All inspections: Northern Lincolnshire and Goole NHS Foundation Trust

Northern Lincolnshire and Goole NHS Foundation Trust provides acute hospital services and community services to a population of more than 450,000 people across North and North East Lincolnshire and East Riding of Yorkshire. The trust has approximately 750 beds across three hospitals: Diana Princess of Wales (DPoW) Hospital at Grimsby in North East Lincolnshire, Scunthorpe General Hospital in North Lincolnshire and Goole and District Hospital (based in the East Riding of Yorkshire).

The leadership of the trust had improved since our last inspection in 2019 but this was not yet enough to make an impact on the trust overall rating, however, we did see some areas improvement in ratings for core services from our previous inspection. Members of the board articulated they felt much more enabled, supported, listened to and empowered to undertake their roles than previously. The leadership team led by the CEO and chair had identified that the trust needed to continue with existing plans and strategies in order to improve both the people’s experience of services and the culture within the organisation more broadly. This was a message we heard consistently throughout our inspection.

It was recognised by the board there had been challenges regarding the trust's organisational culture over the last few years. To address this, targeted and focused work had been undertaken with the board and executive team. The trust had made good progress in strengthening its operational financial management and governance arrangements but there was further work needed to ensure new arrangements and ways of working were embedded at all levels throughout the trust.

Whilst the improvements in leadership and culture were evident since our previous inspection, the trust recognised more work needed to be done to embed service improvements and for these changes to be reflected in positive patient outcomes. When inspecting the core services at the trust we saw that some of the changes that had happened at a senior level in the organisation had not yet become embedded at ward/department level. There continued to be a slow progress in some areas against our previous inspection findings particularly in urgent and emergency care, medicine and end of life.

Information and data overall were well managed across the trust. New systems had been developed to strengthen data collection, analysis and we saw evidence of information being used to drive improvements and demonstrate sustained successes. However, we did see instances on wards and departments where patient information was not stored securely.

The trust was committed to continually learning and improving services. Quality improvement methods had been introduced and staff understood the skills needed to use them, and the trust recognised that there was a need to sustain and continue this commitment to improvement overall.

Whilst we inspected during the COVID 19 pandemic the risks and concerns identified by CQC during the inspection were not the result of the immediate pressures faced by the trust as a result of the COVID pandemic. The trust has reported the long-lasting impact of the COVID 19 pandemic for the preceding two years. These included the significant impact on staffing, increase in overall attendances, sub-optimal patient flow throughout services, ambulance pressures, increased wait times, the prolonged period of command and control arrangements and service remodelling.

We carried out this unannounced inspection of acute services provided by this trust as part of our continual checks on the safety and quality of healthcare services and as at our last inspection we rated the trust overall as requires improvement. The trust was in special measures to help it improve

We also inspected the well-led key question for the trust overall.

Our rating of some services improved. We rated them as requires improvement because:

We rated safe, effective, responsive and well-led as requires improvement, and caring as good.
At Diana Princess of Wales Hospital, we rated six core services as requires improvement and one core service as good. At Scunthorpe General Hospital, we rated five core services as requires improvement and three core service as good. At Goole and District Hospital, all core services are now rated as good. In rating the trust, we took into account the current ratings of the services (including Community Services) not inspected this time.
Across most services there was still insufficient numbers of staff within the right qualifications, skills, training and experience to provide the right care and treatment. We observed issues in relation to staffing levels, vacancies and saw gaps in both nursing and medical rotas.
The services provided mandatory training in key skills to staff but had not ensured everyone had completed it. Across most services there were continued low levels of mandatory training.
Within urgent and emergency care people could not access the service when they needed it and continued to experience long delays waiting for treatment. The departments continued to experience long ambulance handover times as a result of access and flow issues.
Waiting times, referral to treatment and arrangements to admit, treat and discharge across several core services continued to be a challenge. We noted that that across both sites, there were long lengths of stay which impacted negatively on access and flow throughout the hospital.
The trust was continuing to develop a more open culture and improve communication with patients, their families and staff but there was more work required to progress this and have an impact.
Visibility of senior leadership team was variable across the services we inspected.

However:

We saw good examples of patients receiving compassionate care, with staff ensuring patients privacy and dignity was maintained. Patients and partners were happy with the care provided.
We saw that the trust had worked hard to improve performance in terms of elective pathways and complaints management.
Since the last inspection there had been a marked improvement in actions to address the backlogs for waiting times and reporting times within diagnostic services.

How we carried out the inspection

You can find further information about how we carry out our inspections on our website: www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

Our rating of this service improved. We rated it as good because:

The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
Staff provided good care and treatment in line with nationally recognised guidance. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information.
Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However:

Staff morale was low within the service. This was due to a protracted re-structuring process.
Patient’s post-operative blood pressure was not always recorded in the dental care records following intravenous sedation.
There had been some issues with the boiler at Cromwell Primary Care Centre. This had led to a lack of hot water for four days on one occasion. There had been a delay in reporting this as a significant event.

Our rating of the trust stayed the same. We rated it as requires improvement because:

We rated safe as inadequate. We rated effective, responsive and well led as requires improvement. We rated caring as good.
Our rating of Diana Prince of Wales Hospital stayed the same. We rated it as requires improvement. Of the nine services we inspected, we rated three as inadequate and we rated six services as requires improvement.
Our rating of Scunthorpe General Hospital stayed the same. We rated it as requires improvement. Of the nine services we inspected, we rated three as inadequate, five as requires improvement and one as good.
Our rating of Goole and District Hospital stayed the same. We rated it as requires improvement. Of the five services we inspected, we rated two as inadequate and three as good. Our decisions on overall ratings take into account the relative size of services. We have used our professional judgement to reach fair and balanced ratings.
Our rating of the trust’s community services stayed the same. We rated community health services as requires improvement. We rated one of the three services as requires improvement and two as good.
We rated well-led for the trust overall as required improvement.
We rated the trust’s use of resources as requires improvement.

Our rating of this service improved. We rated it as good because:

The service had made improvements to many areas of concern we identified at the last inspection.
The service had a vision for what it wanted to achieve and a strategy to turn it into action, developed with all relevant stakeholders. The vision and strategy were focused on sustainability of services and aligned to local plans within the wider health economy. This was an improvement since our last inspection.
The service managed patient safety incidents well. Staff recognised and reported incidents and near misses. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
The service used systems and processes to safely prescribe, administer, record and store medicines. The division had introduced a new pathway for prescribing governance and non-medical prescribers were now given the opportunity to discuss their prescribing history and report during supervision. Prescription pad use and storage was audited for all non-medical prescribers.
The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and development. Staff told us that supervision had improved since the last inspection.
Leaders and teams used systems to manage performance effectively. They identified and escalated relevant risks and issues and identified actions to reduce their impact. They had plans to cope with unexpected events. Staff contributed to decision-making to help avoid financial pressures compromising the quality of care.
Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. Staff provided emotional support to patients, families and carers to minimise their distress and supported and involved patients, families and carers to understand their condition and make decisions about their care and treatment.
Staff gave patients practical support and advice to lead healthier lives. Complex care matrons provided health coaching for patients with long term health conditions to empowered them to manage their own conditions and to promote their own health.

However:

The service did not always have enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. We found that most teams were in a better position with staffing than at our last inspection, however, some teams were still under pressure due to vacancies and high sickness levels. The service had mitigation in place to manage staffing issues.
People could not always access the service when they needed it and did not always received the right care in a timely way. Therapy staff in the care networks were not able to see patients within the recommended timescale and there were still long waits for patients to be assessed in the continence service. This was identified as an issue at our last inspection.

