ for identifying potential problems affecting the quality of patient care and
treatment at the trusts which warrant further review. It was intended that these measures should not be reviewed in isolation and no judgements were made at the start of the
review about the actual quality of care being provided to patients at the trusts.
Key principles of the review
The review process applied to all 14 NHS trusts was designed to embed the following principles:
1) Patient and public participation – these individuals have a key role and worked in partnership with clinicians on the reviewing panel. The panel sought the views of the
patients in each of the hospitals and also considered independent feedback from stakeholders, related to the Trust, which had been received through the Keogh review
website. These themes have been reflected in the reports.
2) Listening to the views of staff – staff were supported to provide frank and honest opinions about the quality of care provided to hospital patients.
3) Openness and transparency – all possible information and intelligence relating to the review and individual investigations will be publicly available.
4) Cooperation between organisations – each review was built around strong cooperation between different organisations that make up the health system, placing the
interest of patients first at all times.
Terms of reference of the review
The review process was designed by a team of clinicians and other key stakeholders identified by NHS England, based on the NHS National Quality Board guidance on rapid
responsive reviews and risk summits. The process was designed to:


Determine whether there are any sustained failings in the quality of care and treatment being provided to patients at these Trusts.
Identify:
i.
Whether existing action by these Trusts to improve quality is adequate and whether any additional steps should be taken.
ii.
Any additional external support that should be made available to these Trusts to help them improve.
iii.
Any areas that may require regulatory action in order to protect patients.
3
The review follows a three stage process:

Stage 1 – Information gathering and analysis
This stage used information and data held across the NHS and other public bodies to prepare analysis in relation to clinical quality and outcomes as well as patient and staff
views and feedback. The indicators for each trust were compared to appropriate benchmarks to identify any outliers for further investigation in the rapid responsive review
stage as Key Lines of Enquiry (KLOEs). The data pack for each trust reviewed is published at http://www.nhs.uk/NHSEngland/bruce-keogh-review/Documents/trust-datapacks/ulh-data-packs.pdf

Stage 2 – Rapid Responsive Review (RRR)
A team of experienced clinicians, patients, managers and regulators (see Appendix II for panel composition), following training, visited each of the 14 hospitals and observed
the hospital in action. This involved walking the wards and departments, interviewing patients, trainees, staff and members of the Board. The report from this stage was
considered at the risk summit.

Stage 3 – Risk summit
This brought together a separate group of experts from across health organisations, including the regulatory bodies. They considered the report from the RRR, alongside
other hard and soft intelligence, in order to make judgements about the quality of care being provided and agree any necessary actions, including offers of support to the
hospitals concerned. A report following each risk summit has been made publically available.
Methods of investigation
The three day announced RRR visit took place at the Trust’s three acute sites: Grantham Hospital, Lincoln County Hospital and Pilgrim Hospital Boston on Monday 17 June,
Tuesday 18 June and Wednesday 19 June 2013. A variety of review methods were used to investigate the KLOEs and enable the panel to consider evidence from multiple
sources in making their judgements.
The visit included the following methods of investigation:

Interviews
Nine interviews took place with members of the Board and selected members of staff based on the key lines of enquiry during the visits. See Appendix III for details of the
interviews undertaken.

Observations
Ward observations enabled the panel to see the Trust undergo its day to day operations. They allowed the panel to talk to current patients, and their families where
observations took place during visiting hours. They allowed the panel to speak with a range of staff and observe the quality of care and treatment being provided to patients.
The panel was able to observe the action by the Trust to improve quality in practice and consider whether any additional steps should be taken.
4
Observations took place in sixty one areas of The Trust split across the three hospitals; Grantham Hospital, Lincoln County Hospital and Pilgrim Hospital, Boston. See
Appendix IV for details of the observations undertaken.

Focus Groups
Focus groups provided an opportunity to talk to staff groups individually to ask each area of staff what they feel is good about patient care in the Trust and what needs
improving. They enabled staff to speak up if they felt there was a barrier that was preventing them from providing good quality care to patients and what actions might the
Trust need to consider improving, including addressing areas with higher than expected mortality indicators.
Focus groups were held with seven staff groups during the announced site visit, with mixed groups being held across the three main hospital sites. See Appendix IV for
details of the focus groups held.
The panel would like to thank all those attending the focus groups who were open with the sharing of their experiences and balanced in their perceptions of the quality of care
and treatment at the Trust.

Listening events
Public listening events give the public an opportunity to share their personal experiences with the hospital, and to voice their opinion on what they feel works well or needs
improving at the Trust in relation to the quality of patient care and treatment. A listening event for the public and patients was held on the evening of 17 June 2013 at The
White Hart Hotel in Lincoln and on the evening of 18 June 2013 at The White Hart Hotel in Boston. These were open events, publicised locally, and attended by c.65
members of the public and patients at each event.
The panel would like to thank all those attending the listening event who were open in sharing of their experiences and balanced in their perceptions of the quality of care and
treatment at the Trust.
We would also like to express our thanks to those families and patients who have contacted us through the patient voice website or through ‘Cure the NHS Lincolnshire’. The
panel has considered each story in detail and whilst we cannot respond to individual complaints we want you to know that the panel will take on board your comments as part
of the review.

Review of documentation
A number of documents were provided to the panellists at the Trust during the site visit. Whilst not every document was reviewed in detail, they were available to the
panellists to validate findings as considered appropriate. See Appendix VI for details of the documents available to the panel

Unannounced visit
The unannounced out-of-hours visit took place at Lincoln County Hospital and Pilgrim Hospital, Boston on the evening of Thursday 19 June 2013. This focused observations
in areas identified from the announced site visit, see Appendix VII.
5
Next steps
This report has been produced by Dr Ruth May, Panel Chair, with the full support and input of panel members. It has been shared with the Trust for a factual accuracy check.
This report was issued to attendees at the risk summit, which focussed on supporting United Lincolnshire Hospitals NHS Trust (“the Trust”) in addressing the actions identified
to improve the quality of care and treatment.
Following the risk summit the agreed action plan will be published alongside this report on the Keogh review website. A report summarising the findings and actions arising
from the 14 investigations will also be published.
6
2. Background to the Trust
This section of the report provides relevant background information for the Trust and highlights the areas identified from the data pack for further investigation.
Context
United Lincolnshire Hospitals NHS Trust is the principal acute provider of healthcare across the three main hospital sites (Boston, Grantham and Lincoln) for the residents of
Lincolnshire. The Trust also provides a number of services within smaller community hospitals (at Louth, Gainsborough, Skegness and Spalding) owned by other
organisations.
Lincolnshire’s resident population of 700,000 exceeds the Royal College of Surgeons preferred catchment population for an acute general hospital providing a full range of
facilities.
Lincolnshire is the second largest county in England (2700 square miles), and the Trust provides its services across its three main sites.
Transport and road links between the sites are poorly developed compared with many other parts of England, with travelling time between sites of 50 minutes to one hour.
To maintain local access the Trust replicates service provision across the county. The Trust and wider health community has recognised the future challenges to sustaining
the current service configuration across all services in Lincolnshire, including acute provision. The whole health and social care community is committed to a sustainability
review for Lincolnshire.
The Trust provides a full range of District General Hospital (DGH) based services with General Medicine and General Surgery being the largest inpatient specialties; and
Ophthalmology being the largest for outpatients. Lincoln County is unusual in that it is a DGH providing Radiotherapy Services, normally a tertiary centre function.
In 2012 the Trust had 657,315 outpatient’s attendances and 157,391 inpatient attendances. The day case rate over the same period was 82%, that is, patients entering and
leaving hospital on the same day.
With a total of 1,079 beds it has a market share of 78% for inpatient activity within a 5 mile radius of the Trust sites. The market share falls to 74% within a 10 mile radius and
49% at a 20 miles radius. In the three localities covered by the Trust, 2.4% of Lincolnshire’s population belong to non-white ethnic minorities.
The Trust’s HSMR level has been above the expected level for the last 2 years and the Trust was therefore selected for this review.
The health profile of the area is generally similar to that of England’s average with some areas that are worse than the national average with several indicators that fall lower
than what would be expected. The Trust covers seven district/borough council areas: Boston, East Lindsey, West Lindsey, North Kesteven, South Kesteven, South Holland,
the City of Lincoln Council; and one County Council: Lincolnshire.
The following matters are pertinent to this review:

Long term unemployment in Lincoln is higher than the national average but both Boston and South Kesteven show above average employment
7

The levels of deprivation in Lincoln are worse than the national average together with the proportion of children in poverty in Lincoln being greater than the national
average. Both Boston and South Kesteven perform more favourably on these metrics

Smoking during pregnancy throughout the county is worse than England’s national average

Teenage pregnancy levels (under 18) in Lincoln and Boston are significantly greater than the English national average, although for South Kesteven a lower than average
prevalence is noted

Alcohol specific hospital stays are significantly greater than the average in Lincoln and Boston although below average for South Kesteven

Rates of smoking in adults is above the national average

The number of physically active adults is below the national average

Hospital stays for self harm are significantly higher in Lincoln than the national average but fall within the national average for Boston and South Kesteven

Lincoln and Boston also witnesses a much higher level of drug misuse incidents than the national average

Life expectancy for male and females is lower than the national average in Lincoln and Boston with the respective figures

Population data indicate that early deaths related to cancer are higher in Lincoln than the national average

Population data indicate that early deaths related to heart diseases are also higher in the trust, specifically, Boston and Lincoln

Acute sexually transmitted infections are significantly greater in Lincoln than the national average
The health profile for the Trust is complex, with some areas being more deprived than others and some facing greater health challenges than others for specific diseases as
articulated above. The variety of health needs of the population it serves poses a significant challenge for this Trust.
Key messages from the Trust data pack
Mortality indicators
The Trust has an overall HSMR higher than expected for the past two years; with scores of 113 and 111 for the FY 2011 and FY 2012 respectively; the number of actual
deaths in the hospitals within the trust is higher than the expected level and above the statistically expected range. Further analysis of this demonstrates that non-elective
admissions are the primary contributing factor to this figure. Elective admissions are within the expected range, with an HSMR of 80.
8
The official SHMI was within the expected range at 110 for the period October 2011 to September 2012 and therefore as the Trust was not an outlier for SHMI for two
consecutive periods, it was not selected for review on the basis of its SHMI. It was noted that the Trust has a SHMI of 109 (December 2011 to November 2012), which is
statistically above the expected range.
There is variation between SHMI and HSMR data across the three sites at which the Trust provides services.
Similar to the HSMR, non-elective admissions are seen to be contributing primarily to the overall Trust SHMI. The Trust had nine high mortality alerts for diagnostic groups
since 2007 and five requests for investigation relating to mortality from the CQC since 2009. The Trust has provided full responses to each of these and no further action has
been required by the CQC.
In depth reviews of the Trust by CQC have revealed the following areas as common themes of concern:

Fluid balance monitoring

Delays in implementing treatment plans

Clinical documentation issues

Delays in implementation of the Liverpool Care Pathway

Failure to escalate the deteriorating patient

Risk of falling during stays in hospital

Senior review, particularly post operatively
Together with the Care Quality Commission (CQC) Healthcare Evaluation Data (HED), Health and Social Care Information Centre and Dr Foster reviews have notified the
following 8 mortality indicators out of 13 used nationally, as outside the expected ranges:

Overall HSMR

Emergency specialty groups much worse than expected (CQC)

Emergency specialty groups worse than expected (CQC)

Diagnosis group alerts to CQC

Diagnosis group alerts followed up by CQC
9

Non-elective mortality (SHMI and HSMR)

30 day mortality following specific surgery / admissions

Mortality among patients with diabetes
Diagnosis coding depth has an impact on the expected number of deaths. A higher than average diagnosis coding depth is more likely to collect co-morbidity which will
influence the expected mortality calculation. For The Trust, it is apparent that for elective admissions, the Trust has been consistently performing below the national average
for coding depth. The average diagnosis coding depth for non-elective admissions has also been close to the national average and the most recent quarter shows the trust is
above the national average. The Trust make below average use of palliative care coding on admission (using diagnosis codes rather than treatment speciality). This may
impact on the mortality indicators.
Leadership and governance
The Trust has had 9 CEOs in 11 years and has consistently experienced major turnover of directors during this time. In addition to existing substantive directors (Chief
Executive, Deputy Chief Executive, Director of Operations) the current Board is also composed of 2 interim directors: the Director of Nursing and the Director of Facilities as
well as an Acting Director of Finance. The current Medical Director is working on a part time basis.
There is a new Director of HR/Organisational Development who is shared with another local provider. New substantive Medical, Nursing and Facilities Directors have recently
been appointed but have not yet commenced in post. The Board also consists of a Chairman and 5 non executives. Two additional non-executives are in the recruitment
process.
The Governance Committee, a sub-committee of the Board that provides assurance on quality governance is chaired by a Non Executive Director.
The Quality & Safety Committee reports to the Governance Committee and is chaired by the Medical Director. Since the departure of the last Medical Director, this has been
chaired by a senior member of his team.
The Trust set up the pan-Trust Mortality Reduction Board in 2010. In 2012, this was further supported by a new system at site level; site-based mortality reduction committees
at main hospital sites, which report into the pan-Trust Mortality Reduction Board. The current Director of Nursing is an interim member of the executive team and the Trust has
recently appointed a new Director of Nursing from within the Trust patient services team.
Recent reviews by the CQC identified minor concerns in relation to two outcomes: staffing, and the care and welfare of people who use services. This represents a significant
improvement on the Trust’s CQC inspections in prior years, which had identified a number of major concerns. The Trust is not currently a Foundation Trust, however in
December 2012 the Board conducted a self-assessment of its performance against Monitor quality governance framework. The Board self assessed a score of 14.0 (aspirant
trusts must receive a score of 3.5 or lower to be authorised as a foundation trust). This score included two ‘reds’ (indicators of major concern) and did not meet expectation in
the following areas:

‘Is the Board sufficiently aware of potential risks to quality?’

