Source · CQC inspection
Pilgrim Hospital
Provider United Lincolnshire Teaching Hospitals NHS Trust
Type NHS Healthcare Organisation
Region East Midlands
Last inspected 14 May 2026
Overall rating: Good View full CQC report
Domain ratings
Safe
Good
Effective
Good
Caring
Good
Responsive
Good
Well-led
Good
Current CQC assessment
Good
The service is performing well and meeting our expectations.
Ratings by service
Medical care (Including older people's care)
Good
Medical care (Including older people's care)
Good
Medical care (Including older people's care)
Good
Urgent and emergency services
Requires Improvement
Urgent and emergency services
Requires Improvement
Regulatory breaches & enforcement
Breaches identified (2)
Breach
Safe
At the time of the onsite assessment the evidence indicated that there was one breach of the legal regulations in relation to safe storage of medicines.
Breach
Safe
Therefore, at the time of publication, this is not an ongoing breach.
Earlier inspection findings
Must-do actions (5)
Must-do action 1 of 5
Must do
Safe
The trust must ensure systems and processes to check nationally approved child protection information sharing systems are fully embedded and compliance is monitored.
Must-do action 2 of 5
Must do
Safe
The trust must ensure the trust standard operating procedure for management of reducing ambulance delays is fully implemented.
Must-do action 3 of 5
Must do
Safe
The trust must ensure that all medicines are stored safely and securely.
Must-do action 4 of 5
Must do
Safe
The service must ensure systems and processes to check nationally approved child protection information sharing systems are fully embedded and compliance is monitored.
Must-do action 5 of 5
Must do
Safe
The service must ensure the trust standard operating procedure for management of reducing ambulance delays is fully implemented. Patients waiting on ambulances should be reviewed by medical staff within an hour and within 30 minutes where the national early warning score is five or more or requiring prioritisation.
Should-do actions (38)
Should-do action 1 of 38
Should do
Safe
The trust should ensure that staff complete mandatory training in line with trust targets. Including but not limited to the highest level of life support, safeguarding and mental capacity training.
Should-do action 2 of 38
Should do
Safe
The trust should ensure they provides sufficient numbers of nursing and medical staff to safely support patients.
Should-do action 3 of 38
Should do
Well-led
The trust should ensure there are mechanisms for providing all staff at every level with the development they need through the appraisal process.
Should-do action 4 of 38
Should do
Well-led
The trust should ensure the requirements of duty of candour are met.
Should-do action 5 of 38
Should do
Safe
The trust should ensure it continues to review and manage the work required to improve medicines management across the organisation.
Should-do action 6 of 38
Should do
Well-led
The trust should ensure they are using timely data to gain assurance at board.
Should-do action 7 of 38
Should do
Safe
The trust should ensure all patient records and other person identifiable information is kept secured at all times.
Should-do action 8 of 38
Should do
Responsive
The trust should ensure it has access to communication aids and leaflets available in other languages.
Should-do action 9 of 38
Should do
Safe
The trust should ensure the design, maintenance and use of facilities, premises and equipment keep patients safe.
Should-do action 10 of 38
Should do
Safe
The trust should ensure that falls and mental health risk assessments and transfer documentation are in place for patients when they are required and that completion risk assessments and transfer documentation are audited.
Should-do action 11 of 38
Should do
Safe
The trust should ensure, the paediatric area within the Emergency Department, nursing and medical staffing requirements meet the Royal College of Paediatrics and Child Health (RCPCH).
Should-do action 12 of 38
Should do
Well-led
The trust should ensure, the paediatric area within the Emergency Department, governance processes are fully implemented and aligned to the Royal College of Paediatrics and Child Health (RCPCH) standards for children in the emergency department.
Should-do action 13 of 38
Should do
Well-led
The trust should ensure effective systems are in place to review the service risk register.
Should-do action 14 of 38
Should do
Safe
The trust should ensure ambient temperature checks are undertaken in theatres for medicines storage as per trust policy.
Should-do action 15 of 38
Should do
Caring
The trust should ensure an interpreter is used as per trust policy to ensure all young people, parents or guardians are able to consent to care and treatment and fully understand clinical conversations.
Should-do action 16 of 38
Should do
Safe
The trust should ensure cleaning records are completed as per trust policy.
Should-do action 17 of 38
Should do
Responsive
The trust should consider discussing mixed sex accommodation with young people proactively rather than reactively.
Should-do action 18 of 38
Should do
Responsive
The trust should consider the use of a communication tool to support staff working with children who have additional needs.
Should-do action 19 of 38
Should do
Effective
The trust should ensure that a patient’s food and fluid intake is accurately recorded.
Should-do action 20 of 38
Should do
Well-led
The trust should consider adding specific action plans to the service risk register.
Should-do action 21 of 38
Should do
Safe
The trust should ensure that safety checks of new ward environments are fully completed before moving patients.
Should-do action 22 of 38
Should do
Effective
The trust should ensure national audit outcomes are continued to be monitored and any areas for improvement acted upon.
Should-do action 23 of 38
Should do
Safe
The trust should consider monitoring staff’s compliance with the systems in place to enable learning from incidents.
Should-do action 24 of 38
Should do
Effective
The trust should continue to work towards increasing the number of midwives who are competent in theatre recovery to ensure women are recovered by appropriately skilled staff.
Should-do action 25 of 38
Should do
Well-led
The trust should improve the completion of safety, quality and performance audits to ensure these are consistently completed effectively, to enable safety and quality concerns to be identified and acted upon.
Should-do action 26 of 38
Should do
Safe
The trust should ensure that policies and procedures in place to prevent the spread of infection are adhered to.
Should-do action 27 of 38
Should do
Safe
The trust should ensure patients at risk of self harm or suicide are cared for in a safe environment meeting standards recommended by the Psychiatric Liaison Accreditation network (PLAN) and mental health risk assessments and care plans are completed for all patients at risk.
Should-do action 28 of 38
Should do
Safe
The trust should ensure triage is a face to face encounter with a patient for ambulance conveyances.
Should-do action 29 of 38
Should do
Safe
The trust should ensure patients at risk of falling undergo a falls risk assessment and falls preventative actions are in place.
Should-do action 30 of 38
Should do
Safe
The trust should ensure deteriorating patients are identified and escalated in line with trust policy.
Should-do action 31 of 38
Should do
Safe
The trust should ensure the, paediatric area within the Emergency Department, nursing and medical staffing requirements meet the Royal College of Paediatrics and Child Health (RCPCH).
Should-do action 32 of 38
Should do
Safe
The trust should ensure effective systems are in place to investigate incidents in a timely manner and identify and share learning from incidents to prevent further incidents from occurring.
Should-do action 33 of 38
Should do
Effective
The trust should ensure clinical pathways and policies are updated in line with national guidance.
Should-do action 34 of 38
Should do
Well-led
The trust should ensure, the paediatric area within the Emergency Department, governance processes are fully implemented and aligned to the Royal College of Paediatrics and Child Health (RCPCH) standards for children in the emergency department.
Should-do action 35 of 38
Should do
Well-led
The trust should ensure effective systems are in place to review the service risk register.
Should-do action 36 of 38
Should do
Responsive
The trust should consider all key services being available seven days a week.
Should-do action 37 of 38
Should do
Well-led
The trust should consider routine monitoring or auditing of waiting times for children to have a medical review as per the Royal College of Paediatrics and Child Health (RCPCH).
Should-do action 38 of 38
Should do
Well-led
The trust should consider giving ward managers direct access to training systems for their areas in order to monitor and action mandatory training needs of their teams on a more regular basis.