Our rating of this service went down. We rated it as requires improvement because:

The service did not have enough staff to meet national guidance. Key management roles were unfilled.
The service had not maintained its performance since our last inspection. For example, outcome measurement and local audit work had not taken place for the previous nine months, so leaders did not know how effective their service was.
Staff knew how to report incidents but these were not discussed systematically and team meeting minutes did not show evidence of discussion or learning from incidents.
There was no organisational strategy or vision.
Safeguarding and mandatory training rates were low, and below the trust target.
A specialist end of life service was not available 24 hours a day, seven days a week.
There was a lack of governance systems to oversee safety, performance and risk within the service.
Staff did not receive regular supervision, or in the case of the home care team, any supervision. Appraisal rates were below trust target which was something we had told the trust they must improve at our last inspection.
Complaints were not always acted upon in line with trust policy.
Rates of key training such as the use of syringe drivers to deliver medicine to people receiving end of life care, and mental capacity act training, were low, and where applicable, below trust targets.
Shortages of key equipment meant that electronic records were not always updated contemporaneously, and staff could not always access the systems they needed when working away from their base.

However:

Staff provided effective emotional support to patients and their families and feedback confirmed this.
Equipment was clean and available for use when needed. Staff working in patients’ homes used appropriate techniques and personal protection equipment to minimise the risk of spread of infection.
Staff worked well with other partners and teams both within and outside the trust.
There had been no complaints about the service in the last 12 months.
Staff felt respected, supported and valued, and were focussed on the needs of patients receiving care.
Mandatory training rates were good and staff met the target for eight of nine training modules.

Our rating of this service went down. We rated it as requires improvement because:

There had been many changes in leadership at all levels throughout the division which offered little stability or continuity to teams. Staff told us they rarely saw middle or senior managers but they did feel supported by their team leaders.
The service did not have a clear strategy for what it wanted to achieve.
Morale was generally low in the service and there was still a feeling amongst staff that the acute hospital side of the trust did not value them. Despite this, there was a sense of pride for the care they provided to patients.
The service had shortages in both nursing and therapy staffing which was having an impact on service delivery to patients.
The service was not always able to respond in a timely way to meet the needs of patients, especially in the continence service, unscheduled care and therapy services.
The service was still not consistently sharing feedback and learning from incidents. Individual staff said they rarely received feedback when they had reported an incident and we did not find any evidence of how learning was shared wider than local teams.
Non-medical prescribers were not receiving the necessary support and supervision to ensure they were prescribing safely and in line with best practice.
Appraisal rates for the service were not meeting the trust target of 95% and nursing staff were not receiving regular supervision to provide them with support and monitor the effectiveness of the service.
Staff we spoke with in community and therapy services were not aware of how to identify, record, highlight and share the information and communication needs of people with a disability or sensory loss. This meant the service was not meeting the Accessible Information Standard.

However:

We found compliance with mandatory training had improved since our last inspection. Staff we spoke with were up to date with their mandatory training and told us that they could access training easily.
Staff had a good understanding and knowledge of safeguarding and understood their roles and responsibilities under the Mental Capacity Act 2005. They knew how to support patients who lacked the capacity to make decisions about their care.
Staff treated patients with respect and maintained their dignity. We saw that staff had a good rapport with patients and relatives and involved them in decisions about their care and treatment.
We saw good examples of multidisciplinary and multiagency working.

We rated well-led as inadequate. We rated safe, effective and responsive as requires improvement. We rated caring as good.

Our rating of Diana Prince of Wales Hospital stayed the same. We rated it as requires improvement. We rated two of the hospital’s nine services as good, six as requires improvement and one as inadequate.

Our rating of Goole and District Hospital went down. We rated it as requires improvement. We rated three of the hospital’s five services as good, one as requires improvement and one as inadequate.

Our rating of Scunthorpe General Hospital improved. We rated it as requires improvement. We rated two of the hospital’s nine services as good, six as requires improvement and one as inadequate.

Our rating of the trust’s community services went down. We rated community health services as requires improvement. We rated two of the three services as requires improvement and one as good.

We rated well-led for the trust overall as inadequate. This was not an aggregation of the core service ratings.

Our rating of this service went down. We rated it as requires improvement because:

Some medical emergency equipment and medicines had passed their expiry date.
Contents of medical emergency kits were not in line with nationally recognised guidance.
Equipment was not always serviced appropriately.
The process for manually scrubbing used instruments did not reflect nationally recognised guidance.
The storage of re-usable dental burs did not reflect nationally recognised guidance.
The system for ensuring emergency equipment and medicines did not pass their expiry date was not effective.
An X-ray audit had not been completed since 2015 and the infection prevention and control audit had not identified the issues we identified during the inspection.

However:

Staff had the qualifications, skills, training and experience to keep patients safe. Incidents were reported and acted upon. Clinical records were clear, concise and accurate.
The service provided care and treatment based on national guidance and evidence of its effectiveness. Staff of different kinds worked together as a team to benefit patients. Staff understood their roles and responsibilities under the Mental Capacity Act 2005 and with regards to Gillick competence.
Staff cared for patients with compassion. We observed staff treating patients with dignity and respect.
The service took account of patients’ individual needs. The appointment system met patients’ needs. The service dealt with complaints positively and efficiently.
Managers promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. There was a clearly defined management structure. Managers were visible and approachable. Staff engaged with patients and other dental care professionals to continuously improve the service being provided.

Our rating of this service stayed the same. We rated it as good because:

The equipment and environment was visibly clean and had been serviced appropriately and marked as clean.
Centralised store rooms for medicines and equipment were locked securely. Unused medicines were disposed of appropriately.
Incidents were reported appropriately. There was good learning and a good proposed action plan from the one incident that we were notified of.
There were sufficient staff to carry out a good seven-day service for community end of life care.
The Macmillan specialist palliative care team demonstrated a good knowledge of the Gold Standard Framework and were supporting general practitioners to achieve this.
Staff discussed and advised about nutrition and hydration with patients and their families. We observed appropriate health promotion advice given.
Patients had anticipatory medicines in place to both treat and ease their symptoms in place should they experience them.
Most patients, who chose to do so, were able to die in their own home.
Staff new to the team were given a comprehensive induction package and continual support to ensure their competence. Staff had regular clinical supervision.
There was good multi-disciplinary team work. Documentation was completed correctly.
Staff had a good knowledge of the mental capacity act and deprivation of liberty safeguards procedures.
We observed that all staff were caring in their roles and nothing appeared too much trouble.
Patients were able to access complementary therapies to ease their symptoms should they wish.
Patients and their families were given sufficient information and time to both ask any questions and to have them answered satisfactorily.
There were no complaints about the service in the year prior to our inspection and all patients and their relatives were extremely positive about the care and support they received.
The service was well led and worked cohesively to the needs and wishes of the patients and their relatives.
We reviewed guidelines that were in date, such as new guidelines on patients’ differing spiritual and cultural needs in end of life care.

However:

We observed that some out of date guidelines and leaflets had not been removed from the intranet and as such there was a risk that staff could access out of date guidance. We escalated this to staff during our inspection and we were told it would be dealt with immediately.
We found one vial of out of date medicine in the medicines store.
We found nine blood sample bottles that were out of date.
The number of staff that had received an appraisal did not meet the trust target.

We carried out a follow-up inspection of Northern Lincolnshire and Goole NHS Foundation Trust from 22 to 25 November 2016 to confirm whether the trust had made improvements to its services since our last inspection, in October 2015. We also undertook unannounced inspections on 17 October and 8 December 2016.