‘Are there clearly defined, well understood processes for escalating and resolving issues and for managing quality performance?’
10
An independent assessment in March 2013 scored the Trust as 9.5, with an improvement in the area ‘Are there clearly defined, well understood processes for escalating and
resolving issues and for managing quality performance?’
The Trust continues to undertake actions to improve its quality governance performance although the panel found little evidence that some of these matters had been
addressed.
Key self identified risks for the Trust relate to service provision, demand and sustainability, mortality, progress reliability, staffing and skills, lack of whole system provision,
patient records and culture.
In 2012/13, the Trust achieved cost improvement savings of £14.5m. The Trust plans to save £22.4 million in 2013/14 through cost improvement programmes (CIPs). £20.4
million has been identified as per submission to the Trust Development Authority (TDA) on 24 May 2013. The Trust currently has an ‘amber’ Monitor governance risk rating,
although it is not a Foundation Trust, indicating that there is “minor or moderate concerns” in terms of any future authorisation.
A high level review of the effectiveness of the Trust’s quality governance arrangements, including the use of mortality information on a local basis, was a key line
of enquiry for the review.
Clinical and operating effectiveness
The Trust was reviewed on its clinical and operational effectiveness based on nationally recognised key performance indicators. The Trust has high rates of severe
hypoglycaemic episodes and low rates of patients receiving a foot risk assessment in 2012. They were also an outlier for the percentage of discharged patients who are
prescribed beta blockers following a myocardial infarction and for the proportion of patients having surgery within 36 hours following hip fractures.
The Trust sees 93.7% of A&E patients within 4 hours which is below the 95% expected level. The achievement of the 95% expected level varies from site to site.
For referral to treatment, 90.6% of patients start treatment within the 18 week expected time which is above the target level. This has been a consistent trend from April 2012
to March 2013.
The Trust’s crude readmission rate which is the percentage of patients that were discharged and then re-admitted within 30 days is within the expected range when compared
against the national average, at 11.3%. The average length of stay is shorter than that of the national average.
The Patient Reported Outcome Measures (PROMs) dashboard shows that there has been some decline in performance across the six measures, with one instance (Hip
Replacement Oxford Hip Score) of being below the lower 99.8% control limit.
The data in this area highlighted some specific key lines of enquiry including, Respiratory Medicine, Stroke and Diabetes, all of which were highlighted as areas
to review in the key lines of enquiry under clinical and operating effectiveness.
Patient experience
Of the 9 measures reviewed with Patient Experience and Complaints there are seven which are rated ‘red’ which means the indicators are outside of the expected range:
11

National Inpatient Survey: The national inpatient survey 2012 measured a wide range of aspects of patient experience. A composite ‘overall measure’ is calculated for
use in the Outcomes Framework. This measure uses a pre-defined selection of 20 survey questions to rate the Trust on aspects including access to services, coordination of care, information and choice, relationship with staff and the quality of the clinical environment. The Trust sits below the national average with an overall
measure of 73.8 compared with the national average at 76.5

Cancer survey: of the 58 questions, 22 were ranked in the bottom 20% whilst only 2 were in the top 20%. The main negative focus relates to overall care and care
and treatment for inpatients

Patient Environment Action Team (PEAT - privacy and dignity: The scores for privacy and dignity were shown as ‘acceptable’ across some sites – this is a low rating
on this indicator

PEAT - environment: The scores for environment are routinely shown as ‘acceptable’ across all sites – this is a low rating on this indicator

Friends and family test (FFT): The Trust showed a decline in scores for the Midlands and East FFT to an overall score of 63 placing the Trust in the bottom quartile of
the submissions

Patient voice comments: In the two years to 31 January 2013, there were 241 comments on The Trust of which 165 were negative (68%). The negative focus
includes a lack of professionalism displayed by staff (notes not filled in for example), lack of organisation and too much focus on targets

Complaints about clinical aspect: Within the Trust, 704 written complaints were submitted during 2011-12 of which 73% related to clinical aspects of care, compared
to the national average of 47%. The Ombudsman currently rates the Trust as A-rated. The Ombudsman investigates complaints escalated to it by complainants who
are not satisfied with the Trust's response. It rates Trusts on whether they have implemented the recommendations made at the end of an investigation in a
satisfactorily and timely manner, helping to ensure that Trusts learn from mistakes. The Ombudsman rates each Trust’s compliance with recommendations and
focuses on monitoring organisations whose compliance history indicates that they present a risk of non-compliance.
The complaints process and the appropriateness of language used in front of patients by doctors and the manner by which patients are treated are highlighted as
areas to observe in the key lines of enquiry under patient experience.
Keogh review patient voice comments
The patient voice comments received directly to the Keogh review website (at the time of writing this report) identified the following themes from 33 emails and letters:
Positive
Patient was happy with services provided by Pilgrim Hospital. Admitted to A&E where care was very good.
Appointments are on time.
Receptionist was attentive and professional. Nurse was supportive and the operation and physiotherapy went
well. All the staff were brilliant and care was excellent.
12
Excellent treatment and attention at orthopaedic ward. Physiotherapy was also very good.
Patient had to wait 7 hours for a bed for an operation. Intensive Care ward was very good, staff were brilliant.
As an outpatient there is a long wait to see a consultant but the staff are helpful and consultant is informative
Negative
Lack of communication between patient and staff at all levels.
Mistakes in surgery and diagnosis
Patient was undressed with the curtains not shut, no respect for dignity
Delay in providing treatment and medical forms
Buzzers not working and ward overcrowding, concerns about cleanliness
Operations cancelled and appointments rearranged, long waits for diagnostic procedures and pain relief
Poor attitude of staff with no respect for dignity of the patients, no help with basic tasks or personal hygiene
Concerns about controlled drug management not being addressed
Too few staff
Inappropriate language and lack of sensitivity towards patients, staff being rude to patients
Staff raised concerns in the following areas:

Issues with staffing including recruitment, retention, use of agency, release of staff for training

Poor escalation procedures

Lack of stability within the Trust at senior level.

Poor communication and engagement with staff and patients
Poor communication, poor note taking, discrepancies in notes and communicated issues.
Inappropriate use of ‘do not resuscitate’ order, poor communication of test results
No response or poor response in relation to a complaint made
Poor management of medication being taken by a patient in advance of hospital admission
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‘Disregard’ of available treatment due to age of patient, no assistance with eating
Poor after care
Key lines of enquiry were followed in the review based on what patients say about the quality of care and treatment of patients and what the Trust is doing in
response to this feedback.
Workforce and safety
A review of the workforce data flagged a number of ‘red rated’ indicators:

The Trust’s sickness levels across all staff types (medical, nursing, other staff and overall) are rated red. This means that staff sickness rates are above the national
average for each of these groups.

Turnover rate of staff is also higher than the Midlands and East Region median with a joining rate lower than the average at 5.7% compared to 5.9% and a leaving
rate of 7.5% compared with 6.7%. This means that more staff than average are leaving the Trust and fewer staff than average are joining the Trust.

The Trust’s spend on agency staff was 5.1% of its total staff costs in 2011/12. This compares to an average in the Midlands and East region of 4.2%
In addition to the above, a number of factors were identified from the General Medical Council’s (GMC) National Training Scheme Staff Survey in 2012. These include:

Worse than expected staff engagement

The number of staff that would recommend the organisation as a place to work is below the national average

The number of staff that, if a friend or relative needed treatment they would be happy with the standard of care provided by this organisation is below the national
average

Staff did not see ‘care of patients’ as the organisation’s top priority
Further concerns were raised by the Deanery, when, in October 2011, it considered removal of junior doctors. However the Trust was able to sufficiently demonstrate that
doctors in training were no longer working in wards without adequate supervision, and there was a more equitable workload. At Pilgrim Hospital in Boston, the Deanery
conducted a full quality review of training in all specialties after student nurses were removed from the site by the Nursing and Midwifery Council in July 2011. The Deanery
undertook five further visits in 2012 and confirmed that rotas had been reorganised to ensure appropriate workload and supervision for trainee doctors, who are also now
receiving appropriate education. This site was noted as having persistent recruitment issues. The Deanery continues to undertake routine monitoring of arrangements.
The NMC temporarily removed student nurses from one site during February 2011 following concerns expressed by the CQC. The situation was investigated and students
were returned to the site in July 2011.
14
At Grantham and District Hospital, the Deanery quality management activity indicated that there were issues with handover and clinical supervision in medical and emergency
medicine posts. The Deanery met with the Trust in November 2012 to discuss the issues. An action plan dated February 2013 indicated that there is now 24/7 middle grade
cover, and the rota has been revised to improve handover. The Deanery continues to closely monitor the site.
Key lines of enquiry were included in the review focusing on how the Trust is assured over its workforce in relation to out of hours cover and how it is
responding to concerns raised by the Deanery in recent months and years.
The Trust is ‘red rated’ in the following two safety indicators:

For methicillan resistant staphylococcus aureus (MRSA) infection rates, the Trust was in the bottom third of 143 trusts nationally over the three years from 2010 to 2012.
The Trust’s infection rate in relation to other Trusts has improved in 2012, and places ULH close to the average for all Trusts. The Trust has informed us that whilst its
MRSA infection rates were above average nationally over the three years from 2010 to 2012, the rate of infection was significantly lower than the highest rates recorded
across the country and the Trust has performed at or below the maximum acceptable ceiling for MRSA infection rates for the last 4 years.

Clinical Negligence payments have exceeded contributions to the ‘risk sharing scheme’ for two of the last three years. Payout exceeded contributions by a total of £4.9m
over this period.
The Trust has had 12 ‘never events’ since 2009. ‘Never events’ have potential to cause harm to patients and are judged as easily preventable by Department of Health (DH)
guidelines.
The Trust is above the average levels for all acute Trusts for pressure ulcers throughout the last 12 months. Between December 2012 and March 2013 there has been an
increase in the percentage of ulcers from 1.1% to 2.9%.
Key lines of enquiry were included in the review focusing on how the Trust is assured over the safety of care in its hospitals.
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3. Key Lines of Enquiry
The Key Lines of Enquiry (KLOEs) were drafted using the following key inputs:

The Trust data pack produced at Stage 1 and made publically available

Insights from the Trust’s lead Clinical Commissioning Group (CCG), West Lincolnshire CCG

Review of the patient voice feedback received specific to the Trust prior to the site visit
These were agreed by the panellists at the panel briefing session prior to the RRR site visit. The KLOEs identified for the Trust were the following:
Theme
Key Line of Enquiry
Governance and leadership

Can the Trust clearly articulate its governance processes for assuring the quality of treatment of care? Are the
leadership roles and responsibilities clearly defined for the quality processes? Can staff at all levels of the
organisation describe the key elements of the quality governance processes
Clinical and operational effectiveness

What governance arrangements does the Trust have to monitor clinical and operational performance data at a
senior level? What processes does the Trust have in place to support monitoring mortality data and clinical
effectiveness? Has the Trust data identified any issues? What actions is the Trust taking to address issues
noted?
Patient experience

How does the Trust review patient experience data and engage with patients to seek views about their
experience? What are the key themes from patients on their experiences? What action is it taking to address the
key themes emerging? What do patients say about the quality of care in the Trust during our
observations/interviews?
Workforce

How is the Trust addressing staffing issues as raised through the Deanery?

How is the Trust responding to out of hours staffing issues? How is the Trust responding to issues with qualified
nursing ratios, nursing hours to patient day and high sickness rates?
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Theme
Key Line of Enquiry
Safety

How engaged are staff in the Trust’s quality strategy? What do staff groups interviewed (including trainee groups)
say are the main barriers in the Trust to delivering high quality treatment and care for patients? How does the Trust
review and monitor its patient safety indicators? What actions are taken to improve patient safety?
Trust Specific – General Medicine and
Elderly Care

What actions is the Trust taking to address issues in general medicine including treating elderly care patients?
How is the Trust managing its stroke patients? How is the Trust responding to high mortality flags in oncology,
respiratory and thoracic medicine? How does the Trust manage patients with Diabetes and what action is it taking
to prevent avoidable deaths?
Trust Specific – Urgent Care

How does the Trust manage its Urgent Care Pathway?
Trust Specific – Obstetrics

What actions is the Trust taking to address issue relating to obstetrics and the high number of deaths attributed to
perinatal conditions?
Trust Specific – Critical Care and Surgery

How is the Trust managing its critical care pathway and what actions is it taking to address the higher than
expected mortality rates in this area? How is the Trust responding to the contributing factors such as deteriorating
EWS score rates, shock cardiac arrest triggers and deteriorating renal function triggers within its crude surgical
mortality rate?
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4. Findings
Introduction
The following section provides a detailed analysis of the panel’s findings, including good practice noted, outstanding concerns and prioritisation of actions required.
Summary of findings
A number of areas of good practice were identified as part of our review, notably:

We met with some dedicated, committed and loyal staff

Monthly mortality reviews have good attendance with good clinical engagement

The Interim Director of Nursing has provided strong leadership to the nursing team

The Matrons at all sites displayed strong leadership, especially at Grantham Hospital

Many wards displayed safety thermometer data sets

Plan for Every patient on wards

Evidence of innovation e.g. Red Lid Scheme for Hydration/medication; phlebotomy service at weekends which takes pressure off junior doctors

The Colorectal team at Lincoln hold an annual patient listening event

Patient experience and stories are now part of the Trust Board meetings

Safety and quality dashboards displayed on the wards

Proactive work around dementia in particular wards

GP support within the Grantham A&E Department that enables the most appropriate care to be provided to the patient

The Trust is embarking upon a major review of services, with its Health and Social Care partners in Lincolnshire, to address the sustainability challenges for the whole
community

The Chief Executive, who was fairly recently appointed, is sighted on the complex issues in the organisation of aligning a Board driven strategy into fabric of every
part of the organisation
18
During our visit, an issue was identified in relation to inadequate staffing levels within all three hospital sites. The panel formally escalated this to the CQC after the
unannounced visit.
In addition, concerns around satisfactory completion of ‘do not attempt resuscitation’ (DNAR) forms were also raised. This was escalated to the Trust management team for
immediate action. The Trust has completed a review of all patients with DNAR forms across all three hospitals and every DNAR form has now been signed off by a consultant
and discussed with both patients and relatives as appropriate.
As part of the review process, the panel received a submission from a former Chief Executive of the Trust. As with all evidence received through the public communication
channels, the panel has reviewed this and triangulated this with its findings. This submission highlights issues with governance and staffing levels which triangulate with the
findings detailed in this report.
The main priority areas identified for action in each of the key lines of enquiry themes are below.
Leadership and governance:

There is a disconnect between leadership at Board level and leadership at clinical levels within the organisation: The Trust should ensure there are clear and
active discussion lines between the clinical leaders at ward level, the clinical directors and the Trust Board to ensure that leadership of the organisation is joined up
and consistent. The Trust should focus on engaging clinical teams rather than specialties or separate professional groups.
Clinical and operational effectiveness:

The panel was unable to easily see or understand how escalation worked for both actions taken in managing deteriorating patients and also managing
patient flow as there seemed to be no standardised process in operation across the specialties and sites: The Trust should seek to clarify its escalation policy
and ensure that it uses the ‘track and trigger’ system effectively across all the Trust sites. Staff should ensure that escalation responses are appropriate and well
documented in response to managing deteriorating patients. In addition the Trust should ensure that patient flow is planned and managed appropriately. An IT
solution needs to be found to allow the ambulance inbound system to be visible in A&E.
Patient experience:

The complaints process is confusing and not fit for purpose: The Director of Nursing and the Company Secretary should review the handling of complaints and
the processes whereby complaints can be systematically fed back and used by staff teams to improve service delivery. This should include creating a PALs function.
Complaints should be seen as everyone’s responsibility – not just the complaints team / board.

Patient experience is not seen by patients to be at the heart of the organisation and service improvement: The Trust should implement a patient experience
action focussed improvement plan that should include: real time patient feedback, evidence of listening and responding and using and working with patients to codesign service improvement.
Workforce:
19

Staffing levels were, in some areas and at certain times of the day, low. The panel formally escalated its concerns to the CQC on 21 June 2013: The Trust
should consider urgently the staffing levels and mix throughout the Trust, covering: nursing numbers and appropriate use of agency and bank staff; Matron cover at
Pilgrim Hospital, Boston; dependency of patients including 1:1 care, assistance with eating and assistance using toileting facilities, and; middle grade cover and
appropriate supervision of junior doctors, especially out of hours.

Workforce planning is poor with no recruitment plans and no plans in place to cover maternity leave, sickness and annual leave other than through the
use of agency, bank staff or, in the case of medical staffing, locums: The Trust should document and implement a recruitment plan with immediate effect to fill
the short term vacancies but also consider its medium term requirements. The Trust should also seek to firm up its strategic plans, including the level of future service
provision at all three main hospital sites and the community sites. This should be done in conjunction with stakeholders. Student nurse posts should be advertised
earlier.
Safety:

Quality strategy could not be consistently articulated by all staff and non executive directors: The Trust should confirm the key quality priorities for the Trust
and ensure these are widely understood by staff using campaigns and listening events as well as emails, the intranet and Ward to Board initiatives.
General Medicine and Elderly Care

Lack of awareness of the Mental Capacity and Deprivation of Liberty Act 2005 in relation to the Trust’s responsibilities in allowing patients to leave wards
if they are deemed capable and wish to: Staff should ensure that they are fully compliant with mandatory training requirements and adult safeguarding is given
clinical engagement as a matter of urgency.
Urgent Care

There were no urgent actions under this KLOE.
Obstetrics

There were no urgent actions under this KLOE.
Critical Care and Surgery

We observed a number of issues with the completion of DNAR forms: The Trust has already undertaken an immediate review of all patients with DNAR forms to
ensure they are accurately and adequately completed. This was completed immediately by the Trust. The Trust should review its process and policies for the
completion for DNAR forms to ensure they meet best practice and legal requirements.
20
The following definitions are used for the rating of recommendations in this review:
Rating
Definition
Urgent
The Trust should take immediate action to respond to these recommendations and ensure improvement in the quality of care
High
The Trust should develop a response and action plan for these recommendations to ensure improvement in the quality of care
Medium
The Trust should implement these recommendations to ensure ongoing improvement in the quality of care
21
Governance and leadership
Overview
The panel’s focus for governance and leadership was on the articulation and understanding of the Trust’s governance processes for assuring the quality of treatment and
patient care and how well embedded this was throughout the organisation.
Through staff interviews, focus groups and review of governance documentation, the panel tested whether staff at all levels could describe the key elements of the quality
governance processes, i.e. policies and procedures, escalation, incident reporting, risk management. The panel also reviewed the Trust’s process to assess the impact of
cost savings plans on quality of patient care and its workforce.
Summary of findings
The following good practice was identified:

The Chief Executive, who was fairly recently appointed, is sighted on the complex issues in the organisation of aligning a board driven strategy into the fabric of every
part of the organisation.

The Non Executive Directors report recent more detailed quality discussions at Trust Board and increased confidence that the work on the integrated dashboard
should provide congruence on patient safety and quality, performance and finance.

Monthly mortality reviews have good attendance with good clinical engagement.

The voicing concerns policy has been reviewed with support from staff and is ready for roll out and adoption.

The Interim Director of Nursing has provided strong leadership to the nursing team.

The Matrons at all sites displayed strong leadership and many wards displayed safety thermometer data sets.

The intensive approach and “ Shop in Shop “ has driven substantial improvements in services where there has been concern.

Patient Stories feature at the Trust Board each month.

The Trust Board is embracing the need for a Service Sustainability Review to work with health and social care partners to tackle the emerging clinical viability
challenges across all health services including acute service providers. This will address the real challenges of providing specialist acute services across
geographically distant sites.
The following areas of concern were identified:

There is disconnect between leadership at Board level and front line clinical teams in the organisation. There is also variation in the levels of medical engagement
across the hospital sites with this being strongest at Pilgrim and Grantham Hospitals.
22

The constant change in leadership at the executive level has led staff to feel uncertain and has created cultural problems as identified in the recent organisational
diagnostic. Staff feel there is no clear vision and direction for the Trust and subsequently there is a disconnect between individual, team, directorate and corporate
objectives.

The governance structures and processes reflect the complexity of a large organisation that provides care on three sites that are separated by significant distances.
Staff on the ground were unable to articulate the governance processes for quality of treatment and patient care and patient safety or the Trust’s Quality Strategy.

It was not clear to the panel where the accountability for quality and patient safety lies between Medical Director/ Director of Nursing.

There was some evidence of Board to Ward assurance, however this was not visible to all staff and so there was limited opportunity for the board to evidence to staff
that they truly take ownership of governance of quality of care.

Serious Incidents and Never Events are received by the board via the committee structure but complex structures build delay into this process. Staff report that they
do not receive any feedback on these routinely or in a timely fashion.

There is confusion in the organisation as to whether there is a PALs function to support monitoring of quality and patient experience and how the complaints process
worked. There is no PALs function at ULH.

The engagement of staff and clinicians in the governance processes for assuring the quality of treatment and patient care and the identification and implementation of
the Trust extensive Cost Improvement Plans is variable. Not all CIPs have been assessed for impact on patients and the process for monitoring these is not known or
owned by staff. Non Executive Directors and the Clinical Commissioning Groups reported that they were not sighted on the QIA of the 2013/14 CIP plans. The Chair
of the Audit Committee had seen details about 180 line items but this was not reported at an appropriate level of detail.

There was little evidence of strong medical consultant leadership for the patient safety and quality agenda.
For some of the above areas of concern, the panel identified a number of improvements already planned or underway at the Trust.
Detailed Findings
Good practice identified
The Chief Executive and Vice Chair recognise the culture is not as conducive as it needs to be to provide good patient care and have recently used their reference group
to work with the Execs on a cultural diagnostic and rolling out “ Listening into Action”.
There were some areas within the Trust, such as Stroke Unit, where clinical leaders and staff were able to clearly articulate governance processes and knew their
individual quality metrics.
The established Mortality Review meetings gaining wider clinical support and the proposal to write these into the job plans of the Consultant body.
The interim Director of Nursing has a clear understanding and insight into the shortfalls in the current governance processes and has provided strong leadership to the
nursing teams to improve and raise standards of care.
Wards display patient safety information and the ‘plan for every patient’ methodology is applied to manage care in a coordinated way.
23
Outstanding concerns based on evidence
gathered
Key planned improvements
Recommended actions
(i) There is a disconnect between leadership at
Board level and leadership at clinical levels
within the organisation
The Trust accepts that there is more to do to connect
Clinical Directors and the Board with clinical leadership
at ward level.
The Trust should ensure there are clear
Urgent
and active discussion lines between the
clinical leaders at ward level, the clinical
directors and the Trust Board to ensure
that leadership of the organisation is joined
up and consistent. The Trust should focus
on engaging clinical teams rather than
specialties or separate professional
groups.
The panel observed strong clinical leadership from
the matrons at hospital and ward level but identified
there was a disconnect between this clinical
leadership at ward level, medical clinical leadership
(especially at Lincoln County Hospital) and the
clinical directors and the Board (both executive and
non executive directors).
The panel was informed by the Trust that a number of
initiatives are currently in progress however these were
not observed by the panel on the review visit.
Priority –
urgent, high
or medium
The Executive Team recognise the need to
build stronger connections between
leadership at Board level and leadership at
clinical level.
It is critical that this recognition is adopted
across the entire Trust, by all staff groups
and by the whole Board.
(ii) Clarity is required on what the Trust’s
Quality Strategy is
The panel understand that the Trust is conducting a
review which will lead to an integrated dashboard.
The panel could not clearly identify what the Trust’s
quality strategy is through discussion with staff as
staff could not articulate it to us. There was no clear
view on who is accountable for quality and the
governance process is also unclear.
The panel also understands that the following actions
are underway:


The Trust Board needs to clarify both ‘the
High
who’ and ‘the what’ in the process for
patient safety, quality and governance and
to evidence strong visible leadership in this
area.
Frequent executive-led staff briefings
Refined Team Brief process, involving a toolkit
24
Outstanding concerns based on evidence
gathered
There was little evidence of strong medical
leadership for the patient safety and quality agenda.
Key planned improvements

Recommended actions
Priority –
urgent, high
or medium
The Trust Board needs to ensure that
there is a systematic approach in place for
the collection, reporting and acting upon
information on the quality of services,
patient and clinician insights and that the
processes include feedback and
engagement of staff in learning and
service improvement
High
for managers to cascade key issues to staff
Regular podcasts by execs and senior
clinicians about quality and safety issues
These were not observed by the panel on the
announced and unannounced visits
(iii) The governance structures are complex and
staff on the ground were unable to articulate the
governance processes for quality of treatment
and patient care and patient safety or the Trust’s
Quality Strategy
The panel saw and heard evidence from frontline
staff, including senior clinicians that there was
confusion about the governance structures and
processes for quality and patient safety. This
included a lack of clarity between divisional and
Trust level governance arrangements, a lack of
clarity on the feedback mechanisms for complaints
and reported incidents. Staff in a number of groups,
interviews and visits were unable to describe a
cross-trust, systematic approach to the collection
and reporting of data, its use by the Board to assure
itself of quality and patient safety and the feedback
mechanisms to support learning and service
improvement.
The Trust informed us that the Board held a
development session on Risk and Governance on 22
May 2013. The outputs of this were not reviewed by the
panel during the review process.
The Trust should review its risk registers
and ensure that all high rated risks are
flagged to the Board and addressed
appropriately.
Staff highlighted issues around the governance
process within the Trust.
For example staff highlighted that despite logging a
number of risks rated at level 20 on the risk register,
these had not been escalated to or flagged to the
board. Example risks highlighted are those from 19
25
Outstanding concerns based on evidence
gathered
Key planned improvements
Recommended actions
Priority –
urgent, high
or medium
The Trust informed that the panel that a number of
actions are already underway but these were not
observed or reviewed by the panel during the review
visit.
To undertake a regular programme for all
Board members to visit patient care areas
and to consider adopting the “15 Steps”
approach as implemented at Nottingham
University Hospitals or similar schemes.
This should include announced,
unannounced and out of hours visits.
Medium
The Trust has informed us that it has a communications
plan supporting patient safety campaign however this
was not observed or reviewed by the panel during the
review visit.
To review how the Trust communicates
High
with its staff and to actively respond to staff
views in their preferences for
communications.
Dec 2012:




Risk regarding nurse staffing levels
Risk regarding the failure to recruit nurses
Risk regarding the failure to resource
enough bank staff to cover the escalation
beds
Risk which highlighted the current nursing
gaps on the stroke unit
The Trust informs us that all but one of these risks
have now been closed.
(iv) The constant change in leadership at
executive level has led staff to feel there is no
clear vision and direction for the Trust and
subsequently there is a disconnect between
individual, team, directorate and corporate
objectives
During focus groups, many staff felt that Board Exec
and Non-Exec Members did not make themselves
available on a regular basis to see the quality of
services for themselves.
(v) There was some evidence of Board to Ward
assurance however this was not visible to all
staff and so there was limited opportunity for the
board to evidence to staff that they truly take
ownership of governance of quality of care
During focus groups, many staff groups felt that
communications of issues relating to the quality of
services relied too heavily on the staff intranet and
26
Outstanding concerns based on evidence
gathered
Key planned improvements
Recommended actions
Priority –
urgent, high
or medium
The Director of Nursing and Medical
Director review current incident reporting
processes and implement new processes
High
that other methods of communication including face
to face with Board members, face to face cascade
through team meetings and other methods would be
more meaningful and have greater impact on their
practice.
The Trust executive informed us that the following
initiatives take place although these were not widely
identified by the staff:
 Patient Safety Leadership Walkaround
programme – every ward visited in the past
18 months by a Board member and the
patient safety team
 Risk, Patient Experience and Patient Safety
reports presented and discussed at monthly
Quality and Safety committees, chaired by
Medical Director and attended by nonexecutive director, director of quality
governance
 Direct Board oversight of mortality steering
group (deputy CEO in the chair) and
medical directors key attendees
 Safety and Quality dashboard, reflecting 56
near-real-time indicators of fundamental
care processes reviewed at Quality and
Safety Committee
 Internal compliance team in-depth reviews
of CQC essential standards (Be Assured
programme) reported to Director of Nursing
and Medical Director; most wards reviewed
in past 12 months.
(vi) Serious Incidents and Never Events are
The Trust notes a number of actions underway
received by the board via the committee
however the panel did not observe these during the
structure but complex structures build delay into
27
Outstanding concerns based on evidence
gathered
Key planned improvements
this process. Staff report that they do not receive visit.
any feedback on these routinely or in a timely
fashion
Recommended actions
Priority –
urgent, high
or medium
that ensure the feedback loop to staff and
their active engagement in lessons learnt.
There were examples given to the panel where
incidents had occurred, staff had reported fully, but
had received no feedback or confirmation that the
report had been received.
Some Junior Doctors told us that they had ceased
reporting incidents because they ‘went into a black
hole’.
(vii) There is confusion in the organisation as to
whether there is a PALs function to support
monitoring of quality and patient experience and
how the complaints process worked
The panel is aware that the Trust Board has recognised Complaints/ PALs and patient feedback
both PALs and complaints are issues that require
mechanisms need reviewing.
action.
High
The panel identified that there were many instances
where complaints had not been dealt with to the
satisfaction of the complainant and that the
complaints process was not feeding adequately into
the wider governance of assurance for trend
analyses, early warnings and feedback to staff.
(viii) The engagement of staff and clinicians in
the governance processes for assuring the
quality of treatment and patient care and the
identification and implementation of the Trust
extensive Cost Improvement Plans is variable.
Not all CIPs have been assessed for impact on
patients and the process for monitoring these is
not known or owned by staff. Non Executive
Directors reported that they were not sighted on
The Trust told us that the Board has agreed, as part of
its review of governance arrangements, to establish a
QIPP and Transformation Committee and establish a
QIPP Executive. The panel did not observe these
governance arrangements as part of the review.
To review the mechanism for the
engagement of all those affected by
proposed CIPs in their development and
agreement.
To ensure the Board is assured that it has
strong clinical engagement in the
development of all CIPs and that QIAs
have been carried out in all cases prior to
High
28
Outstanding concerns based on evidence
gathered
the 2013/14 CIP plans
Key planned improvements
Recommended actions
Priority –
urgent, high
or medium
commencement of any plans.
The engagement of staff and clinicians in the
development and agreement of CIPs is patchy. Not
all schemes have had quality impact assessments
as part of process and unclear as to how these are
monitored.
The Trust executive team told us that 65% of CIPs
have been impact assessed with the balance to be
finalised in July prior to implementation.
29
Clinical and operational effectiveness
Overview
The panel’s focus for clinical and operational effectiveness was to explore how the Trust used clinical and operational performance data at a senior level. Looking specifically
at what processes the Trust has in place to support monitoring mortality data and clinical effectiveness and what the Trust’s data identified and what action is the Trust taking.
Through staff interviews, focus groups and review of documentation, the panel tested whether staff at all levels could describe the key operational data and policies and
procedures, escalation, incident reporting, risk management. The panel also reviewed the Trust’s process to assess the impact of cost savings plans on quality of patient care
and its workforce.
Summary of findings
The following good practice was identified:

Mortality Reviews are discussed at Clinical Directorate Level monthly underpinned by weekly reviews at ward level. We found some evidence of the shared learning
and/or changes to practice but this was not widespread.

Good evidence of displaying patient safety thermometer / harm free care metrics on wards.

Plan for Every patient on wards.

Evidence of innovation e.g. Red Lid Scheme for Hydration/medication; phlebotomy service at weekends which takes pressure off junior doctors.

A Trust wide nursing and skill mix review has been undertaken with Board agreement to invest £7 million over 2 years. A recruitment plan is underway to implement
this.

Achievement of CQUIN 2012-13 regarding the reduction of patient moves.
The following areas of concern were identified:

The panel was unable to easily see or understand how escalation worked through discussions with staff as there seemed to be no standardised process in operation
across the specialities and sites. We understand from discussions with the executive team that the Trust does have a standardised approach which is linked to the
track and trigger system at patient level and a standardised escalation processes are a feature of the revised Operations Directorate structure however this did not
come across in discussions with staff.

Staffing levels are flagged as an area of risk which potentially compromises patient safety and optimal care for patients. The cover at weekends and out of hours is
minimal for both medical and the nursing teams. Some wards also expressed concerns that general staffing levels were such that they could not free staff up to escort
patients to diagnostics which resulted in extended length of stay. This has been discussed in detail under KLOE5 (Workforce) below.

There were a number of concerns flagged with regard to ‘do not attempt resuscitation’ (DNAR) forms and record keeping. This is also discussed under KLOE 10
(Critical Care) below.
30

At individual site level there was lack of knowledge/awareness of the actual operational data such as readmissions and mortality data.

Staff raised concerns regarding outliers not getting appropriate care from the right consultant teams and difficulties in getting consultants to review patients.

Staff reported that many patients get moved resulting in lack of continuity of care and sub optimal care so there are concerns flagged with regard to flow /surge and
capacity planning.