To get to the heart of patients’ experiences of care and treatment we always ask the same five questions of all services: are they safe, effective, caring, responsive to people’s needs, and well-led? Where we have a legal duty to do so, we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

When we last inspected this trust, in October 2015, we rated the trust overall as ’requires improvement’. We rated safe, effective, responsive, and well-led as ‘requires improvement’. We rated caring as ‘good’. Scunthorpe General Hospital was rated as ‘inadequate’ overall, Diana Princess of Wales Hospital was rated as ‘requires improvement’ overall and Goole District Hospital was rated ‘good’ overall. In community services community adult services was rated as ‘requires improvement’ overall, end of life care was rated as ‘requires improvement’ overall, children’s and young people’s services was rated as ‘good’ overall with safe rated as ‘requires improvement’ and dental services was rated as ‘good’ overall.

Following the inspection in October 2015 there were six breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations. These were in relation to staffing, safe care and treatment, dignity and respect, premises and equipment, good governance and need for consent.

The trust sent us an action plan telling us how it would ensure that it had made improvements required in relation to these breaches of regulation. At this inspection we checked whether these actions had been completed.

In November 2016 we inspected:

Diana Princess of Wales Hospital
Scunthorpe General Hospital
Community Adult Services – safe and well led domains
Community end of life care services – effective, responsive and well led domains
Community children and young people’s services – safe domain

We did not inspect Goole District Hospital as the services provided at this hospital were rated as good in October 2015. We carried out a follow up inspection of community services and looked specifically at the domains that were rated as ‘requires improvement’ following the October 2015 inspection.

We rated Northern Lincolnshire and Goole NHS Foundation Trust as ‘inadequate’ overall. Safe and well led were rated as ‘inadequate’, effective and responsive were rated as ‘requires improvement’ and caring was rated as ‘good’. We rated Scunthorpe General Hospital as ‘inadequate’ overall. We rated Diana Princess of Wales Hospital as ‘requires improvement’ overall. We rated community services as ‘good’.

Key Findings:

There was insufficient management oversight and governance at Board, senior and middle management levels, of the identified risks and performance of the trust that has resulted in reoccurrence of patient backlogs and a deteriorating overall position with regard to referral to treatment times and patients waiting for follow up outpatient appointments and diagnostic tests in endoscopy.
The trust had a Board Assurance Framework (BAF) and a corporate risk register in place, there were concerns that the risks recorded remained on the BAF for prolonged periods of time even after mitigations had been put into place. There were 24 risks recorded on the BAF of which many were rated as amber. There were concerns that the right assurances were not in place.
There were concerns regarding the capacity and capability of the divisional management teams specifically with regard to the recognition, recording and mitigation of risks within the core services and ensuring timely action to address risks.
We found poor leadership and oversight in a number of services, notably maternity services and urgent care. In these services leaders had not led and managed required service improvements robustly or effectively. In addition service leads had tolerated high levels of risks to quality and safety without taking appropriate and timely action to address them.
There was some improvement in strengthening of governance processes across the trust. However, there were gaps in how outcomes and actions from audit of clinical practice were used to monitor quality in some services.
Nursing and medical staffing had improved in some areas since the last inspection. However, there were still a number of nursing and medical staffing vacancies throughout the trust, staff turnover in some areas were particularly high especially in medical care, emergency departments, surgical services, and services for children and young people.
The trust had systems in place to manage staffing shortfall as well as escalation processes to maintain safe patient care. However, a number of registered nurse shifts remained unfilled despite these escalation processes and we saw examples of wards not meeting planned staffing levels and high patient acuity not identified appropriately.
There had been a lack of improvement since the inspection in 2015, areas of concern had not been fully addressed in a sustained way and there had been deterioration in a number of services. Safety processes were not always adhered to in some services.
Assessing and responding to patient was risk was inconsistent and did not support early identification of deterioration. This was particularly evident in the Emergency Department (ED) at Scunthorpe General Hospital (SGH), where the national early warning scores (NEWS) were not recorded in the majority of records we reviewed and in maternity services.
Paediatric Early Warning Score (PEWS) was not in use in the ED at SGH and although used at DPoW, had not been consistently completed, following a review of records. We were not assured that the identification and escalation of deterioration in a child’s condition would be recognised.
The standard of documentation was variable, for example in ED across both sites we reviewed a total of 56 sets of patients’ records (37 adults and 19 children) fully and found completion of documentation was variable and at times inadequate to ensure delivery of safe care.
We found poor infection prevention and control processes and standards of cleanliness in the ED at SGH. Mandatory training rates in infection control were variable across the trust with low rates in the area where concerns were identified.
In 2015, we said that the trust must ensure there is an effective process for providing consistent feedback and learning from incidents. During this inspection learning from incidents remained inconsistent and variable between directorates. Staff we spoke to, reported a varying standard of feedback and learning from incidents.
We found inconsistent practice with regard to resuscitation trolley checks, fridge temperature checks and medication checks, across the trust.
The trust had significant access and flow issues which had not changed since the inspection in 2015. The trust performance with referral to treatment times and management of capacity and demand had shown either no or minimal improvement since 2015. The trust was not meeting the 4-hour waiting tome target in ED.
Patient flow through the hospital remained an issue with a significant number of patients cared for on non-medical or non-speciality wards. A ‘buddy ward’ system was in place, however there was still confusion regarding which consultant should review which patient. Patients who were moved more than once could be under the care of different consultants during their stay in hospital.
Not all management teams had a detailed understanding of the performance data, an ability to plan capacity to meet demands on services or credible recovery plans that would address the areas of concern.
In 2015, we raised concerns regarding the numbers and reporting processes of mixed sex breaches. The trust had updated the policy for eliminating mixed sex accommodation, which was in line with Department of Health guidance (November 2010). However, the trust has continued to report mixed sex breaches in a number of core services. For example in medicine at Scunthorpe 14 mixed sex breaches had been reported.
The trust participated in national and local audit programmes however trust performance was mixed across most of the core services with many showing performance that was worse than England averages. There was also variation in patient outcomes between the two hospital sites.
The endoscopy unit had lost their Joint Accreditation Group (JAG) accreditation in August 2016 due to an audit that was not submitted within the necessary timescales and communication issues.
In maternity services we had concerns regarding the completion of the K2 training package (an interactive computer based training system that covered CTG interpretation and fetal monitoring) for midwives and medical staff in maternity.
Concerns remained regarding the organisational culture. There were a number of themes that emerged from discussions with staff relating to there still being a disconnection between the executive team and staff, there was a sense of fear amongst some staff groups regarding repercussions of raising concerns and bullying and harassment. Feedback from management teams had a more positive focus.

However,

The hospital-level mortality indicator (SHMI) statistics from July 2015 to June 2016 showed that the SHMI remains in the ‘as expected’ banding with a figure of 110.
The trust had taken action in some areas since the 2015 inspection, for example the trust had stopped using Band 4 nurses awaiting professional registration numbers within the registered nurse establishment.
Improvements had been made across the community services for adults, children and young people’s services and end of life care. There were robust safeguarding processes in place for both adults and children in community services.
We saw pathways in place that complied with the National Institute for Health and Care Excellence (NICE) guidelines, professional and local guidelines.
New roles had been developed including Assistant Nurse Practitioners and Acute Care Physicians.
There were improvements in critical care services, there was a clear vision and governance processes were effective.
There was a new management team in surgery that were able to demonstrate an understanding of the challenges and the areas that required further improvement. They had only recently come into post and had not had sufficient time to implement the changes required to address the ongoing concerns.
There were improvements in the ophthalmology service specifically with regard to the cancellation of clinics and clinical oversight of this process.
The trust was in the process of expanding the nursing teams for people living with dementia and who had learning disabilities.
Overall we observed staff treating patients with dignity and respect. Patients told us staff were caring, attentive and helpful. Staff responded compassionately to pain, discomfort and emotional distress in a timely and appropriate way.