Not all CIP projects had quality impact assessments to look at how they would affect patient safety and care and the arrangements for monitoring these projects.
Monitoring seemed to focus on achieving the financial targets. This is discussed in more detail under KLOE 1 (Governance and Leadership) above.
Detailed Findings
Good practice identified
The practice of mortality reviews has been well supported by the staff and reported good engagement with this process.
There were some areas within the Trust, such as Oncology, Stroke, Maternity and Critical Care where clinical leaders and staff were able to clearly articulate the
detailed processes to support the mortality and quality reviews of care for patients.
Every ward displayed some safety and quality information on the boards which was open for all staff, patients and visitors to see. This information often included
pressure ulcers, falls and VTE assessments; however there was some inconsistency in the information that was displayed and the level of detail available.
The use of a plan for every patient was a simple, effective and visible daily record of each patient’s status / actions for that day and for planning discharges.
Outstanding concerns based on evidence gathered
Key planned improvements
(i) The panel was unable to easily see or understand how escalation
worked for both actions taken in managing deteriorating patients and
also managing patient flow as there seemed to be no standardised
process in operation across the specialties and sites
The Trust told us that it recognises that the inbound
information system is mid-implementation, and not yet
fully operational from an ambulance trust perspective.
As part of the implementation phase there are a
number of issues to be resolved, including IT. These
Staff were unable to articulate the escalation policy that was consistent and issues will be resolved as part of the implementation
trust wide. We found examples of good escalation processes (such as A&E plan, prior to going live. The Trust hopes that this will
at Boston) but other areas where processes were not clear or well
reduce the number of inappropriate placement of
formulated.
patients within the department.
There was a Track and Trigger warning score in place which emphasised
The Trust tells us that it has already changed the
Recommended actions
Priority –
urgent, high
or medium
The Trust should seek to
clarify its escalation policy
and ensure that it uses the
‘track and trigger’ system
effectively across all the
Trust sites. Staff should
ensure that escalation
responses are appropriate
and well documented in
response to managing
deteriorating patients.
Urgent
31
Outstanding concerns based on evidence gathered
Key planned improvements
that a score >4 would lead to a newly admitted patient from A&E at Lincoln
on the Medical EAU to be brought to the attention of a doctor immediately
although it was not clear that this was being used appropriately.
working of Bailgate to an ambulatory care facility.
Recommended actions
Priority –
urgent, high
or medium
In addition the Trust should
ensure that patient flow is
planned and managed
appropriately.
There was an escalation policy at Grantham (made available to the review
team) for managing an increase in the number of patients from 6 to 9 in
CCU, but staff were unable to articulate this or demonstrate actions arising
from failure to adhere to this policy.
An IT solution needs to be
found to allow the
ambulance inbound system
to be visible in A&E.
A&E at Lincoln did not make use of the ambulance inbound information to
plan capacity needs due to IT issues. This can lead to inappropriate
placement of patients within the department.
The panel observed inappropriate use of Bailgate on a frequent basis with
patients being transferred to await an appropriate bed.
An elderly orthopaedic patient was observed on our unannounced visit who
had been transferred to Bailgate. The staff were not familiar with a brace
being worn and this was an additional move for this patient.
The Trust told us about the achievement of its CQUIN 2012-13 regarding
the reduction of patient moves.
(ii) At individual site there was lack of knowledge and awareness of
the actual operational data such as readmissions and mortality data
During visits and focus groups staff were unable to describe the mortality
rates/issues and therefore unable to describe what actions the trust had
taken.
(iii) Staff raised concerns that outliers were not getting appropriate
care from the right consultant teams and difficulties in getting
consultants to review patients
The Trust tells us that the Board has adopted an
evidence-based mortality reduction plan. This was not
evidenced to the panel as being communicated during
the review period.
The Board and the CDs
need to ensure that this
information is made
accessible to staff,
discussed at team /ward
meetings.
High
The Trust is implementing a virtual hospital framework,
which when embedded and fully utilised should ensure
good capacity management and escalation.
The capacity and surge
High
plan for the Trust needs to
be embedded and there
needs to be understood and
32
Outstanding concerns based on evidence gathered
There were a large number of concerns raised by staff and indeed patients
about inconsistency of care and or sub optimal care as a result of being an
outlier and being moved about between wards.
The panel attended a bed management meeting at Lincoln County Hospital
where the current Trust position was discussed however there was no
discussion regarding capacity required for the next 12 hour period and no
evidence of forward planning to ensure capacity planning for overnight.
Key planned improvements
Recommended actions
The new build scheme will provide sufficient cubicles to
enable earlier review and planning
consistently applied actions
with particular regard to
managing patient flow.
Priority –
urgent, high
or medium
The Trust should continue
with its implementation of
the virtual hospital
framework.
Details regarding expected admissions and capacity were part of the
framework but the Trust did not actively use this in the meeting as a
measure for when to escalate.
The Trust had a written escalation plan but did not use this at the meeting
despite not having enough beds available for the next 12 hour period.
At the meeting a decision was made that the Trust would actively outlie
patients as there were not enough medical beds. There were no other
actions taken. The panel would have expected to see action regarding
creation of capacity by the home units.
Outlying patients at the meeting attended appeared to be the primary
option for managing capacity demands (this approach of course creates a
number of problems that are well documented regarding the care of
patients outside their home wards and access to clinical expertise
appropriate with their condition). Patients being moved or cared for on an
outlying ward was a key area of concern raised to the panel at the patient
listening events.
The Bostonian ward at Pilgrim was aimed at private or mainly urology
patients, however some medical patients were on this ward and solely
cared for by one stroke consultant who at times of being on leave would
get a registrar to review patients.
33
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
Priority –
urgent, high
or medium
Escalation at Lincoln was late and the panel observed patients moved just
before the 4 hour threshold, sometimes inappropriately to Bailgate ward. At
the unannounced visit, 50% of patients on Bailgate required admission to
specialist beds and not a Clinical Decision Unit. This compromised flow
from the A&E department.
34
Patient experience
Overview
The panel focused on how the Trust understands and responds to patient feedback on their experience through discussing this with patients and staff on wards and at the
focus groups and listening events, as well as reviewing board and ward level information on patient experience.
Summary of findings
The following good practice was identified:

There were areas of the hospitals visited where Friends and Family Test scores were displayed.

The Intensive Treatment Unit (ITU) has a call back service for patients and relatives.

The Colorectal team at Lincoln hold an annual patient listening event.

Patient experience and stories are now part of the Trust Board meetings.

The Trust also informed us that there are a wide range of improvements and projects currently in progress within the Trust in line with the Patient Experience
Strategy. Action plans are in place against the national inpatient, outpatient and A&E surveys and a workplan against the strategy. The strategy is aligned to the 14
standards and was widely consulted on (including PCT/CCGs) before being ratified at Quality & Safety Committee. Real time surveys have been in use since June
2012 and are reported on widely including within Board reports and to sites and services.
The following main areas of concern were identified for patient experience:

The complaints process is confusing and not fit for purpose.

Patients told us that they felt that the patient experience is not at the heart of the Trust’s strategy.

The Non Executive Directors (NEDs) interviewed could not articulate patient experience vision and actions taken in response to this.

There is no triangulation by the Trust of patient experience, staff experience and incident reporting.

Pain recognition and treatment in patients with dementia was not well managed.
35
The panel did not identify any improvements already underway or planned at the Trust.
Whilst accepting that there were negative stories from patients as part of the review process, the Trust articulated to us that it is committed to listening and learning from
these.
During 2012 - 2013 the Trust informs us that 113 stories were posted on ‘Patient Opinion’ which use a criticality scale against each story. 74% of these stories were rated as
zero, that is, ‘no criticism / positive feedback’.
Alongside this, the Trust has been collecting real time surveys for 12 months which includes free text comments. These are included in Trust Board reports as an overview
report and sent weekly to all wards. The Trust tells us that on average 25 – 30% of these stories are negative comments.
Detailed Findings
Good practice identified
There were areas of the hospitals visited where Friends and Family Test (FFT) scores were displayed prominently. The panel observed clear actions to address FFT
feedback on specific wards however this was not consistent across the Trust.
The Intensive Treatment Unit (ITU) has a call back service for patients and relatives which patients told us was valued and of use.
The Colorectal team at Lincoln hold an annual patient listening event to hear the views of patients and negotiate agreed actions to take in response. It is disappointing to
note that the Executive team do not form part of this listening event.
Patient experience and stories are now part of the Trust Board meetings although this is relatively recent therefore it is too soon to comment on any actions that have been
taken as a result.
Outstanding concerns based on evidence gathered
(i) The complaints process is confusing and not fit for
purpose
Key planned
improvements
The Trust Chief Executive
and Director of Nursing told
Recommended actions
Priority –
urgent, high
or medium
The Director of Nursing and the Company Secretary should
review the handling of complaints and the processes whereby
complaints can be systematically fed back and used by staff
Urgent
The panel observed a number of issues related to the
36
Outstanding concerns based on evidence gathered
Key planned
improvements
Recommended actions
Priority –
urgent, high
or medium
us that they are now sighted teams to improve service delivery. This should include:
on complaints; a review of
 Improving understanding and visibility of complaints
There were a number of complaints raised at the Patient
complaints is underway
methods with staff and patients.
and Public listening events where patients raised
concerns that their complaint had not been responded to however this was not
 Educate front-line clinical staff to respond more effectively
evidenced to the review
satisfactorily.
to complaints and ensure accountability and ownership.
panel during the visit.
Patients told the panel that they felt ‘scared’ to complain
as they were worried they would be labelled and this
 Continue to liaise with and meet patients to ensure their
would affect the quality of the care they received.
concerns are addressed.
complaints process:



There is confusion as to whether PALs exists at the
Trust.

Ensure complaints are responded to promptly.

All complaints are referred to an administrative function.


There is no sign off of complaints by the Chief
Executive, Medical Director or Director of Nursing.
Review size and structure of complaints team to ensure it
is fit for purpose.


Creation of a PALs function.
Learning from complaints is not systematic or Trust
wide.

Complaints need to be seen as everyone’s responsibility –
not just the complaints team / board. Devolve complaints
management to Directorate/specialty level rather than a
centralised process to improve ownership.

Review the process and person responsible for ensuring a
complaint is answered in a timely manner.

Complaints are dealt with on a department by
department basis and the process is inconsistent.

There is a perceived lack of visibility of complaints
methods by patients.
Based on patient feedback, no one appeared to control or
own the complaints process.
(ii) Patient experience is not seen by patients to be at
the heart of the organisation and service improvement
The panel found that patient experience is not integrated into
the Trust’s strategy. The approach to patient experience was
inconsistent across the Trust and the Trust approach could
not be articulated by key staff groups both at focus groups
The Trust executive informs
us that there are a wide
range of improvements and
projects currently in
progress within the Trust in
line with the Patient
Experience Strategy. These
The Trust should implement a patient experience action
focussed improvement plan that should include:
 real time patient feedback
 evidence of listening and responding
 using and working with patients to co-design service
improvement
Urgent
37
Outstanding concerns based on evidence gathered
Key planned
improvements
Recommended actions
and as part of our interviews and observations.
were not reviewed by the
panel during the visit.
The whole trust staff should engage with this process.
(iii) The Non Executive Directors (NEDs) interviewed
could not articulate patient experience vision, actions,
issues
None noted
The NEDs should ensure they have the appropriate level of
awareness in relation to patient experience issues, including
performing ‘walk arounds’ of wards and have ‘drop in clinics’ for
patients to come and talk to them.
The NEDs were unable to articulate to the panel the Trust’s
patient experience strategy as well as any patient
experience issues that the Trust may be experiencing.
(iv) Pain recognition and treatment in patients with
dementia was not well managed
Priority –
urgent, high
or medium
High
In addition, the NEDs should be involved in any development of
a patient experience strategy, alongside patient experience
group.
None noted
NHS choices website for the Trust has stories of poor
responses to request for analgesia.
The Trust should carry out an audit cycle of pain assessment
and widely published with a campaign to improve awareness
and compliance with appropriate guidelines.
High
The Trust should introduce a pain assessment tool for people
with dementia supported by the necessary training.
The panel noted consistent infrequent monitoring of pain
documented on the vital signs charts across all 3 sites.
The Trust has no standardised pain assessment tool for
people with dementia or other patients who cannot express if
they are in pain verbally, for example, the Abbey Pain Scale.
A patient with severe dementia and bedbound on ward 5 at
Grantham had not had a pain assessment; the patient was
assessed as being in pain by a clinician on the panel. The
staff nurse providing his care was able to articulate how he
would know a patient with dementia was in pain however did
not respond appropriately to the patient in question.
(v) There is no triangulation by the Trust of patient
None noted
The Trust should triangulate its patient experience data with
Medium
38
Outstanding concerns based on evidence gathered
experience, staff experience and incident reporting
Triangulation of complaints, patient experience, staff
experience and incident reporting could help the Trust to
identify key themes, training gaps, systematic failures or
linkages between events
Key planned
improvements
Recommended actions
Priority –
urgent, high
or medium
staff experience and incident reporting to identify key themes
arising and cross cutting issues.
This should be reported to the Trust Board by the Director of
Nursing.
39
Workforce
Overview
The panel’s focus for workforce was on how the Trust was addressing staffing concerns raised by the Deanery and also the issues noted about out of hours, nurse staffing
ratios and high sickness absence.
Summary of findings
The following good practice was identified:

We met some dedicated, committed and loyal staff who often work over and above their shift hours.

Matrons showed excellent clinical leadership at ward level.

Recruitment of new consultants and middle grade medical staff al sites, especially in emergency medicine.

Junior doctors said they gained good experience with easy access to senior supervision in-hours and in most areas.

The Trust recognises the clear linkage between recruitment / retention of key clinical staff and service viability. This will be a key issue for the sustainable service review.
The following areas of concern were identified for workforce:

Staffing levels were, in some areas and at certain times of the day, low. The panel formally escalated its concerns to the CQC on 21 June 2013.

Workforce planning is poor with no recruitment plans and no plans in place to cover maternity leave, sickness and annual leave other than through the use of agency,
bank staff or, in the case of medical staffing, locums.

Supervision was found to be inadequate out of hours.
For some of the above areas of concern, the panel identified a number of improvements were planned or already underway at the Trust.
Detailed Findings
Good practice identified
Matrons and band 7 nurses showed some really excellent clinical leadership at ward level, leading by example, with a good presence on the wards.
There has been additional recruitment at consultant and middle grade level at all sites which has strengthened the team, in particular in emergency medicine.
The staff we spoke to across all three sites and across multiple disciplines came across as committed, dedicated, hard working and loyal to the Trust. We genuinely
identified that staff wanted to give the best possible care that they could.
40
Outstanding concerns based on evidence gathered
(i) Staffing levels were, in some areas and at certain times of the day,
low. The panel formally escalated its concerns to the CQC on 21 June
2013.
Key planned improvements
The Trust has completed a
comprehensive review of nursing
numbers and skill mix. The Board has
agreed to invest £7 million over 2 years
a) Nurse Staffing
in the nursing workforce. An
Pilgrim Hospital, Boston
implementation group is in place and
On our unannounced visit at Pilgrim Hospital, Boston we were concerned
active recruitment is underway. A
about the levels of staffing on a number of wards. Staff also expressed
marketing strategy will be developed
concerns about the levels of staffing on a number of wards. We recognise that with local partners to promote the
staff are generally caring, committed and incredibly loyal, however we note
benefits of living in Lincolnshire.
that there are simply not enough of them to do the tasks that are required.
On ward 8A, we saw that at the time of our unannounced inspection there
There is a plan to undertake overseas
were two qualified nurses on duty with two HCAs to care for 28 patients. We
recruitment and to appoint all new
were told that the preferred staffing level would be five nurses and two HCAs
nurses qualifying this summer who
for that shift.
want to work in Lincolnshire.
We were informed that the ward never went below 2 qualified nurses but often
this number was only achieved by filling with bank and/or agency, or staff from
The panel is aware that the Trust’s
other wards.
recruitment programme for increasing
On ward 6A, staff told us that more nurses were required to be sourced from
nurse workforce has been agreed.
bank, agency or other wards on all shifts. We were told that there were only
eight permanent nursing staff to cover three shifts. The staff spoken to flagged
that this situation was placing pressure upon those remaining and that gaps
The Trust tells us that senior clinical
would have to be filled from bank, agency and other wards.
staffing out of hours will be specifically
Staff on this ward stated that bank and/or agency staff were used every day.
considered by the sustainability review.
This has the effect of reducing staff morale. The Trust has a policy regarding
drug administration and the use of agency nurses to perform such tasks it not The Trust tells us that it does
permitted without evidence of IV compliance – this is to maintain patient
experience higher unfilled vacancy
safety. Agency nurses can monitor blood sugar if they can evidence and feel
rates for Doctors, both substantive and
competent to do.
FR-training. The latter will be a feature
of review with the Deanery.
Recommended actions
Priority –
urgent, high
or medium
The Trust should urgently
implement the recommendations
of its nurse staffing review, in
particular taking account of:
nursing numbers and appropriate
use of agency and bank staff;
Matron cover at Pilgrim Hospital,
Boston; dependency of patients
including 1:1 care, assistance with
eating and assistance using
toileting facilities.
Urgent
The Trust should also consider
urgently middle grade cover and
appropriate supervision of junior
doctors, especially out of hours.
As an illustration of the challenges staff face:
 the panel observed a patient crying out for help over a 30 minute
period who was not attended by staff during this time. The panel
flagged this to the nursing staff at the time and we were told that the
patient was fine and called out a lot due to dementia. We were also
41
Outstanding concerns based on evidence gathered