We saw areas of good practice:

There was a new initiative called the virtual ward. Two health care assistants were available all day Sunday to Friday and half days on Saturdays. They were deployed to an elderly medical ward at the start of their shift, and then re-deployed to any area with short notice absence or where one to one patient care was required.
A online call service run by the infant feeding co-ordinator was being offered to support breast feeding mothers within the community setting.
The development of Advanced Midwifery Practitioners and Advanced Nurse Practitioners in gynaecology.
There was a dedicated member of staff to manage interpretation and translation services which also included British Sign Language based at the Diana Princess of Wales hospital (DPoW).
The trust had started to use “John’s campaign” which was being trialled on four wards.
A member of the speech and language therapy staff had received a Health Service Journal award for innovative work on voice banks.
Podiatry services had developed training sessions for patients to care for their own feet if this was considered appropriate. Patients were discharged if this was successful and waiting lists had fallen. We were told that there was to be a cross site review of podiatry services to improve patient access.

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

The trust must ensure that appropriate numbers of staff, both medical and nursing, are available in line with national guidance and patient acuity and dependency, specifically within surgery, medicine, maternity, and to meet the needs of children and young people being cared for, on both the paediatric wards and in ED.
The trust must improve the numbers of all staff receiving an annual appraisal and supervision, especially in children’s wards, surgical areas and the ED, and the actions identified in the appraisals are acted upon.
The trust must ensure that the service risk registers are regularly reviewed, updated and include all relevant risks to the service.
The trust must monitor and address mixed sex accommodation breaches.
The trust must continue to improve its paediatric early warning score (PEWS) system to ensure timely assessment and response for children and young people using services.
The trust must ensure that, following serious incidents or never events, root causes and lessons learned are identified and shared with staff, especially within maternity and surgery.
The trust must ensure that effective processes are in place to enable access to theatres out of hours, including obstetric theatres, and that all cases are clinically prioritised appropriately.
The trust must ensure that the five steps to safer surgery including the World Health Organisation (WHO) safety checklist is implemented consistently especially within maternity and surgery.
The trust must ensure there are effective planning, management oversight and governance processes in place, especially within maternity, ED and outpatients. This includes ensuring effective systems to implement, record and monitor the flow of patients through ED, outpatients and diagnostic services.
The trust must ensure the proper and safe management of medicines including: checking that fridge temperatures used for the storage of medication are checked on a daily basis in line with the trust’s policy.
The trust must ensure that there are effective processes in place to support staff and that staff are trained in the recognition of safeguarding concerns including all staff caring for children and young people receiving the appropriate level of safeguarding training and in outpatient services.
The trust must ensure that actions are taken so enable staff to raise concerns without fear of negative repercussions.
The trust must ensure that a patient’s capacity is clearly documented and where a patient is deemed to lack capacity this is assessed and managed appropriately in line with the Mental Capacity Act (2005).
The trust must ensure that policies and guidelines in use within clinical areas are compliant with NICE or other clinical bodies.

Emergency and Urgent Care

The trust must ensure that there are the appropriate systems in place to maintain the cleanliness of the ED at SGH to prevent the spread of infections.
The trust must ensure that effective timely assessment and/or escalation processes are in place, including the use of the National Early Warning Score (NEWS) system, so that patients’ safety and care is not put at risk, especially within ED.
The trust must ensure that timely initial assessment of patients arriving at the ED takes place and that the related nationally reported data is accurate.
The trust must ensure that ambulance staff are able to promptly register and handover patients on arrival at the ED.
The trust must ensure that patients are assessed for pain relief; appropriate action is taken and recorded within the patients’ notes.
The trust must ensure that patients in ED receive the appropriate nursing care to meet their basic needs, such as pressure area care and being offered adequate nutrition and hydration and, that this is audited.
The trust must ensure the checking of controlled drugs and the safe storage of medications used by the ‘streaming’ nurse in ED at DPoW hospital are in line with trust policy.

Critical Care

The trust must audit compliance with NICE CG83 rehabilitation after critical illness and act on the results.
The trust must review and reduce the number of non-clinical transfers from ICU.

Maternity

The trust must take steps to ensure that appropriate numbers of suitably qualified and experienced midwifery staff and medical staff are available to meet the needs of women being cared for by the service.
The trust must ensure that labour ward coordinators are supernumerary.
The trust must ensure that effective timely assessment and/or escalation processes are in place, including the use of the Modified Early Obstetric Warning Score (MEOWS).
The trust must continue to improve obstetric skills and drills training among medical staff working in obstetrics.
The trust must continue to improve midwifery and medical staff competencies in the recognition and timely response to abnormalities in cardiotocography (CTGs) including the use of ‘Fresh eyes’.

Children and Young People’s Service

The trust must ensure the number of staff who have received training in advanced paediatric life support, is in line with national guidance and the trust’s own target.

Outpatients and Diagnostic Imaging

The trust must complete the clinical validation of all outpatient backlogs and continue to address those backlogs, prioritised according to clinical need.
The trust must continue to take action to reduce the rates of patients who do not attend (DNA).
The trust must continue to take action to reduce the numbers of cancelled clinics.
The trust must continue to strengthen the oversight, monitoring and management of outpatient bookings and waiting lists to protect patients from the risks of delayed or inappropriate care and treatment.
The trust must continue to work with partners to address referral to treatment times and improve capacity and demand planning to ensure services meet the needs of the local population.

There were also areas of poor practice where the trust should make improvements, which are detailed at the end of this report.

On the basis of this inspection, I have recommended that the trust be placed into special measures.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Northern Lincolnshire and Goole NHS Foundation Trust provided services to children and young people up to the age of 19 across North Lincolnshire. The organisation provided a range of services including the family nurse partnership, health visiting, community children’s nursing, looked after children’s team and paediatric therapy services. These services were provided in people’s home, schools, clinics and children’s centres throughout the local area.

Children and young people under the age of 20 made up 23.2% of the population in North Lincolnshire and 11.2% of school children were from a minority ethnic group. The health and well-being of children in North Lincolnshire was mixed when compared with the England average. Infant and child mortality rates were similar to the England average. The level of child poverty was worse than the England average with 19.8% of children under the age of 16 living in poverty. The rate of family homelessness is better than the England average. Childhood obesity levels are in line with the England average; 9.7% of children aged 4-5 years and 20.7% of children aged 10-11 years.

We visited eight locations across the Northern Lincolnshire area. We attended two baby clinics, health visitor bases, children’s therapy bases, the child development centre, and the looked after children’s team, a monthly health visiting team meeting and with parents’ permission, went on three home visits.

We spoke with 46 members of staff, including senior managers and team leaders, health visitors, therapists, specialist nurses, administration and support staff. We did not inspect the school nursing service, as this was not provided by the trust.

Therapy services had moved to electronic records. We were shown how information was inputted and stored on the system and reviewed two electronic records for therapy services and ten records for health visiting.

During our last inspection in October 2015 we rated end of life care as requires improvement for effective, responsive and well-led because:

There was no internal end of care strategy for Northern Lincolnshire and Goole NHS trust.
The trust had taken part in the 2014 National Care of the Dying Audit (NCDAH) and achieved three out of seven organisational key performance indicators (KPI’s). In relation to clinical KPI’s, the trust was better than the England average in only one out of ten areas. It was worse than average in eight out of ten areas, including communication regarding the patient’s plan of care for the dying phase.
We noted that national guidance was not followed in as much as the ‘do not attempt cardiopulmonary resuscitation’ forms (DNACPR) were not audited in the community. It was not known therefore whether decisions were made appropriately or if they were documented clearly.
There had been a significant number of end of life patients (600) admitted to hospital who had died within 24 hours who could have died at home with responsive support.
Staff told us the delivery of care in someone’s preferred place was a priority, however there was no data to support this as no audits had taken place.
Arrangements for monitoring quality of services could be improved; there were gaps in service performance measures. This meant it was harder for the trust to take action to improve performance and the delivery of the service.
We found there was disconnection between the trust board and staff in the community.