Key planned improvements
Recommended actions
Priority –
urgent, high
or medium
told that the patient responded well to reassurance by staff but staff
could only reassure when they had time to do so.
At times there are wards with large numbers of patients who require
some assistance with eating. Like all Trusts this can be a challenge.
The Trust has recently developed a scheme of dining companions. In
addition, on elderly care wards visiting time has been altered to
enable relatives who want to assist with mealtimes to be on the ward.
Non-clinically based nurses are also encouraged to assist. Ward
housekeepers have a system whereby if there are large numbers of
patients requiring assistance, the serving of hot food is staggered so
that patients’ needs are met. An example of good practice is Stow
ward, where all available staff gather together at mealtimes to be
involved and this is led by the housekeeper and Sister. A relative of a
patient on another ward visited on the unannounced visit identified
another patient who had not received timely assistance to eat her
food.
The panel was also told that those patients that required support
when transferring through use of the hoist were not usually supported
to use the toilet away from the bay. They usually used a commode or
bedpan within their bay area.
When asked about the quality of care, a patient on ward 3B noted that "the
staff are excellent, they need more [staff] though".
Grantham Hospital
Overnight cover was the most significant concern and although the Trust
assures us that this never happens we were told by some staff that 1 bank
worker may be the only member of staff on the wards overnight.
Lincoln County Hospital
We observed staffing on Stow Ward of 3 registered nurses (2 establishment
plus 1 agency) with 1 HCA for 32 patients at night during our unannounced
visit. There were insufficient staff available to provide 1 to 1 care for a patient
who required this.
Poor handover of patients was also identified in this ward and not all nurses
questioned could describe how this was managed.
42
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
Priority –
urgent, high
or medium
In A&E during our unannounced visit, staffing numbers matched the
established roster however there were four extra patients being cared for in
the corridors and the central area. Patients being cared for in the central areas
and corridors add pressure to the department’s staffing compliment.
Hatton Ward staffing had been increased in recent months so that there was
3 registered nurses and 3 HCAs on the late shift. During our unannounced
visit we noted that the Band 7 nurse who had been due to leave at 3pm was
still present on the ward (the time of our visit was approximately 7pm). This
band 7 nurse had taken the decision to stay on the ward due to a poor nursing
skills mix.
b) Medical Staffing
Our discussions with staff through focus groups and observing wards
throughout the trust identified that during weekends and out of hours, medical
staffing is not always sufficient to cover the needs of the Trust. Although the
clinical teams had raised their concerns with the Deanery, there were often
gaps in recruitment and in the subsequent on-call rotas. Gaps were often filled
by locum or agency doctors.
Pilgrim Hospital, Boston
The panel observed a number of wards where consultants were required to
work long shifts in order to provide sufficient cover, for example in A&E.
In addition, the number of locums was high.
During the unannounced visit it was also noticeable that, of all the doctors
spoken to, the majority were working beyond their expected shift end time.
When asked about this, these staff noted that there was too much to be done
to have left earlier. There was only junior doctor covering the medical wards
and one doctor covering the surgical wards at night and during the weekend.
Consultants told us that they had concerns about the inability to recruit
consultants to the following specialties: A&E, Radiology in general and breast
and interventional radiology in particular, Health Care of the Elderly physicians
and Stroke physicians.
43
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
Priority –
urgent, high
or medium
Grantham Hospital
During the days at weekends, and overnight, the only doctor covering the
wards is an FY1. There will be a registrar and an SHO covering EAU and they
will be making admission and discharge decisions. The concern we note is
around supervision although the JDs did note that the consultants were
contactable when they needed them and would come to the hospital if
required
The Trust informed us that that at any one time on the weekends and at night
for medicine there will be two junior doctors and a middle grade on site.
These are backed up by consultant o/c (non-resident).
For Orthopaedics and General Surgery there will be a junior doctor during the
day and one during the night (one for each speciality / shift – 4 Doctors in
total). These are supported by non-resident on call – a middle grade for
surgery and a consultant and a middle grade for orthopaedics.
Therefore, the Trust asserts that at any one time during the weekend day or
any night there will be at least 4 junior doctors and a middle grade on site, with
a non-resident on call team of 2 middle grades and 2 consultants. These rotas
are compliant with the working time directive and the Trust covers any gaps
with backfill internally or agency.
The Trust tells us that it is reliant on the Deanery providing candidates for the
posts, which may be a risk from August (as the Deanery may reduce
numbers). The Trust informs us that this risk was raised by the Trust with the
Deanery on their recent visit.
Lincoln County Hospital
Similar issues around out of hours cover and weekend cover were observed
at Lincoln through our conversations with staff and observations of shift
patterns and rotas.
44
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
Priority –
urgent, high
or medium
The Trust has identified a number of
initiatives in place however these were
not evidenced to the panel during the
visit.
The Trust should document and
implement a recruitment plan with
immediate effect to fill the short
term vacancies but also consider
its medium term requirements.
Urgent
In addition, the panel told by staff that middle grade doctors were covering for
each other while the one slept during the night. Nursing staff were unaware of
nd
the location of the 2 middle grade doctor during this time which raises
serious questions about clinical governance. The Trust confirmed this issue is
being investigated by its local counter fraud service (LCFS).
Staff told us that changes made to wards i.e. opening more beds were not
accompanied by associated staffing increases. This was noted in the Hyper
Acute Stroke Unit as in April 2012, capacity was increased from 22 to 28
beds, with no subsequent increase in staff to meet the additional capacity. It
was noted that there is a standard ratio for nurses to patients on this ward and
that at present this ratio is not being met. This is also the case at Lincoln
hospital.
The Trust informed us that the staffing establishment at the stroke unit at
Pilgrim Hospital was 30.43 WTE prior to the business case investment that
increased capacity from 22 to 28 beds.
After the business case investment, the staffing establishment rose to 39.90
WTE. The Lincoln 28 bedded stroke unit is similarly staffed.
(ii) Workforce planning is poor with no recruitment plans and no plans in
place to cover maternity leave, sickness and annual leave other than
through the use of agency, bank staff or, in the case of medical staffing,
locums.
The panel identified a number of gaps in the establishment numbers of
various wards and specialities. Most notably, we were informed by staff that
there was a 20% vacancy rate for AHPs in Boston and a 10% vacancy rate in
Grantham.
It should be noted that the above vacancy rates were not recognised by the
executive team who state that vacancy rates are proactively managed by
Therapy Management and posts are being held vacant to respond to the
The Trust should seek to firm up
its strategic plan, including the
level of service provision at all
three main hospital sites and the
community sites.
Student nurse posts should be
45
Outstanding concerns based on evidence gathered
significant reduction in GP-referred MSK patients as a result of an AQP
initiative in Lincolnshire.
Key planned improvements
Recommended actions
Priority –
urgent, high
or medium
advertised earlier.
The panel felt that gaps had a disproportionate effect on Grantham Hospital
due to its relative smaller size. The panel also noted that the uncertainties
surrounding the future provision of services at Grantham Hospital could act as
a deterrent for applicants. The Shaping Health for Mid Kesteven review which
has now been finalised and made public reinforces the future of services at
Grantham Hospital.
We were told by clinicians and managers throughout the Trust that there were
difficulties recruiting into existing vacancies and staff were not hopeful that the
additional planned recruitment would be filled.
In addition, student nurses told us that posts were advertised by the Trust later
than others and this led to many of them applying for and accepting jobs
elsewhere when they would like to work at ULH.
The panel identified that if effective workforce planning is implemented, this
will assist the Trust with its agency spend and also its high levels of sickness
absence.
When the panel engaged with staff, they opened up and gave us their views,
the Trust should build upon this to create a cohesive team across
management and the clinical professions.
46
Outstanding concerns based on evidence gathered
Key planned improvements
The Trust has identified the following
initiatives in place:
 Hospital at Night review to
The lack of middle grade and consultants on site over night and at weekends
conclude by mid-July 2013,
indicated that there was a lack of supervision of junior doctors. Whilst all junior
with agreed action plan
doctors indicated that they felt they could approach the more senior clinicians
 Senior clinical staff presence
and they were generally available and would come on site if required, the lack
out of hours will be a feature of
of on-site presence raised questions for the panel about supervision.
the sustainability review, with
In addition, the reduction in numbers of nursing staff overnight and at
consideration given to the
weekends raised question about capacity and supervision.
viability of services
 Lincolnshire Sustainable
Our review indicated some issues around out of hours and weekend cover at
Services Review will explicitly
Grantham Hospital but this was the better of the three sites we visited in terms
consider the need for senior
of staffing.
clinical input out of hours and
its impact upon site and service
Our review identified positive feedback from student nurses in relation to their
viability.
experiences, support and mentoring
(iii) Supervision was found to be inadequate, particularly out of hours
Recommended actions
Priority –
urgent, high
or medium
The Trust should review its out of
High
hours and weekend cover and, if
necessary, consider an on-site
presence of consultants and senior
nurses.
47
Safety
Overview
The key line of enquiry in relation to safety focussed on:

How engaged staff are in the Trust’s quality strategy and staff views of the main barriers in the Trust to delivering high quality treatment and care for patients

How the Trust reviews and monitors its patient safety indicators and what actions are taken to improve patient safety
Summary of findings
The following good practice was identified:







Safety and quality dashboards displayed on the wards
Staff aware of patient safety indicators and net promoter score
A number of wards displayed key risks and lessons learnt from incidents
Development of ‘A&E staff competency framework’
Proactive work around dementia in particular wards
Staff competencies in maternity
Pressure ulcer e-learning competencies
The following areas of concern were identified:






Quality strategy could not been communicated to staff and therefore could not be clearly articulated
Staff do not routinely work across sites
Lessons learnt from incidents and examples of good practice are not shared across specialties or across sites
Staffing numbers described as main barrier to delivering quality of care
Equipment management was identified as an issue across all three sites
The panel observed a number of issues with the completion of DNAR forms
Detailed Findings
Good practice identified
Every ward displayed some safety and quality information on the boards which was open for all staff, patients and visitors to see. This information includes
pressure ulcers, falls, patient observations, VTE, dignity, nutrition, catheter management. Some wards also display more detailed analysis of safety and
48
quality metrics.
All the staff were aware of patient safety indicators such as falls and pressure area care as well as their recent friends and family test results.
The Waddington Unit at Lincoln County Hospital in particular was highlighted as an area which displayed a wealth of information including the current key
risks to their service, any recent complaints and key lessons learnt from recent incidents. This was an excellent example of transparency.
At Pilgrim Hospital there has been a development of an A&E staff competency framework which has taken all nurses back to the beginning, ensuring every
member of staff is competent in the key areas. The competency assessment process now being introduced by the Matron, Sister and Nurse Consultant at
Boston Pilgrim deserve special mention. The base lining of all staff against a new competency framework through demonstration of skills is an excellent
tool to assess the abilities of all nursing staff, whilst also providing an evidence base against which Department training needs can be identified and then
delivered.
Wards 6A and 6B at Pilgrim Hospital in particular had improved the support for their dementia patients with the help of the Alzheimer’s Society. More
information is included in KLOE 7.
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
Priority – urgent,
high or medium
(i) Quality strategy could not be articulated by all staff and
non executive directors
The Trust tells us that a structured patient
safety and quality communication plan
has been developed however this was
not evidenced to the panel through
discussion with staff on the ground.
Confirm the key quality priorities for the
Trust and communicate these widely to
staff using campaigns and listening events
as well as emails and the intranet.
Urgent
The Quality strategy has not been communicated effectively to
site staff and therefore this could not be clearly articulated by
the staff we spoke to. Without a clear quality strategy and
shared goals among staff there are no consistent priorities
across the three sites to improve the quality of care provided.
A well understood quality strategy would help to engage staff to
improve the quality of care.
49
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
Priority – urgent,
high or medium
(ii) Not all staff routinely work across sites and lessons
learnt from incidents and examples of good practice are
not shared across specialties or across sites
The Trust informs us that it facilitates the
cascade of good practice by means of
patient safety newsletters and that Trust
safety conferences are also specifically
arranged to support this work.
Develop a plan to rotate staff across the
sites where appropriate, in particular where
there is a risk of deskilling or where good
practice and lessons learnt need to be
shared more frequently.
High
The Trust also informs us that all SUIs
are reviewed for quality and content by a
group which includes the Medical
Director and Director of Nursing. Lessons
learned are discussed at the Sharing
Lessons Learned forum which in turn
informs the content of patient safety
newsletters.
The Trust should consider how to share
across the specialties more regularly
through governance processes and subcommittees.
Not all staff types routinely work across sites which reduces the
sharing of good practice and lessons learnt as well as
potentially deskilling the staff that work in quieter areas. The
panel noted the practical challenges that this may pose.
For example, the nurses that work within paediatrics at
Grantham hospital have seen a 50% drop in referrals in the last
year and often only have 1 patient in the unit at a time. This
significantly reduces the experience and knowledge they can
gain compared to a member of staff working in Lincoln with a
higher volume and complexity of patients.
Lessons learnt from incidents and examples of good practice
are also not shared regularly across specialties.
(iii) Staffing numbers are described as main barrier to
delivering quality of care
That being said, these were not found to
be embedded into the Trust’s processes
through discussion with staff on the
ground.
See KLOE 5 (Workforce)
See KLOE 5 (Workforce)
N/A
One of the wards where this issue was
brought to the attention of the sister has
already started to make improvements.
Digby ward at Lincoln Hospital now
includes the resuscitation trolley check in
the handover, and if it has not been
completed by the night staff it is
A consistent approach to completing the
High
checklist and monitoring compliance should
be determined and rolled out across the
three sites.
Staffing numbers were described as the main barrier to
delivering quality of care in the majority of areas that the panel
visited. This has been covered in more detail in KLOE 5
(Workforce).
(iv) Equipment management was identified as an issue
across all three sites.
Equipment management was identified as an issue across all
three sites; the majority of resuscitation trolleys that were
reviewed had gaps in the daily check without the nurse in
charge being aware. It appeared that this safety check was not
50
Outstanding concerns based on evidence gathered
Key planned improvements
embedded within the organisation or reviewed regularly to
ensure compliance.
completed first thing in the morning.
Recommended actions
Priority – urgent,
high or medium
See KLOE 10
N/A
During the unannounced visit, it was identified that the
defibrillator had not been checked on Bailgate and the nurse in
charge did not know when it had last been done. The panel
ensured the check was done before leaving the area.
(v) The panel observed a number of issues with the
completion of DNAR forms
See KLOE 10
The panel observed a number of issues with the completion of
DNAR forms. This has been covered further in KLOE 10.
51
General Medicine and Elderly Care
Overview
General medicine and elderly care were identified as key lines of enquiry based on review of the data pack and the information submitted by the Trust. The data pack
identified the following issues in particular;

Pneumonia and COPD are flagged as outliers under thoracic, general medicine and critical care for non elective for SHMI and under critical care, thoracic and general
medicine for HSMR,

The Health and Social Care Information Centre 30-day stroke mortality is high and improving substantially below the national average in the data to 2010-11 and;