At this inspection, we rated this service as good. This was because:

The trust had been part of a multi-agency group that was set up to devise and implement an end of life care strategy that encompassed the whole of the local health economy. We looked at the document and found that the vision and purpose of the strategy was to ensure that appropriate care was provided in the appropriate setting at the right time, and to ensure that access to care was seamless and easy, and that the patient’s needs and wishes were central.
Following ratification of the end of life care strategy in June 2016, seven work streams had been developed by the trust, with a member of the senior team having overall responsibility for a sub-working group. These included working groups on; education, bereavement, palliative care, do not attempt resuscitation, long-term conditions, IT, and children and neonatal. Each group met separately and we saw action plans that had been developed, to meet the required outcomes of the strategy. This meant that arrangements for monitoring the quality of services was improving and the trust were taking action to address actions identified from the work streams’ data collection and the National Care of the Dying Audit.
We saw that since our last inspection the number of patients receiving care at the end of life who had died at home had increased whilst the number of patients who had died within the hospital setting had significantly reduced.

During this inspection, we rated this service as good overall. This was because there had been improvements since our last inspection in October 2015. At our previous inspection, we rated safe and well led as requires improvement because:

We found that cleaning schedules were not completed and equipment was out of date for electrical safety testing and maintenance in line with manufacturers’ recommendations. We also saw a policy relating to the use of equipment that was out of date.
Mandatory training compliance was variable with one service only achieving 33% compliance for resuscitation training. This was not identified as a risk and we did not see any plans in place to address this.
Medicines management in relation to controlled drugs was of concern. Staff we spoke with used different methods when disposing of controlled drugs that were no longer required by a patient. When asked, the trust failed to provide evidence that policies were in place to protect patients and staff. We also found medications and hazardous substances in unlocked cupboards at a clinic location.
Staff knew their responsibilities and their role in reporting incidents to make sure they made improvements when things went wrong. We found that reported incidents were investigated however, there was limited evidence from operational staff and team meetings of any lessons learned being shared within teams.
Staff reported a disconnect between community and hospital services.

During this inspection we found:

Mandatory training figures had improved across adult community services however overall teams had not reached the trust target of 95%.
The service prioritised protecting patients from avoidable harm and abuse. Incident reporting was good but greater evidence, that lessons learned were shared across the trust, was required.
We saw a clear policy in place for the management of controlled drugs, to support staff and protect patients. This included the storage and disposal of medicines in the patient’s own home. Staff were aware of this policy and this had begun to be audited monthly.
Record keeping had improved with the use of electronic systems. A recent audit had shown 100% compliance for legible entries and 95% for contemporaneous entries. However, some services were not detailing patient’s religious or spiritual needs.
Business continuity plans were available for all services and staff were aware of these.
Major incident training was provided by the trust for community service staff. There had been a major information technology incident prior to our inspection which staff told us had been dealt with well by managers.
Staff described the vision and strategy for community services and those of their own service, which included local and national developments.
The management structure for community services had been reconfigured in November 2015. Staff we spoke with said that the changes had been positive and they felt more involved in decisions about service provision.
The disconnect between acute and community services had improved with the reconfigured structure however some staff told us that this still required improvement.
Staff told us that their immediate managers were supportive and visible but that they did not see the higher management team very often.
There was a risk register for the service. We saw risks were reviewed at the community and therapy service governance meetings.

Overall rating for this core service: Requires Improvement

We found end of life care to ‘require improvement’ overall. Safe and caring were rated as ‘good’; however, effective, responsive and well-led were rated as ‘requires improvement’.

There was no trust specific end of life strategy or related performance indicators to measure the success of the end of life care services. However, the trust told us they were part of the wider health economies’ strategic groups for end of life care. We found staff were not aware of a vision for end of life care nor what was in place to monitor of the quality of the service provided. The newly-appointed chief nurse was the board lead for end of life care and had previously chaired the end of life strategy group. A non-executive director had been recently identified to provide board support and challenge. The trust had also acknowledged the need for senior clinical leadership and had recently appointed its first two palliative care consultants. Whilst the team were very positive and work had started there was more to do before the impact for patients could be evidenced.
Information provided by the trust indicated that last year, 600 patients from home or care homes died within 24 hours of admission to hospital. In the absence of advanced care plans and seven day specialist services, patients were admitted to hospital rather than spending their final hours at home. The trust had since taken action to deliver a seven-day specialist palliative care service in the community.
The trust had taken part in the 2014 National Care of the Dying Audit (NCDAH) and achieved three out of seven organisational key performance indicators (KPIs). In relation to clinical KPIs, the trust was worse than average in eight out of ten areas, including communication regarding the patient’s plan of care for the dying phase. The trust had taken action on the results of the audit and an individualised care plan and ‘last days of life assessment and care plan’ were being piloted.
We found there was disconnection between the trust board and staff in the community. We observed positive leadership at a local level in the community. Service leaders were visible and approachable. Staff were proud of the care they were able to give and received positive feedback from patients, families and carers; they told us senior managers did not acknowledge this.

However we also found;

There was a multidisciplinary team approach to end of life care in the community. This meant specialist palliative care nurses, community nurses, Macmillan healthcare support workers, therapists, social workers and doctors all worked together for the benefit of patients and their families. Staff kept patients at the end of life safe and protected them from avoidable harm. They followed procedures to support safe care for patients. We saw evidence that staff reported incidents of harm or risk of harm and managers reviewed the reports and identified lessons to be learned to help prevent future incidents. Staff gave medicines to relieve pain and other symptoms correctly and in a timely way.

Staff assessed patients and managed risks as part of an ongoing holistic assessment process. Staff made good use of individual risk assessments for patients receiving end of life care. Senior nurses had advanced communication skills and could speak with patients and families about resuscitation and sign DNACPR forms (do not attempt cardiopulmonary resuscitation).
Community teams were quick to respond to patient need and referrals were prioritised based on need. Specialist staff delivered training to care homes and home care staff to improve the effectiveness of the care they gave. All community nurses were trained in non-medical verification of an expected death; which meant bereaved families did not have to wait for a doctor to attend.
We found positive innovation in using a Macmillan healthcare team to deliver end of life care in the community and the inclusion of a clinical psychologist in community service.

We inspected Northern Lincolnshire and Goole NHS Foundation Trust from 13 – 16 October 2015 and performed an unannounced inspection on 6 November 2015 and the 5 January 2016. This inspection was to review and rate the trust’s community services for the first time using the Care Quality Commission’s (CQC) new methodology for comprehensive inspections.

The acute hospitals had been inspected under the new methodology in April 2014, we therefore carried out a focussed inspection of the core services that had been previously been rated as “inadequate” or “requires improvement”. Due to additional information the inspection team also inspected maternity services and caring across the core services included this inspection.

Focused inspections do not look across a whole service; they focus on the areas defined by the information that triggers the need for the focused inspection. We therefore did not inspect children and young people’s services or end of life services within the hospitals at the follow up inspection. Additionally not all of the five domains: safe, effective, caring, responsive and well led were reviewed for each of the core services we inspected. We inspected the effective domain in A&E and the minor injuries unit as it had not been rated in the previous inspection. We inspected diagnostic imaging services across all three sites as these had not been previously inspected in 2014.