The Trust was rated “high” for mortality among diabetic patients, in a report published by the Yorkshire and Humber Public Health Observatory (YHPHO) and the
National Diabetes Information Service.
Summary of findings
The following good practice was identified:






Forget me not and ‘this is me’ for patients with dementia and cognitive impairments on 6A and 6B at Pilgrim Hospital.
Involvement of the Alzheimer’s society.
Mortality reviews are being carried out across medicine and junior doctors are involved in the process.
Plan for every patient every day Electronic boards for patient location and separate board to use during board rounds (with plans to link these two).
Quality metrics on boards to focus discussions and use of the safety cross for pressure ulcers.
Stroke consultant had easy access to metrics relating to sinap data and could demonstrate progress – information available for all 3 sites from the governance team
and benchmarked against national standards- also good engagement from multidisciplinary team and evidence of good thrombolysis rates.
The following areas of concern were identified:




Little evidence of care bundles being used effectively,
There is clear evidence that whilst the ULHT Dementia programme is still in its early stages there is a clear strategy and action plan in progress which have been
developed with commissioners and partner agencies.
Pain control was found to be generally poor.
Lack of awareness of the Mental Capacity and Deprivation of Liberty Act 2005.
52
Detailed Findings
Good practice identified
Stroke consultant had easy access to metrics relating to sinap data and could demonstrate progress – information available for all 3 sites from the governance team and
benchmarked against national standards- also good engagement from multidisciplinary team and evidence of good thrombolysis rates ( Boston).
The panel identified some areas of best practice on wards 6A and 6B at pilgrim hospital in relation to care of elderly patients with cognitive impairments. There were ‘forget
me not’ magnets on the patient board to identify patients with dementia, although there did not appear to be as many as expected. Patients also had a ‘this is me’
document in their notes which is a simple and practical tool that people with dementia can use to tell staff about their needs, preferences, likes, dislikes and interests. This
work has been supported by the Alzheimer’s society who provides three members of staff to Lincoln Hospital.
Mortality reviews are being carried out across medicine; the panel understands that the Trust now review every death in medicine although the robustness of these reviews
can vary between the three sites. Junior Doctors are also being included in the process for their learning and development.
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
Priority –
urgent, high or
medium
(i) Lack of awareness of the Mental Capacity and Deprivation of
Liberty Act 2005.
Concerns were identified by the panel in relation to the Mental Capacity
and Deprivation of Liberty Act 2005.
The Trust has a Mental Capacity
Act policy in place which it tells us
is compliant with the necessary
legislation and updated to reflect
recent rulings in case law via the
Court of Protection. This was not
referred to by staff at ward level
during our visit.
Staff should ensure that they are fully
compliant with mandatory training
requirements and adult safeguarding is
given clinical engagement as a matter of
urgency.
Urgent
A particular patient was identified by a nurse consultant on the panel
which raised concerns in relation to treatment for delirium. Nursing staff
interviewed could not articulate the implications of the actions taken to
prevent the patient from leaving the ward in relation to the Mental
Capacity and Deprivation of Liberty Act 2005.
Having asked for an expert opinion from the mental health nurse, the
mental health nurse failed to follow the delirium guidelines, specifically
for this patient; assessment of his painful leg, assessment of his
53
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
Priority –
urgent, high or
medium
The Trust tells us that there is a
pain prevention role in Grantham
Hospital. We did not meet this
person during our visit to
Grantham.
Audit cycle of pain assessment should be
carried out and widely published with a
campaign to improve awareness and
compliance.
High
capacity and any deprivation of liberty issues.
Having asked a number of Matrons, sisters and staff nurses the panel’s
observations was that there is a lack of understanding of the Mental
Capacity and Deprivation of Liberty Act 2005, the most common
response was to ask the Trust safeguarding lead.
(ii) Pain control was found to be generally poor
There was consistent infrequent monitoring of pain documented on the
vital signs charts across all 3 sites.
The is no standardised pain assessment tool for people with dementia
or other patients who cannot express if they are in pain verbally, for
example, the Abbey Pain Scale.
A patient with severe dementia and bedbound on ward 5 at Grantham
was identified during the announced visit who was grimacing and
moaning but had not had a pain assessment, although the staff could
articulate how they would identify if a patient was in pain this particular
patient had not been identified.
The panel was informed that the
Trust plans to implement to Abbey
Pain Scale during quarter three,
2013-14.
Introduction of pain assessment tool for
people with dementia supported by the
necessary training.
The Trust should consider effective use of
The panel was informed that the
agreed mortality reduction plan
care bundles and staff should be trained in
There is little evidence of care bundles being used effectively across the has a clear roll out of care bundles order to deliver effective services.
three sites.
across the Trust. This process is
to be overseen by the PMO.
Recently the sepsis care bundle has been introduced, although a
number of staff felt they had not been trained adequately and evidence
suggested that it is not always being used effectively. On one surgical
ward, the sister had ensured all her staff were trained in the new bundle
– this followed an SUI related to sepsis. A matron reported that the
bundle arrived on the wards but only about 30% of staff had been
(iii) Little evidence of care bundles being used effectively
Medium
54
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
Priority –
urgent, high or
medium
None noted
This best practice example should be
shared and rolled out to all areas across
the three sites which care for elderly
patients and those with cognitive
impairments.
Medium
trained in its use.
The panel observed the Oncology ward at Lincoln using the sepsis
bundle and we did see that a patient had been admitted the previous
might because the bundle highlighted the need for admission.
However, a relative at one of our patient listening events identified that
her father was not admitted in a timely matter when he was septic
following chemotherapy. The relative was told by a nurse that there
were no beds in the hospital. The panel was told by a ward sister that
this would no longer happen because of the sepsis bundle now in place.
There is a Pneumonia care bundle being developed as a response to it
being identified as an outlier. This has not yet been rolled out; the pace
at which these care bundles are introduced is a concern and was
highlighted by the Trust Board.
(iv) Good practice above for dementia patients is not wide spread
across the organisation
The best practice identified above on wards 6A and 6B for dementia
patients is not wide spread across the organisation. There were no
other wards identified which used the ‘forget me not’ magnet to identify
patients with dementia or consistent use of the ‘this is me’ leaflet.
Support and training is required to ensure
it is rolled out and used effectively.
An awareness campaign should be
considered.
55
Urgent Care
Overview
The panel’s focus on the management of the urgent care pathway arose from a review of A&E operational effectiveness, evidenced by Trust under performance. Department
of Health data reviewed by the panel indicated that less than 95% of patients were seen, treated, discharged or admitted within 4 hours at Trust A&E Departments from
January-December 2012. However, the Trust did achieve this target overall for the financial year 2012-13 but this varied between its three sites.
Through observation of A&E Departments at 3 Trust sites (Grantham, Lincoln and Boston), associated staff interviews, focus groups and a review of documentation including
the Board Integrated Performance Report, the panel reviewed the processes and effectiveness of the urgent care pathway within the Trust.
Further investigation of A&E performance against the 4 hour target drawing on evidence provided in the Trust Board Performance Report of 29 April 2013, identified that the
Trust overall and the A&E Department at Lincoln achieved the A&E 4 hour target in the period April 12- March 13. Whilst performance was below target at Boston in the
same period, it was on an improvement trajectory from the performance seen in 2011. The view of the panel was that whilst the process improvements observed clearly
needed to be supported and continued, there was not a systemic problem with A&E operational effectiveness, nor the urgent care pathway within the Trust. .
Summary of findings
The following good practice was identified:

GP support within the Grantham A&E Department that enables the most appropriate care to be provided to the patient. Apart from enabling those patients who need
GP care to receive it, the co-location also enables the reinforcement of messages to the public about when treatment within an A&E Department is appropriate.

Panel members identified that despite staffing challenges, the engagement of and support provided by nursing staff deserved a positive commendation. The
enquiries of panel members were dealt with professionally and courteously no matter what time of the day or shift. The observations of the inherent strength of the
nursing leadership (at matron, nurse consultant and sister levels) and junior staff seen across the Trust, were also seen across the Emergency Departments,

The competency assessment process now being introduced by the Matron, Sister and Nurse Consultant at Boston Pilgrim deserve special mention. The base lining
of all staff against a new competency framework through demonstration of skills is an excellent tool to assess the abilities of all nursing staff, whilst also providing an
evidence base against which Department training needs can be identified and then delivered.

Strong Hospital at night team at Lincoln with very professional and effective hand over.
The following areas of concern were identified:

A&E performance trajectory is improving although remains below the 95% expected level

Good practice is not routinely shared across the 3 Trust sites

Urgent Care Staffing remains challenging

Clarification is needed of consultant reviews
56

Escalation is left too late
We identified a number of improvements already planned or underway at the Trust:

The improvement in overall trust performance against the 95% target (underachievement in 2011/12 and achieved in 2012/13) is commended. The investment in
infrastructure, service improvement and Board focus needs to be maintained in order to ensure that all sites exceed the required levels of performance.

The A&E Matron at Boston informed panel members of an ‘A&E Strategy’ paper being taken to Board in July 2013. Given the historic underperformance at Boston,
this attempt to ‘forward look’ and outline clinical and management strategy in order to ensure the delivery of safe and effective services that meet the needs of
patients whilst sustaining minimum standards of performance (such as the A&E 4 Hour target) is commendable. The panel recommend that this work should be
included in a clinical services strategy that addresses the needs of the public and how they are met from the sites that the Trust operates from.

An Accident & Emergency strategy for Lincoln is in place.

The sustainability review will consider as a priority, the clinical sustainability of the three A&E departments operating 24/7, given the national shortage of A&E
consultants.
Detailed Findings
Good practice identified
GP support within the Grantham A&E Department that enables the most appropriate care to be provided to the patient. Apart from enabling those patients
who need GP care to receive it, the co-location also enables the reinforcement of messages to the public about when treatment within an A&E Department
is appropriate.
Panel members identified that despite staffing challenges, the engagement of and support provided by nursing staff deserved a positive commendation.
The enquiries of panel members were dealt with professionally and courteously no matter what time of the day or shift. The observations of the inherent
strength of the nursing leadership (at matron, nurse consultant and sister levels) and junior staff seen across the Trust, where also seen across the
Emergency Departments.
The competency assessment process now being introduced by the Matron, Sister and Nurse Consultant at Boston Pilgrim deserve special mention. The
base lining of all staff against a new competency framework through demonstration of skills is an excellent tool to assess the abilities of all nursing staff,
whilst also providing an evidence base against which Department training needs can be identified and then delivered.
The multi disciplinary team (MDT) input at Grantham was viewed as very good and enabled rapid patient interventions and discharge within the Emergency
Assessment Unit (EAU).
The use of Dictaphone handover at Grantham was viewed as a simple but effective means of ensuring a timely and effective handover.
57
The Trusts internal urgent care board coordinates the development of A&E services.
Outstanding concerns based on evidence
gathered
Key planned improvements
(i) A&E performance trajectory is improving
The Trust tells us that there is an Accident & Emergency
although remains below the 95% expected level strategy for Lincoln in place.
The panel noted that a Boston ‘A&E Strategy’ paper being
Maintaining performance improvement trajectory
and then sustaining A&E operational effectiveness. taken to Board in July 2013.
The Trust informed us that A&E performance is to be
considered by the sustainability review.
(ii) Good practice is not routinely shared
across the 3 Trust sites or between
departments
The Trust identified to the panel that urgent care standards
are agreed pan-Trust however this did not come out in the
review.
Good practice is not routinely shared across the 3
Trust sites visited or indeed between departments.
There does not appear to be any structure for
sharing best practice across what was observed to
be 3 distinct departments that had no common
management or clinical structure.
Recommended actions
Priority –
urgent, high
or medium
The panel recommend that this work
should be included in a clinical services
strategy that addresses the Urgent
Care needs of the public and how they
are met from the all sites that the Trust
operate from.
High
The Director of Nursing and Director of
Operations to review options and
implement a process for sharing best
practice.
High
Director of Operations to invite an
ECIST review of practice along the
Trust urgent care pathway.
There is a particular opportunity to share the
Nursing Competency framework developed at
Boston across all sites.
(iii) Urgent Care Staffing remains challenging
The Trust identified a number of relevant actions will be
undertaken, including:
Given the overall and significant
shortfall in nursing and clinical support
High
58
Outstanding concerns based on evidence
gathered
Despite new appointments, staffing remains
challenging with limited night clinical cover at
Lincoln and nursing vacancies at Grantham.
(iv) Clarification is needed of consultant
reviews
Key planned improvements



International recruitment (for middle grades)
Significantly increased cons numbers since Oct (at
LCH from 1 to 6)
Increased middle grade cover at nights
Recommended actions
Priority –
urgent, high
or medium
at the Trust, the Board should continue
to monitor recruitment progress and
seek assurance on safe levels of
staffing through routine reporting and
unannounced reviews. Challenging the
historic under recruitment to the Trust
requires the active monitoring of service
viability within an overall clinical
services strategy.
None noted
Trust to review ward round processes
and patient discharge policies.
Medium
The Trust informed the panel that risk assessment tools are
active in A&E and MEAU at LCH, which by design lead to
early escalation. These were not being fully utilised by staff
during the review period.
To review patient flow policy and
supporting processes on all sites.
Medium
There appeared to be a general need on all sites
for clarity on the daily process of consultant
reviews including a programme of early ward
rounds that could be repeated in order to assist
early patient discharge. At Grantham, there did
not appear to be any system of delegation for
patient criteria based discharge.
The panel notes that ‘daily senior ward round
reliability’ and ‘time to senior review’ have been
included in the medical process reliability
dashboard, as documented within the Trust’s
mortality reduction plan.
(v) Escalation takes place too late with regard
to ensuring patient flow is maintained
The sense gained through conversation with staff
that escalation within Grantham A&E was left to
59
Outstanding concerns based on evidence
gathered
Key planned improvements
Recommended actions
Priority –
urgent, high
or medium
late i.e. reactive once A&E full rather than
proactively as demand increases and capacity
decreases. Indeed the panel found no evidence of
ongoing risk assessment to inform escalation at
either the Lincoln or Grantham sites.
The panel were told that admissions were, in part,
due to inappropriately timed senior review and
untimely observations (due to lack of nursing staff)
that lead to delayed escalation of care.
The panel observed that patients at Lincoln A&E
were often moved in the last 15-20 minutes of the
4 hour window. These admission should have a
clear plan earlier e.g. after 2 hours in A&E.
See also KLOE2.
60
Obstetrics
Overview
The panel’s focus on obstetric and perinatal mortality was driven by HSMR data which indicated for the period January-December 2012, that perinatal conditions was one
area with a greater number of deaths above the expected level.
Through observation of the Obstetrics and Gynaecology Departments at 3 Trust sites (Grantham, Lincoln and Boston), associated staff interviews, focus groups and a review
of documentation, the panel reviewed the delivery of patient services and the review processes around perinatal mortality.
It became clear that the Trust had commenced its own review of the stillbirth rate, triggered by the Dr Foster HSMR data The report reviewed by the Quality and Safety
Committee in May 2013 was based on a 2 year audit from January 2010 – January 2012 and showed that the stillbirth rate at Lincoln was below the national still birth rate in
2011 and 2012 (2.05 and 4.62 against the national rate of 5.2 per 1000). At Boston the still birth rate in 2011 was below the national average and just above in 2012 (4.1 and
5.3 against the national rate of 5.2 per 1000). The audit findings were not conclusive of any defining factors or common themes but did highlight the need to improve the
accuracy of coding. It is clear that the Trust maintains a monthly focus on perinatal mortality through standing clinical governance arrangements and has action plans in place
at both the Lincoln and Boston sites. The panel were assured that there were no underlying issues with respect to perinatal mortality, on the basis of the evidence presented
and collected.
Summary of findings
The following good practice was identified:

Completed [perinatal] mortality review and monthly perinatal mortality meetings where the multi disciplinary team (MDT) reviews mortality and morbidity.

The development of a new competency development package at Lincoln for all new preceptor Band 5 staff which is being rolled out and will also be used with existing
band 6 staff.

A good escalation policy within the maternity unit which staff clearly understand.

Good understanding of the patient complaints and Serious Incident processes.

Early commencement in August 2013 of the Friends and Family Test.
The following areas of concern were identified:

The Trust has not reviewed mortality from February 2012 onwards.

There was no clear information displayed at Grantham on how to provide patient feedback.

Midwife driven service with little consultant engagement.
61

Whilst staffing did appear to have moved in line with establishment, the panel was not assured that the specialist staffing requirement was similarly matched nor that
staffing levels were resilient.

The panel noted the community midwife workload in the coastal area and short staffing of the team.

Sensitivity of appointment scheduling of a multi disciplinary obstetrics and gynaecology clinic. Whilst the panel recognised the limitations of space, it was observed
that particular care was required in scheduling Gynaecology and Obstetrics outpatient appointments in the women’s outpatient area at Grantham. Even if clinics for
infertility, termination of pregnancy, antenatal etc are scheduled so as not to occur alongside each other, there is a need to clearly identify the clinic area, and
consider the positioning and content of display board materials.

Safety checks of equipment were not made.
For all the above areas of concern, we identified a number of improvements already planned or underway at the Trust.


The panel noted the recent review of staffing conducted using the Birthrate Plus model and the adjustments made. Staffing numbers need to be updated to include
specialist staff.
Risk investigation is well established. The panel would encourage the Trust to ensure that the process is owned and conducted by the full multi-disciplinary team.
Detailed Findings
Good practice identified
Monthly MDT review of mortality and morbidity; and the submission of a stillbirth report to the Trust Quality and Safety Committee.
The development of a new competency development package at Lincoln which is being rolled out to Band 5 and existing staff.
A good escalation policy within the maternity unit which staff clearly understood.
Early commencement in August 2013 of the Friends and Family Test.
Joint investigation but from separate supervisory and management perspectives of incidents; this makes best use of time and minimises impact on staff.
Birth after thought service offered by the Trust to all women.
Change in practice in response to a complaint. e.g. Wheelchairs being provided to take Mothers to their transport on discharge following C-Sections.
Eye catching and comprehensive Infection Control display board on Lincoln Nettleham ward.
Comprehensive introduction to Lincoln ante/post natal ward by the ward sister which commenced with an explanation of staff uniforms.
62
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
Priority –
urgent, high or
medium
(i) The Trust has not reviewed perinatal mortality trends although
mortality is reviewed on a monthly basis
Ongoing monthly reviews of
mortality and morbidity
The Trust should continue its review of the
trends in perinatal mortality data for 2012
and provide an update to their current
stillbirth report (informed by audit from Jan
2010- Jan 2012).
High
None noted
Trust to clarify patient complaints, feedback High
and advice arrangements (note this is a
wider trust observation and is also
included in KLOE 3)
None noted
To review capacity alongside policy and
process to ensure that the requirements for
consultant and MDT engagement are
clarified to add value.
High
Birthrate Plus model recently used.
Trust to confirm funding decision for
additional midwifery staff and to update
establishment to include specialist staff
requirement.
High
Our review identified that the Trust had commenced its own review of
the stillbirth rate, triggered by the Dr Foster HSMR data The report
reviewed by the Quality and Safety Committee in May 2013 was based
on a 2 year audit from January 2010 – January 2012.
The monthly meetings do not cover trends in the perinatal mortality
rates.
(ii) There was no specific information displayed at Grantham
antenatal clinic on providing feedback about maternity services at
Grantham.
No information on providing patient feedback was displayed at
Grantham.
(iii) Midwife driven service with little consultant engagement
The service appears to be driven by midwives with little apparent
consultant engagement even though the service is officially led by a
Clinical Director. Whilst actual practice may be different, it is notable
that the guidance flowchart for SI investigation does not include any
consultant engagement in the process.
(iv) Whilst the clinical component of birthrate plus has been
applied, there was less assurance around the specialist staffing
requirements and maintenance of resilience of staffing levels out
of hours.
The day to day challenges of staffing also become more acute when
considering the tapering of staff over the day and night e.g. on Lincoln
Nettleham Ward the staffing on the night shift is less than 50% of the
63
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
Priority –
urgent, high or
medium
None noted
Trust to review outpatient clinic scheduling
and layout alongside display board
materials
High
None noted
Trust to action in accordance with own
Safety and Quality requirements
High
day shift eg 7 trained and 2 untrained in the morning reducing to 5+2
later, reducing to 2+2 overnight. This ward also covers the transitional
care area out the staffing described.
The panel noted that whilst the workload of the community midwife
team in the coastal area was as expected, the team was short staffed.
This was recognised and this community team is currently not part of
the on call escalation for supporting the labour ward.
(v) Sensitivity of appointment scheduling of a multi disciplinary
Obstetrics and Gynaecology clinic
Whilst the panel recognised the limitations of space, it was observed
that particular care was required in scheduling Gynaecology and
Obstetrics outpatient appointments in one clinical area at Grantham.
Even if clinics for infertility, termination of pregnancy, antenatal etc are
scheduled so as not to occur alongside each other, there is a need to
clearly identify the clinic area and consider the positioning and content
of display board materials.
(vi) Safety checks of equipment were not made
There were gaps in daily checking of essential equipment on Lincoln
labour ward.
64
Critical Care and Surgery
Overview
Critical care and surgery were identified as key lines of enquiry based on review of the data pack and the information submitted by the Trust. The data pack identified critical
care medicine as a mortality outlier under both SHMI and HSMR.
The panel also focussed on how the Trust is responding to the contributing factors such as deteriorating Early Warning Score (EWS) rates, shock cardiac arrest triggers and
deteriorating renal function triggers within its crude surgical mortality rate.
Summary of findings
The following good practice was identified:



Clear articulation of the Trust’s ‘track and trigger’ process for early warning of deteriorating patients and escalation.
Outreach team and ‘hospital at night’ team.
Surgical Emergency Assessment Unit (SEAU) triage and score all patients to prioritise and escalate.
The following areas of concern were identified:




The panel observed a number of issues with the completion of DNAR forms.
There was a lack of understanding around why the Critical care pathway was identified as an outlier.
The Trust often has insufficient capacity in its High Dependency Units (HDU) and Critical Care Units (CCU).
Patients were in inappropriate clinical areas due to capacity issues.
Detailed Findings
Good practice identified
The majority of staff that the panel spoke to during ward observations could clearly articulate the Trust’s ‘track and trigger’ process for early warning of
deteriorating patients and escalation to medical staff although it should be noted that this is not in place at Pilgrim Hospital, Boston.
There is an outreach team for critically ill and deteriorating patients; the team try to stop patients from requiring intensive care. The outreach team are
covered by a ‘hospital at night’ team out of hours which consists of experienced nurses who support staff with critically ill patients. At Boston, however, the
lack of outreach and hospital of night was raised as a problem.
65
SEAU (surgical emergency assessment unit) at Lincoln Hospital triage and score all patients on arrival to prioritise and escalate any who need immediate
medical attention. SEAU was also an area where track and trigger was well understood by staff.
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
Priority –
urgent, high or
medium
(i) We observed a number of issues with the completion of DNAR
forms
Pilgrim Hospital, Boston
The panel looked at four DNAR forms on a ward and found the
following matters:
 Only one was completed correctly with a MCA assessment and
best interests supporting the decision.
 IMCAs had not been involved in decisions
 Lack of evidence of appropriate dialogue with patients
 There was some evidence of family involvement but not in all
cases
 Consultant sign off had not taken place
The Trust undertook an immediate
review of DNAR forms in the
hospitals and the current policy is
going to be updated and matched
with best practice from elsewhere.
The Trust has already undertaken a review
of all patients with DNAR forms to ensure
they are accurately and adequately
completed. This was completed
immediately by the Trust.
Urgent
In addition, the Trust should review its
process and policies for the completion for
DNAR forms to ensure they meet best
practice and legal requirements.
We were present on the ward when a cardiac arrest took place during
our unannounced visit and observed comments and discussion about
whether a DNAR existed or not during resuscitation. The panel’s view
was that staff were not aware of the process around DNAR and that
they were not aware of the wishes of individual patients on the ward.
On another ward we reviewed one DNAR form that had been
completed appropriately and accurately.
Lincoln County Hospital
The panel looked at two DNAR forms on one ward at Lincoln County
Hospital and the following issues were noted:
 One patient had two different DNAR forms among the notes,
one completed in March and one in April
 Lack of evidence of appropriate dialogue with patients
 Neither form identified whether the decision not to resuscitate
would be reviewed
 The nurse on the ward was not clear on which DNAR form
66
Outstanding concerns based on evidence gathered