At the inspection in April 2014 we found the trust was in breach of regulations relating to patient care and welfare, staffing, premises, staff support and governance.

Overall at the October 2015 inspection we rated the trust as "required improvement" overall. The trust was rated as “good” for being caring. The trust was rated “required improvement” in the domains of safe, effective, responsive and well-led. The core service of outpatients was rated inadequate at Scunthorpe General Hospital (SGH) and Diana Princess of Wales (DPoW) hospital. There was evidence of harm to patients within the outpatient services because of poor management of the follow up appointment system. There were no significant concerns identified within the diagnostic services we inspected where we found patients were protected from avoidable harm and received effective care.

The community services we rated as good for dentistry and children’s services with community health services for adults and end of life care, rated as required improvement. Scunthorpe General Hospital was rated inadequate overall, Diana Princess of Wales Hospital was rated as required improvement overall and Goole Hospital was rated as good overall.

Our key findings were as follows:

We were assured by the quality of the governance arrangements in place. However, we were significantly concerned that these governance arrangements were not either widely understood, applied or embedded to ensure the delivery of high quality care.
We found within the trust there had been improvements in some of the services and this had meant a positive change in some of the ratings from the previous CQC inspection notably within critical care at Diana Princess of Wales hospital. However we found that the services in A&E at Scunthorpe, outpatients and surgical services had either not improved or had deteriorated since our last inspection.
There were significant gaps in the medical rotas for some specialities: both A&E and critical care services were not staffed in line with nationally recommended levels of consultants and A&E was not staffed to the trust’s own recommended levels. The medical cover overnight at Scunthorpe was delaying care and treatment of some patients.
Whilst the trust was actively recruiting to nursing posts, there remained a high number of nursing posts vacant on a significant number of wards and other services. Shift co-ordinators on each ward also had a cohort of patients to care for. On most wards there were two registered nurses overnight; frequently one of these would be bank or agency. We saw examples of delayed care and staff who were not familiar with ward environments and specialities. This was raised at the time of inspection and the trust are undertaking a review of nurse staffing and developing the shift co-ordinator role.
There was a backlog of patients requiring outpatient follow up and high levels of clinic cancellations resulting in patients being cancelled on multiple occasions. There was a lack of clinical involvement in the cancellation process and a lack of clinical validation of the patients who were waiting for follow up appointments.
There was lack of oversight and accountability of the outpatient processes and associated backlogs with actions slow and lacking sufficient senior managerial involvement at core service level. The issues regarding outpatient backlogs was raised at the inspection. The trust took immediate action and provided monitoring information which indicated that all 30,000 patients in the backlog had been reviewed and validated by 31 December 2015.
There were gaps in learning from incidents in almost all acute and community services. There were systems and processes in place to support the dissemination of learning. However staff told us that they did not receive or access feedback/learning from incidents. We were therefore not assured that learning from incidents was effective.
At the time of the inspection the trust was a mortality outlier for deaths from acute bronchitis and cardiac dysrhythmias.
The Summary Hospital-level Mortality Indicator (SHMI) for the trust was 111 which was higher than the England average (100) in June 2014. For the period July 2014 – June 2015 the SHMI was 109.7 which was within the ‘as expected range’ nationally. The SHMI is the ratio between the actual numbers of patients who die following hospitalisation at the trust and the number that would be expected to die on the basis of average England figures, given the characteristics of the patients treated there.
The Hospital Standardised Mortality Ratio (HSMR) was 99.2 which was similar to the England ratio (100) of observed deaths and expected deaths.
Staff were not aware of how to record minimum and maximum temperatures for medication fridges; what the recommended range was or that this was necessary for safety and efficacy of medicines. We saw several examples where a temperature had been recorded outside of recommended range but no action had been taken.
There was not sufficient resource identified including specialist staff, training and systems in place to care for vulnerable people, specifically those with learning disabilities and dementia. However, there was a highly motivated and compassionate quality matron who had the lead for dementia and also learning disabilities.
There had been managerial change within critical care which was beginning to have a positive impact with regard to development of the service. There had been significant improvements in the delivery and location of high dependency services at the DPoW hospital since the initial comprehensive inspection of 2014.
At our inspection in April 2014 we found that not all clinical staff who required level 3 safeguarding of children training had received it. At this inspection, we found that clinical staff were now in the process of being trained up to level three in safeguarding children. However, the numbers of staff who had received the level three training was below the trust’s 95% target. The records provided to us by the trust showed that no medical staff in the emergency department had undertaken level three safeguarding children training.
Community nurses were not aware of policies and procedures in relation to the management and disposal of controlled drugs in patients’ own homes. Staff we spoke with used different methods to dispose of drugs that were no longer required by a patient.
There appeared to be a disconnect between acute and community services. Staff told us that the community services staff voice was not heard at board level and many did not feel they were part of the trust.
There was no trust specific end of life strategy or related performance indicators to measure the success of the end of life care services. We saw that national guidelines were used by staff however it was not possible to tell if patients’ preferences at end of life were met, as outcomes such as preferred place of care, were not measured. However, the trust were part of the wider health economies’ strategic groups for end of life care.
Community dental services were effective and focused on the needs of patients and their oral healthcare.
There was a lack of evidence that an acuity tool was used to allocate caseloads to health visitors and staff were not aware that there was not a designated doctor for the looked after children’s team. Additionally three-monthly safeguarding supervision had not been taking place for health visitors, which did not meet guidance.

We saw several areas of outstanding practice including:

The dental health education team developed a package of resources offering oral health promotion support and training to dental practices in the North Lincolnshire region. This online learning package enabled dental professionals to earn continuing professional development hours as part of the General Dental Council requirements to maintain their registration. They could also use the resources to take part in a strategy called ‘making every contact count’, aimed at improving the community’s oral health.
There was a highly motivated and compassionate quality matron who had the lead for dementia and also learning disabilities.
The development of a pressure sore assessment tool known as a ‘pug wheel’ to support staff in the accurate identification of pressure damage. This had been developed by the tissue viability team.
The Frail Elderly Assessment and Support Team gave elderly patients, immediate access to physiotherapy / occupational therapy assessment as well as nursing and medical assessment. Social services would also be involved in assessment with the aim of providing immediate treatment / assessment and initiation of community based care or services. The aim of this service was that patients should be able to return to their usual place of residence with the support of community services.

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

Action the trust MUST take to improve acute services:

The trust must ensure that there are sufficient numbers of suitably skilled, qualified and experienced staff in line with best practice and national guidance, taking into account patients’ dependency levels. This must include but not be limited to: medical staff within the emergency department (ED) and critical care, nursing staff within ED, medicine and surgery. It must also include a review of dedicated management time allocated to ward co-ordinators and managers. It must ensure adequate out of hours anaesthetic staffing to avoid delays in treatment. The trust must ensure there are always sufficient numbers of radiologists to meet the needs of people using the radiology service.
The trust must ensure that the significant outpatient backlog is promptly addressed and prioritised according to clinical need. It must ensure that the governance and monitoring of outpatients’ appointment bookings are operated effectively, reducing the numbers of cancelled clinics and patients who did not attend, and ensuring identification, assessment and action is taken to prevent any potential system failures, thus protecting patients from the risks of inappropriate or unsafe care and treatment.
The trust must ensure that all risks to the health and safety of patients with a mental health condition are removed in Scunthorpe emergency department (ED). This must include the removal of all ligature risks, although must not be limited to the removal of such risks. The trust must undertake a risk assessment of the facilities (including the clinical room and trolley areas, but not be limited to those areas), with advice from a suitably qualified mental health professional.
The trust must ensure that the recently constructed treatment rooms at Scunthorpe ED that were previously used as doctors’ offices are suitable for the treatment of patients on trolleys. This must include ensuring that such patients can be quickly taken out of the room in the event of an emergency.
The trust must ensure that staff at core service/divisional level understand and are able to communicate the key priorities, strategies and implementation plans for their areas.
The trust must improve its engagement with staff to ensure that staff are aware, understand and are involved in improvements to services and receive appropriate support to carry out the duties they are employed to perform.
The trust must ensure there are timely and effective governance processes in place to identify and actively manage risks throughout the organisation, especially in relation to critical care and ensuring the equipment is included in the trust replacement plan.
The trust must ensure it acts on its own gap analysis of maternity services across the trust to deliver effective management of clinical risk and practice development.
The trust must have a process in place to obtain and record consent from patients and/or their families for the use of the baby monitors in critical care and for the use of CCTV in coronary care.
The trust must ensure the safe storage and administration of medicines including the storage of oxygen cylinders on the intensive care unit at DPoW hospital. The trust must ensure staff check drug fridge temperatures daily and record minimum and maximum temperatures. Additionally it must ensure staff know that the correct fridge temperatures to preserve the safety and efficacy of drugs and what action they need to take if the temperature recording goes outside of this range. Patient group directions for medications within ED must be reviewed and in date.
The trust must ensure equipment is checked, in date and fit for purpose, including checking maternity resuscitation equipment and critical care equipment is reviewed and where required, included in the trust replacement plan.
The trust must ensure that action is taken to address the mortality outliers and improve patient outcomes in these areas.
The trust must ensure there is a robust process for providing consistent feedback and learning from incidents.
The trust must review the validation of mixed sex accommodation occurrences, ensure patients are cared for in an appropriate environment and report any breaches.
The trust must ensure the reasons for Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR) are recorded and is implemented in line with best practice within surgical services.
The trust must ensure the Five Steps for Safer Surgery including the WHO check list is consistently applied and practice is audited.
The trust must review the effectiveness of the patient pathway from pre-assessment through to timeliness of going to theatre, and the number of on the day cancellations for patients awaiting operations.
The trust must ensure policies and guidelines in use within clinical areas are compliant with NICE or other similar bodies.
The trust must ensure there are adequate specialist staff, training and systems in place to care for vulnerable people specifically those with learning disabilities and dementia.
The trust must stop including newly qualified nurses awaiting professional registration (band 4 nurses) within the numbers for registered nurses on duty.
The trust must ensure it continues to improve on the number of fractured neck of femur patients who receive surgery within 48 hours The trust must ensure that staff, especially within surgery, have appraisals and supervision, and that actions identified in the appraisals are acted upon.

Action the trust MUST take to improve community services:

The trust must ensure three-monthly safeguarding supervision takes place for health visitors.
The trust must ensure all staff are up to date with appraisal and mandatory training.
The trust must ensure it has an end of life care vision and strategy in place supported by key performance indicators that reflects national guidance and ensure staff are included in the development of these.
The trust must have effective systems in place to assess, monitor and improve the quality of the end of life care services, including auditing preferred place of care and other patient outcomes.
The trust must ensure that all community equipment is tested for electrical safety and evidence is available to show that equipment is serviced in line with manufacturers recommendations.
The trust must ensure that all substances which could be harmful are stored appropriately, specifically within the Ironstone Centre.
The trust must ensure that procedures for managing controlled drugs in patients’ homes are standardised and all staff follow guidelines for the safe management and documentation in relation to controlled drugs.
The trust must ensure that record keeping meets all appropriate registered body standards.

Additionally there were other areas of action identified where the trust should take action and these are listed at the end of each report.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Overall rating for this core service: Requires Improvement

We found community health services for adults to be ‘requires improvement’ overall. Effective, caring, and responsive were rated as ‘good’. Safe and well-led were rated as ‘requires improvement’.

The service prioritised protecting patients from avoidable harm and abuse. Incident reporting was good but there was a lack of evidence from operational staff that lessons learned and changes to practice were shared and implemented.

All areas we visited were visibly clean and well maintained however; cleaning schedules were incomplete in most areas we visited. We found limited evidence in relation to the electrical ‘PAT’ testing and servicing of some medical devices and equipment used when treating patients. We requested specific evidence from the trust but this was not provided. This included the servicing details for electric patient plinths and other fixed equipment at the Ironstone centre. We also requested a copy of the policy for the washer disinfector at the Ironstone centre because the one we saw was due to be reviewed in 2007, again this was not provided.

Medicines management in relation to controlled drugs was of concern. Community nurses were not aware of any policies in relation to the management of controlled drugs and when requested the trust failed to provide evidence that policies were in place to protect patients and staff.

Paper-based record keeping was variable between services with some staff groups not complying with the recommended minimum standards set by their registered body. We found better compliance with electronic records.

Mandatory training compliance was variable between services. Some teams displayed 100% compliance whilst for others compliance was low, for example, 33% for resuscitation training which was well below the trust target.

Business continuity plans were available for all services and staff were aware of these. Major incident training was provided by the trust for community service staff.

Staff were able to access information on the trust intranet and used guidelines to maintain and refresh their practice skills. There was little evidence that community services contributed to local or national audit, other than a record keeping audit that we saw and the national stroke audit. We asked the trust for evidence of community service audits but did not receive any data to show that local and national audit or benchmarking was completed other than those mentioned. Staff were not aware of any action plans or learning as a result of these audits. However, we saw that an action plan had been created following the record keeping audit.

We saw a variety of patient information leaflets provided by the trust, which explained patient conditions and after care arrangements in all areas that we visited. Patients gave good feedback about the care and treatment they received from staff. We observed staff treating patients with dignity, respect and compassion during our inspection.

Staff were not able to describe any overarching vision or strategy for community services. Some teams shared with us the visions they had for their own services but a senior member of staff told us that they received little or no feedback from the senior team for example when business cases, to support new initiatives, were submitted. Information provided by the trust post-inspection, showed that there had been a recent consultation programme outlining the rationale and service changes that were planned. This had included roadshows for staff being held. Staff we spoke with told us that they were aware that services were being reconfigured.

There appeared to be a disconnect between acute and community services. Some senior staff reiterated this; a matron told us that she felt the community voice had not been heard but that she was championing the services to ensure that this improved. Staff told us that their immediate managers were supportive and visible but that they did not see the higher management team very often. The management structure for community services had been recently reconfigured with the new structure due to come in place on 1st November 2015. Staff we spoke with knew about the changes that were taking place. There was a risk register for the services. Managers were aware of the risks however, there was no evidence to indicate that any action was being taken at trust level to mitigate or resolve the risks. There was a clear governance structure however; the governance processes and feedback were not embedded within the community service teams.

Overall rating for this core service Good

We found community health services for children, young people and families to be ‘good’ overall. Effective, caring, responsive and well-led were rated as ‘good’. Safe was rated as ‘requires improvement’.

Care and treatment was evidence based and staff were competent. The organisation had implemented evidence based programmes, such as the family nurse partnership programme. There were policies and procedures in place to support staff and these could easily be accessed.
There was good evidence of multidisciplinary and multi-agency working across the services.
Staff were motivated and focused on providing high quality care with positive comments given by the patients we spoke with. Services were planned and delivered to meet the needs of the local population in line with the commissioning framework of the organisation.
There were support networks in place to ensure children and young people were protected and Staff worked hard to meet the needs of children and families in vulnerable circumstances.
The senior management team were clear on the vison to provide a collaborative approach to working across the whole trust. Managers were visible and accessible and there was a focus on seeking the views of service users.

However, we rated the safe domain as ‘requires improvement’ because:

Many staff were not aware of learning or feedback from incidents.
There was a lack of evidence that an acuity tool was used to allocate caseloads to health visitors, and staff were not aware that there was not a designated doctor for the looked after children’s team.
Three-monthly safeguarding supervision had not been taking place for health visitors, which did not meet national guidance published in March 2014.

Overall rating for this core service Good

Overall, we rated community dental services at this trust as ‘good’.

Dental services were effective and focused on the needs of patients and their oral healthcare. We observed examples of teams working together effectively in the service. The service was able to meet the needs of the patients who visited the clinics for care and treatment because of the flexible attitude of all staff.

The service protected patients from abuse and avoidable harm. Systems for identifying, investigating and learning from patient safety incidents were in place, however, the service did not have a culture of reporting incidents. Infection control procedures were in place and audits had been carried out. The environment and equipment were clean and well maintained.

The patients we spoke with, and their relatives and carers, said they had positive experiences of care. We saw good examples of staff providing care with compassion, and of effective interactions between staff and patients. We found staff to be hard working, caring and committed to the care and treatment they provided. Staff spoke with passion about their work and showed, through their actions, how dedicated they were.

At each of the clinics we visited, staff responded to patients’ needs. Effective multidisciplinary team working ensured staff provided patients with care that met their needs, at the right time. Through effective time management, delays to treatment were kept to reasonable limits.

The service was well led. The operational management team of the service was visible and staff told us the culture was open and transparent. Staff said that they felt well supported and that they could raise any concerns. The service had a strategy with aims and objectives for promoting dental health.

Northern Lincolnshire and Goole NHS Foundation Trust serves a population of more than 350,000 people living in North and North East Lincolnshire and East Riding of Yorkshire. In total the trust employs around 6,500 staff and has 850 beds across three hospitals, Diana Princess of Wales, Scunthorpe General Hospital and Goole and District Hospital. Other locations registered with the Care Quality Commission include Monarch House and Community Equipment Store.

We carried out this comprehensive inspection because the Northern Lincolnshire and Goole NHS Foundation Trust was placed in a high risk band 1 in CQC’s intelligent monitoring system. The trust was also one of 14 trusts, which were subject to a Sir Bruce Keogh (the Medical Director for NHS England) investigation in June 2013, as part of the review of high mortality figures across trusts in England. At that time, there were concerns around a lack of senior clinical leadership in relation to clinical issues, the approach to medical handovers, patient flow management, standards of clinical documentation, a lack of trust wide sharing of lessons learnt from clinical incidents including serious untoward incidents and Never Events. In addition, the review found low levels of mandatory training in some areas, issues regarding hydration, nutrition and promoting hand hygiene, as well as the process of responding to complaints being seen by patients as inaccessible and slow.

We completed an announced inspection of the trust between 23 and 25 April and on 8 May 2014, and an unannounced visit took place on 6 May 2014. We did not inspect the community service provision at the trust as part of this inspection.

Overall, this trust was found to require improvement, although we rated it as good in terms of having caring staff.

Our key findings were as follows:

There were arrangements in place to manage and monitor the prevention and control of infection, with a dedicated team to support staff and ensure policies and procedures were implemented. We found all areas visited clean. Methicillin-Resistant Staphylococcus Aureus (MRSA) and Clostridium difficile (C.difficile) rates were within an acceptable range for the size of the trust.
There were significant vacancies with nursing and medical staff in some areas. The trust was actively recruiting into these posts. In the meantime, staff were able to work additional hours and bank, agency and locum staff were used to fill any deficits in staff numbers.
Patients were able to access suitable nutrition and hydration including special diets. Patients reported that on the whole they were content with the quality and quantity of food provided.
Best practice and national guidance was not consistently applied across some specialities.
Mortality rates are improving for this trust. There had been a reduction in the summary hospital level mortality indicator (SHMI) rate and the trust was now at 109, which is within the ‘as expected’ range.
Work was in progress to improve the patient experience, including initiatives to engage with patients, increase feedback responses and improve the handling of complaints.

We saw some areas of outstanding practice including:

The maternity service at Scunthorpe General Hospital had won a national award for promoting a normal birth experience. A midwifery-led vaginal birth after caesarean section clinic had been introduced which worked with women who had a previous caesarean section. This meant that women were given increased opportunities to have a natural birth.
The facilities team received the National Annual Hospital Estates and Facilities Management Association Team of the Year Award, with the Hotel Services Manager being awarded Project Manager of the Year for improving patient and staff experience. This included the creation of a multi-skilled role – ward caterer, ward domestic and nursing support.

Importantly, to improve quality and safety of care, the trust must:

Ensure that there are sufficient qualified, skilled and experienced staff, particularly in the A&E department, and medical and surgical wards. This is to include provision of staff out of hours, bank holidays and weekends at Scunthorpe General Hospital and Diana, Princess of Wales Hospital.
Review the skills and experience of staff working with children in the A&E departments to meet national recommendations at Scunthorpe General Hospital and Diana, Princess of Wales Hospital.
Review the consistency of care and level of consultant input, particularly out of hours and at weekends in the High Dependency Unit at Diana Princess of Wales Hospital.
Review care and treatment to ensure that it is keeping pace with National Institute of Clinical Excellence guidance and best practice recommendations, particularly within the intensive therapy units and the high dependency unit at Scunthorpe General Hospital and Diana, Princess of Wales Hospital.
Ensure that the intensive therapy unit uses nationally-recognised best-practice guidance in terms of consultant wards rounds and reviewing admissions to the unit.
Review delayed discharges from intensive therapy unit in terms of the negative impact this can have on patients.
Review the environment and lay out of the accident and emergency department at Scunthorpe General Hospital so that it can meet the needs of children and patients with mental health needs.
Ensure that the designation of the specialty of some medical wards reflect the actual type of patients treated at Scunthorpe General Hospital and Diana, Princess of Wales Hospital .
Review the on-call medical rota covering patients admitted with gastrointestinal bleeding (GI bleed).
Ensure that the availability of emergency theatre lists at Scunthorpe General Hospital is improved.
Ensure that there is an improvement in the number of Fractured Neck of Femur patients who had surgery within 48 hours at Scunthorpe General Hospital and Diana, Princess of Wales Hospital.
Ensure there is appropriate care planning and a paediatric early warning scoring system on the neonatal intensive care unit and that there is consistent nutritional and tissue viability screening and assessment on paediatric wards.
Ensure that all staff attend and complete mandatory training, particularly for safeguarding children and resuscitation at Scunthorpe General Hospital and Diana, Princess of Wales Hospital.
Ensure that staff have appropriate appraisal and supervision at Scunthorpe General Hospital and Diana, Princess of Wales Hospital.
Review the effectiveness of handovers, particularly in the medical services at Scunthorpe General Hospital and Diana, Princess of Wales Hospital.
Ensure that all patient documentation is appropriately updated and maintained including documentation for mental capacity assessments and risk assessments at Scunthorpe General Hospital and Diana, Princess of Wales Hospital.
Ensure that reasons for Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) are recorded and are in line with good practice and Guideline at Scunthorpe General Hospital and Diana, Princess of Wales Hospital.
Ensure that DNACPR orders confirm discussion with patients or family members and whether multidisciplinary teams are involved before an order is put in place at Scunthorpe General Hospital and Diana, Princess of Wales Hospital.
Review access to soft diets outside of meal-times at Scunthorpe General Hospital and Diana, Princess of Wales Hospital.
Review the ‘did not attend’ and waiting times in outpatients’ clinics and put in steps to address issues identified.

Professor Sir Mike Richards

Chief Inspector of Hospitals

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up. Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.

We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.

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Professor Sir Mike Richards

Professor Sir Mike Richards