Key planned improvements
Recommended actions
Priority –
urgent, high or
medium
None noted.
The Trust should ensure that there are
appropriate escalation processes in place
for managing deteriorating patients,
including the use of outreach services to
support the ‘hospital at night’ team. Staff
should ensure that there is an appropriate
response to escalation.
High
should apply.
The panel was unable to identify any entry in the patient’s
notes to suggest that a DNAR form was appropriate/needed
Another patient had an active DNAR form dated June
The DNAR form noted that the decision not to resuscitate
would not be reviewed, the panel noted that the patient records
identified the patient as 'MFFD' (medically fit for discharge)
although it is recognised that a DNAR may remain appropriate
even where patients no longer require acute hospital care.
The panel looked at three DNAR forms on another ward and noted the
following:
 One DNAR form did not identify whether the decision not to
resuscitate would be reviewed
 Of the 3 DNAR forms examined by the panel, only 1 was fully
completed but this one had not been discussed with the patient
or relatives.
(ii) The Trust has work to do in relation to its processes for
escalating deteriorating patients and responding appropriately.
Our review of critical care found that the Trust had undertaken
significant work on its ICNARC (intensive care national audit and
research centre) data which shows a strong performance in this area.
The panel notes that the alert from HSMR and SHMI might reflect a
sub group of patients, who were admitted and died within CCU, but
when incorporated into the overall ICNARC data, did not result in the
Trust being flagged as an outlier. The diagnostic groups included in
critical care medicine with higher mortality in this alert are mainly
pneumonia and septicaemia. The Trust has undertaken work on
septicaemia with the sepsis bundle as discussed under KLOE for
General Medicine and Elderly Care and the panel has been informed
that some work has commenced on a care bundle for pneumonia.
The Trust should move to embed the
quality and safety work in a programme of
improvement linked to the problems
identified and aligning staff engagement to
this work.
The Trust should plan the medical
workforce in the context of the specific
problems relating to recruitment and
67
Outstanding concerns based on evidence gathered
Key planned improvements
Priority –
urgent, high or
medium
engagement with the Local Education and
Training Boards (LETB) in this.
Whilst the panel had no fundamental concerns in this area, the panel
identified that the Trust did not have sufficient outreach services on a
24/7 basis throughout the Trust and that escalation of deteriorating
patients was not always well managed. Staff told us that they often felt
unable to escalate deteriorating patients due to a lack of capacity.
(iii) The Trust often has insufficient capacity in its High
Dependency Units (HDU) and Critical Care Units (CCU)
Recommended actions
The Trust should clarify the quality
governance arrangements and
communicate arrangements to staff.
None noted
Review of and adherence to the Trust’s
escalation plan, particularly in relation to
discharge.
High
The panel was informed of the joint Review of and adherence to the Trust’s
work being undertaken by the Trust escalation plan, particularly in relation to
with primary care to minimise
discharge.
inappropriate admissions,
especially end of life care.
High
The Trust often has insufficient capacity in its High Dependency Units
(HDU) and Critical Care Units (CCU). However, the panel notes that
HDU capacity is currently being reviewed at Pilgrim Hospital. This can
result in some cancellations and holding patients in recovery for longer
than usual while they wait for a bed to become free.
This is often as a consequence of delayed discharges from the Trust as
a whole rather than a capacity issue in HDU/ITU. Staff at Boston stated
that patients were often waiting for a bed on the wards well after a
decision to discharge.
(iv) Patients were in inappropriate clinical areas due to capacity
issues
During the announced visit a number of patients were identified as
being in inappropriate clinical areas with reasons cited by staff as due
to capacity issues, particularly with the urgent care pathway. On the
unannounced visit, it was recorded that 3 out of the 7 patients on
Bailgate (short-stay unit at Lincoln Hospital) should have been in other
wards as they required orthopaedic admission for surgery or
rehabilitation.
There is a risk associated with outliers that the patients do not receive
the right quality of care from appropriate nursing and medical staff.
68
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
Priority –
urgent, high or
medium
The Bostonian was used as a mixed ward of surgical and medical
patients and there was no clear ‘medical team’ looking after the
patients admitted with medical problems.
Patients raised concerns at the focus group that they were outliers on
surgical wards with infrequent visits by the parent medical team (both
Lincoln and Boston patient focus groups),
69
5. Conclusions and support required
The review identified a number of good areas of practice across the Trust, with some great examples of excellent care being delivered to patients. Some staff groups and
particular individuals at the Trust also received praise. The review also identified a number of areas of outstanding concern across all ten key lines of enquiry which will
require urgent or high priority action to address as identified in the detailed findings section. The Trust recognises that there are steps it needs to take to address the
concerns raised by the review. Some improvement plans are already in motion, and the review team thinks these should be expedited. Other things may be areas that the
Trust has not yet considered and the panel recommends the Trust quickly develops action plans to address these concerns. A number of these areas are recommended for
discussion at the risk summit to consider what support may be required from the Trust to address these concerns.
Urgent priority actions for consideration at the risk summit
Problem identified
Recommended Action for discussion
Leadership and governance:
The Trust should ensure there are clear and active discussion lines between the
clinical leaders at ward level, the clinical directors and the Trust Board to ensure
that leadership of the organisation is joined up and consistent. The Trust should
focus on engaging clinical teams rather than specialties or separate professional
groups.
There is a disconnect between leadership at Board
level and leadership at clinical levels within the
organisation (page 24).
Support required by the Trust
The Executive Team recognise the need to build stronger connections between
leadership at Board level and leadership at clinical level.
It is critical that this recognition is adopted across the entire Trust, by all staff
groups and by the whole Board.
Clinical and operational effectiveness:
The panel was unable to easily see or understand
how escalation worked for both actions taken in
managing deteriorating patients and also
managing patient flow as there seemed to be no
standardised process in operation across the
specialties and sites (page 32).
The Trust should seek to clarify its escalation policy and ensure that it uses the
‘track and trigger’ system effectively across all the Trust sites. Staff should ensure
that escalation responses are appropriate and well documented in response to
managing deteriorating patients.
In addition the Trust should ensure that patient flow is planned and managed
appropriately and there is consistent and early use of existing escalation policy.
An IT solution needs to be found to allow the ambulance inbound system to be
visible in A&E.
70
Problem identified
Recommended Action for discussion
Patient experience:
The Director of Nursing and the Company Secretary should review the handling of
complaints and the processes whereby complaints can be systematically fed back
and used by staff teams to improve service delivery. This should include creation of
PALs. Complaints should be seen as everyone’s responsibility – not just the
complaints team / Board.
The complaints process is confusing and not fit for
purpose (page 37).
Patient experience:
Patient experience is not seen by patients to be at
the heart of the organisation and service
improvement (page 38).
Workforce:
Staffing levels were, in some areas and at certain
times of the day, low. The panel formally escalated
its concerns to the CQC (page 41 - 45).
Support required by the Trust
The Trust should implement a patient experience action focussed improvement
plan that should include:
 real time patient feedback
 evidence of listening and responding
 Using and working with patients to co-design service improvement
The whole trust staff should engage with this process.
The Trust should urgently implement the recommendations of its nurse staffing
review, in particular taking account of: nursing numbers and appropriate use of
agency and bank staff; Matron cover at Pilgrim Hospital, Boston; dependency of
patients including 1:1 care, assistance with eating and assistance using toileting
facilities.
The Trust should also consider urgently middle grade cover and appropriate
supervision of junior doctors, especially out of hours.
Workforce:
Workforce planning is poor with no recruitment
plans and no plans in place to cover maternity
leave, sickness and annual leave other than
through the use of agency, bank staff or, in the
case of medical staffing, locums (page 46 - 47).
Safety:
The Trust should document and implemented a recruitment plan with immediate
effect to fill the short term vacancies but also consider its medium term
requirements. The Trust should also seek to firm up its strategic plans, including
the level of future service provision at all three main hospital sites and the
community sites. This should be done in conjunction with stakeholders. Student
nurse posts should be advertised earlier.
The Trust should continue to confirm and communicate its key quality priorities for
the Trust to staff using campaigns and listening events as well as emails, the
71
Problem identified
Recommended Action for discussion
Quality strategy has not been communicated
effectively and therefore could not be articulated by
all staff and non executive directors (page 50).
intranet and Ward to Board initiatives.
General Medicine and Elderly Care:
Staff should ensure that they are fully compliant with mandatory training
requirements and adult safeguarding should be given clinical engagement as a
matter of urgency.
Lack of awareness of the Mental Capacity and
Deprivation of Liberty Act 2005 in relation to the
Trust’s responsibilities in allowing patients to leave
wards if they are deemed capable and wish to
(page 54 - 55).
Critical Care and Surgery:
We observed a number of issues with the
completion of DNAR forms (page 67 -68).
Support required by the Trust
The Trust has already undertaken an immediate review of all patients with DNAR
forms to ensure they are accurately and adequately completed. This was
completed immediately by the Trust. The Trust should review its process and
policies for the completion for DNAR forms to ensure they meet best practice and
legal requirements.
72
Appendices
73
Appendix I: SHMI and HSMR definitions
HSMR definition
What is the Hospital Standardised Mortality Ratio?
The Hospital Standardised Mortality Ratio (HSMR) is an indicator of healthcare quality that measures whether the mortality rate at a hospital is higher or lower than you would
expect. Like all statistical indicators, HSMR is not perfect. If a hospital has a high HSMR, it cannot be said for certain that this reflects failings in the care provided by the
hospital. However, it can be a warning sign that things are going wrong.
How does HSMR work?
The HSMR is a ratio of the observed number of in-hospital deaths at the end of a continuous inpatient spell to the expected number of in-hospital deaths (multiplied by 100)
for 56 specific groups (CCS groups); in a specified patient group. The expected deaths are calculated from logistic regression models taking into account and adjusting for a
case-mix of: age band, sex, deprivation, interaction between age band and co-morbidities, month of admission, admission method, source of admission, the presence of
palliative care, number of previous emergency admissions and financial year of discharge.
How should HSMR be interpreted?
Care is needed in interpreting these results. Although a score of 100 indicates that the observed number of deaths matched the expected number; in order to identify if
variation from this is significant confidence intervals are calculated. A Poisson distribution model is used to calculate 95% and 99.9% confidence intervals and only when
these have been crossed is performance classed as higher or lower than expected.
SHMI definition
What is the Summary Hospital-level Mortality Indicator?
The Summary level Hospital Mortality Indicator (SHMI) is a high level hospital mortality indicator that is published by the Department of Health on a quarterly basis. The SHMI
follows a similar principle to the general standardised mortality ratio; a measure based upon a nationally expected value. SHMI can be used as a potential smoke alarm for
potential deviations away from regular practice.
How does SHMI work?
1) Deaths up to 30 days post acute trust discharge are considered in the mortality indicator, utilising ONS data
2) The SHMI is the ratio of the Observed number of deaths in a Trust vs. Expected number of deaths over a period of time
3) The Indicator will utilise 5 factors to adjust mortality rates by
a.
b.
c.
d.
e.
The primary admitting diagnosis
The type of admission
A calculation of co-morbid complexity (Charlson Index of co-morbidities)
Age
Sex
74
4) All inpatient mortalities that occur within a Hospital are considered in the indicator
How should SHMI be interpreted?
Due to the complexities of hospital care and the high variation in the statistical models all deviations from the expected are highlighted using a Random Effects funnel plot
Some key differences between SHMI and HSMR
Indicator
Are all hospital deaths included?
When a patient dies how many times is this counted?
HSMR
No, around 80% of in hospital deaths are included,
which varies significantly dependent upon the
services provided by each hospital
If a patient is transferred between hospitals within 2
days the death is counted multiple times
Does the use of the palliative care code reduce the
relative impact of a death on the indicator?
Does the indicator consider where deaths occur?
Yes
Is this applied to all health care providers?
Yes
Only considers in hospital deaths
SHMI
Yes all deaths are included
1 death is counted once, and if the patient is
transferred the death is attached to the last
acute/secondary care provider
No
Considers in hospital deaths but also those up to 30
days post discharge anywhere too.
No, does not apply to specialist hospitals
75
Appendix II: Panel Composition
Panel role
Panel Chair
Name
Panel role
Name
Ruth May
Board Level Nurse
Marion Collict
Lay representative (Patient/public
representative)
Jackie Wilkinson
Board Level Nurse
Lynne Wigens
Board Level Nurse
Pol Toner
Lay representative (Patient/public
representative)
Jean Gallagher
Lay representative (Patient/public
representative)
Howard Naylor
Junior Doctor
Nassim Parvizi
Junior Doctor
Saheel Mukhtar
Doctor
Mike Lambert
Doctor
Charles Mann
Doctor
Sonia Swart
Doctor
Geoff Hunnam
Student Nurse
Jane Philpott
Student Nurse
Madalina Veturia Fabian
Board Level Nurse
Senior Nurse
Birte Harlev Lam
Senior Nurse
Vicki Leah
CQC representative
Alan Swain
Senior Trust Manager
Cara Charles Barks
Senior Regional Support
Mark Driver
Senior Regional Support
Trish Thompson
Senior Regional Support
Shelley Bewsher
CCG Observer
Wendy Martin
Area Team Observer
Aly Rashid
Area Team Observer
Manjit Darby
Nancy Fontaine
76
Appendix III: Interviews held on announced visit
Interviewees
Date held
Vice Chairman, Chief Executive, Chair and Director of Performance and Improvement
17 June
Interim Medical Director, Medical Director (not yet in post), Deputy Director of Nursing, Head of Quality, Interim Director of Quality Governance
17 June
Director of Operations, Director of Human Resources and Non Executive Directors
17 June
Complaints Team
18 June
Interim Director of Nursing
18 June
CCGs
18 June
Deputy Director of Patient Services
19 June
Deputy Director of Operations
19 June
Chair of Audit Committee and Vice Chairman and Chair of Governors
19 June
77
Appendix IV: Observations undertaken
Observation area
Date of observation
Grantham Hospital
Observation area
Date of observation
MEAU
18 June
Obstetrics and Gynaecology
17 June
Oncology
18 June
Accident and Emergency
17 June
Stroke Ward
18 June
CCU
17 June
Theatres
18 June
Respiratory
17 June
Digby Ward
18 June
Maternity
17 June
SEAU
18 June
General Surgery and Theatres
17 June
Stow Ward
18 June
Outpatients
17 June
Shuttleworth Ward
18 June
Rehabilitation
17 June
Mitchell Ward
18 June
EAU
17 June
Navenby Ward
18 June
MMU
17 June
Paediatrics - Rainforest Ward
18 June
Stroke – Ward 1
17 June
Paediatrics - Safari Ward
18 June
SEAU Ward
18 June
Lincoln County Hospital
EAU
18 June
Burton Ward
18 June
Accident and Emergency
18 June
Johnstone Ward
18 June
Maternity
18 June
ICU
18 June
Obstetrics
18 June
Hatton Ward
20 June
Gynaecology
18 June
Digby Ward
20 June
78
SEAU
20 June
CDU
20 June
A&E
20 June
Ward 5A – General Surgery
20 June
Ward 8B – Cardiology Ward
20 June
Pilgrim Hospital, Boston
Maternity
19 June
Ward 7B – Respiratory
20 June
Obstetrics
19 June
Ward 3A – Elective Orthopaedics/
Ophthalmology
20 June
Gynaecology
19 June
Ward 3B - Trauma and Orthopaedics
20 June
Vascular Ward
19 June
A&E
20 June
Gastro Ward
19 June
CCU
19 June
ICU
19 June
Bostonian
19 June
Accident and Emergency
19 June
CDU
19 June
6A and 6B – Elderly Care Wards
19 June
Stroke Ward
19 June
7A and 7B
19 June
Theatres and Recovery
19 June
2b – Day case Ward
19 June
Labour Ward
19 June
Ward 6A – Elderly Care
20 June
Ward 6B – Elderly Care
20 June
79
Appendix V: Focus groups held
Focus group invitees
Focus group attendees
Date held
Trainee Nurses and Junior Doctors - Grantham
18 registered attendees
17 June
Senior Doctors and Senior Staff - Grantham
26 registered attendees
17 June
Senior Nurses - Grantham
15 registered attendees
17 June
Other health professionals and non clinical staff - Grantham
18 registered attendees
17 June
Trainee Nurses and Junior Doctors - Lincoln
18 registered attendees
18 June
Senior Doctors and Senior Staff - Lincoln
24 registered attendees
18 June
Senior Nurses - Lincoln
22 registered attendees
18 June
Other health professionals and non clinical staff - Lincoln
29 registered attendees
18 June
Trainee Nurses and Junior Doctors - Boston
26 registered attendees
19 June
Senior Doctors - Boston
Were seen individually
19 June
Senior Nurses - Boston
42 registered attendees
19 June
Other health professionals and non clinical staff - Boston
26 registered attendees
19 June
80
Appendix VI: Information available to the RRR panel
Customer Care Screening Tool
Patient Experience (G. Collier)
CSAS Incident Report 04/1/2013
Serious Incident Investigation Report Jun-13
CSAS Incident Report 04/06/2013
Serious Incident Investigation Report May-13
CSAS Incident Report Apr-13
Serious Incident Investigation Report Apr-13
CSAS Incident Report Apr-13
Ward Information Pilgrim Hospital Mar-13
Dixon ward info and FFT comments
Dixon ward graphs
Inpatient care quality audit and patient feedback
02-May-13
Medicine administration competency 2012-2013
Sepsis training
Track and Trigger 2012
Track and Trigger 2013
Band 5 time out day agenda/attendance list
Medications Management 04-Jul-12
Quality review 25-Apr
Quality governance-internal review of
compliance (stow, Clayton and Dixon) 23Apr-12
Process product FMEA 03/11/2011
Ward list
Process product FMEA 17/01/2012
Process product FMEA 17/01/2012
Process product FMEA 03/11/2011
ULHT Annual Plan 2013-14
ULH - Financial Plan - 2013-14
ULH Future Mgmt Arrangements 08/11/2010
Pilgrim Management Group Meeting Minutes 28Feb-13
Vascular service option appraisal 20-Jun-11
East Midlands Vascular Network - requirements to centralise
vascular inpatient services
Management of behaviour and psychiatric
symptoms of dementia (BPSD) Feb-12
Pilgrim Management Group Meeting Minutes
25-Apr-13
Notes of Vascular Hub Options Appraisal Meeting 27Apr-11
Vascular timeline 2011
Letter from MD and DoN Feb-13
Email re CIPs and QIA 29-Apr-13
CSAS Incident Report Aug-12
ULH org chart
ULH In-patient care going home survey (incl Friends
and Family test)
Alzheimer’s society - 'this is me' leaflet
Track and Trigger Step Up chart
Midwives day and night checking and cleaning list (13/5/13 18/6/13) 17-Jun-13
ULH Proforma for the management of drug
incidents errors
81
Work roster - Digby short stay (June July 2013)
Consultant info card template Aug-10
A&E daily activity sheet template May - 13
Managing long waiting patients in A&E through escalation
Lincoln A&E patient flow - chart
A&E clinical quality indicators 09-Jun-13
1to1 ward sister report for matrons monthly meeting
(template) 28.5.12
Patient Experience (Alan Tolley) Jun-13
Work roster - GDH ward 2 (may June 2013)
EAU GP Referral Form (template)
Grantham Exclusion Protocol 21/09/2012
Grantham Admission Protocol 21/09/2012
Advice sheet - acute back pain
Advice sheet - high temperature (child)
Advice sheet - chest injury
Friends and Family template
Perinatal meeting learning points - May 13 07-May13
Perinatal meeting attendance list - May 13 07May-13
Perinatal meeting learning points - March 13 13-Mar-13
Perinatal meeting attendance list - March 13 13Mar-13
Perinatal meeting learning points - March 13
13-Mar-13
Perinatal meeting learning points - Jan 13 10-Jan-13
Perinatal meeting learning points - Dec 13 07Dec-13
Perinatal meeting attendance list
- Oct 12 04-Oct-12
Perinatal meeting learning points - Oct 12 04-Oct-12
Perinatal meeting learning points June 12 09Jun-12
Perinatal meeting learning points - June 12
08/06/2012
Perinatal meeting attendance list - April 12 27-Apr-12
Perinatal meeting learning points - April 12 27Apr-12
Perinatal meeting learning points - March 12 06Mar-12
Perinatal meeting learning points - March 12 Mar-12
Paediatric Gov Meeting Dates 2013
2014 V4
Minutes of the Private Trust Board Meeting
07-May-13
Minutes of the Private Extra Trust Board Meeting - 22 May
2013 22-May-13
Alex Ward Admission Criteria
Management structure, deputies May-12
Management structure, deputies 3.1A May-12
Dixon ward action plan 06-Jun-13
Handover sheet sdm (7.6.13 8.6.13 - night.
SDM= Stephens) Jun-13
Lincoln operational escalation policy 14/11/2012
Opening beds checklist – Clayton 16/03/2013
ULH org chart work roster - Digby short stay
(may June 2013)
82
Opening beds checklist - template
Lincoln Site Adverse weather plan - 12/13 06.11.12
Lincoln A and E escalation plan Dec-12
Outlier policy for medicine Jan-13
Trust wide outlier policy Reviewed Aug 2012 DRAFT Aug12
SOP for the repatriation of patients Mar-13
SOP for outlying surgical patients 10-Jan-13
SOP for staff support with increased demand in A&E
Incident policy final revised Jan 13 (FINAL)[1] 08Jan-13
Clinical Systems Analysis Manual v1.2
Clinical Systems Analysis and contextual risk factors
Mortality Reduction - Saving lives in Lincolnshire
11/06/2013
Mortality and Quality of Care - Internal Review
01/05/2013
Mortality reviews carried out and ongoing – June 2013
01/06/2013
SQD data - pressure ulcers - June13 01/06/2013
Pressure Ulcer performance March 2013
17/06/2013
Raw data from PUNT pressure ulcer management tool Cat 3 and 4 March 2013 Mar-13
WHISTLE BLOWING POLICY draft5
2013.03 Lincoln site scorecard Mar-13
Medicine and A&E Lincoln Scorecard March 2013 Mar-13
INTEGRATED PERFORMANCE REPORT PERIOD TO 30th April 2013 28-May-13
UROLOGY BUSINESS IMPROVEMENT PLAN
2013 - project groups - version2 18/04/2013
Urology Business Plan 2013 v9
Shaping Health for Mid Kesteven - Consultation
Cure Lincolnshire submission20-Febto review team
13
Letter from Chief Exec of Lincolnshire Partnership
NHS Trust to Sir Bruce Keogh
Record of PNM&M Attendances
83
Appendix VII: Unannounced site visit
Agenda item
Lincoln County Hospital
Entry into Lincoln County Hospital and announced arrival to site manager
Accident & Emergency
Observations undertaken of the following:



Accident & Emergency
Hatton and Digby Wards
SEAU
Meeting held with site manager to understand current staffing and patient levels
Panel left Trust and announced exit
Pilgrim Hospital, Boston
Entry into Pilgrim Hospital, Boston and announced arrival to site manager
Observations undertaken of the following:






Accident & Emergency
Wards 3A and 3B
Wards 6A and 6B
Ward 5A
Ward 8B
Ward 7B
Meeting held with site manager to understand current staffing and patient levels
Panel left Trust and announced exit
84