Archived: Cumberland Infirmary

Updated 22 November 2018

Cumberland Infirmary (CIC) is part of North Cumbria University Hospitals NHS Trust which was created in 2001 by the merger of Carlisle Hospitals NHS Trust and West Cumberland NHS Trust and became a University Hospital Trust in September 2008.

The trust is not a foundation trust. Its main commissioner is Cumbria Clinical Commissioning Group (CCG), which commissions around 85% of its services, with NHS England commissioning a further 13%. CIC is a provider of acute hospital services serving mainly the Carlisle and North Cumbria areas. It is a general hospital providing 24-hour A&E with trauma unit status, consultant-led maternity services and special care baby unit, a range of specialist clinical services, and outpatient clinics. It has 500 beds (410 of which are inpatient). The consultant-led emergency department at Cumberland Infirmary, Carlisle is open 24 hours a day, seven days a week to provide an accident and emergency service for children and adults. Separate entrances were used for walk-in patients and patients arriving by ambulance and there was a reception and waiting area for walk-in patients. Of the 19 bays in the department, 10 in the majors’ area were available for isolation of patients. A separately equipped cubicle was available for ophthalmic treatment. A separate area of the department was designated for children, with a children’s waiting area and a children’s treatment room. A designated room for psychiatric assessment was available for patients with mental health needs with some safety features fitted. The resuscitation area comprised three bays which included one equipped for paediatric patients.

At the time of this inspection the trust provided 224 medical inpatient beds and 50 day-case beds located across 13 wards covering 14 medical specialities. The medical service accounted for over 50% of the overall trust inpatient bed capacity. CIC provided surgical services for general surgery, head and neck, ENT, orthopaedics, gynaecology, and ophthalmology. There were six wards, an operating suite, a day-case unit, an assessment unit, and a ward which had a mix of medical and surgical patients. In total the surgical division had 80 day-case and 157 inpatient beds.
The trust had a total of 15 adult critical care beds and the Intensive Care National Audit and Research Centre (ICNARC) data indicated that there were around 1150 admissions a year, with 850 at the CIC site. Across two sites there were eleven ‘intensive care’ (ITU) beds for complex level 3 patients who require advanced respiratory support or at least support for two organ systems, and four ‘high dependency’ (HDU) beds for level 2 patients who require very close observation, pre-operative optimisation, extended post-operative care, or single organ support. This also included care for those ‘stepping down’ from level 3 care. Beds were used flexibly, with the resources to increase and decrease the numbers of either ITU or HDU admissions. CIC provided care and treatment for maternity and gynaecology patients in Carlisle and the surrounding rural areas of North Cumbria.

The maternity services comprised outpatient clinics, post-natal and ante-natal ward, and a delivery suite. Community midwifery services were provided by midwives employed by the trust. There were 10 maternity beds. Services for children and young people at CIC included a 16-bed children’s ward and an eight-bed short stay assessment unit. A children’s outpatient department was adjacent to the children’s ward and there was a special care baby unit (SCBU) with 12 commissioned cots. The Specialist Palliative Care Team (SPCT) service at NCUH Palliative care was commissioned by the Clinical Commissioning Group and delivered in the trust by staff from the local mental health trust. The SPCT at CIC comprised one 0.8 WTE consultant post shared with the community and the Loweswater Suite, with two sessions per week of hospital support, one 0.8 WTE staff grade doctor who mainly worked in the Loweswater Suite, and two WTE Macmillan nurses.

An End of Life Care team was established at NCUH and consisted of a lead bereavement nurse, a chaplain and a bereavement officer. The outpatient departments held clinics for various specialities throughout the trust across the different hospital sites. Diagnostic imaging was available at CIC and West Cumberland Hospital. Clinics were held in the main outpatient department and departments such as ophthalmology. Diagnostic imaging services were mainly provided from two locations – CIC and West Cumberland Hospital – with limited services at Workington Community Hospital, Penrith Hospital, and Cockermouth Community Hospital. Diagnostic imaging at CIC provided plain film x-rays, ultrasound, CT, MRI, and interventional treatments. Acute clinical work, including fluoroscopy, was concentrated at CIC and West Cumberland Hospital. The service offered a range of diagnostic imaging, image intensifiers in theatres, and interventional procedures. The trust provided diagnostic imaging figures for all sites for each modality.

Updated 22 November 2018

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

• Registered nurse staffing shortfalls and registered nurse vacancies continued on all wards, however, this was most prevalent in the medical care group. Several registered nurse shifts remained unfilled despite escalation processes. Medical staffing cover remained challenging and locum cover was significant. Additional support was not always available for wards with more complex patient needs, such as one to one support due to behavioural problems or aggressive tendencies.
• There had been several serious incidents where patients had suffered harm as a result of missed diagnosis, late escalation of deterioration or delay in receiving treatment. The emergency department had a designated mental health assessment area that did not meet best practice guidance for a safe metal health assessment room. It contained inappropriate equipment and several ligature risks. We raised this during the core service inspection and the department took action to change the room and make it safer when we retuned for the well led inspection. Mental health patients also experienced long waits in the department as they waited to see mental health specialists from the local mental health trust.
• Mandatory training was not always completed by medical or nursing staff in a timely manner and compliance with mandatory training targets was low for both nursing and medical staff.
• Some areas had achieved appraisal target rates, however, staff across the trust reported that the quality of appraisals was poor.
• National and local guidelines were not fully embedded, some departments were not meeting the majority of the audit standards.
• The electronic systems for recording staffing levels and patient acuity was not used consistently throughout the trust.
• Prescribing policies were not followed and on occasions staff had difficulty following controlled drug procedures due to limited staffing. Intravenous fluids were not always secured as per the trusts medicines policy.
• There were a large number of bed moves after 10pm where patients had been moved for non-medical reasons and there remained many medical outliers being cared for on non-medical wards.
• Staff had a variable understanding and awareness of consent issues, the Mental Capacity Act and Deprivation of Liberty Safeguards.
• Staff morale was variable in each area we visited however we did see some areas where it had improved from our previous inspection.
• We were not assured that safeguarding training was delivered in accordance with Adult and Children Safeguarding Levels and Competencies for healthcare, intercollegiate guidance (2016).
• Governance systems varied from ward to ward in terms of quality. We found that staff on several wards did not know what the risk register was and ward managers were were unable to voice what risks were on it.
• Throughout the inspection staff told us that senior leaders lacked visibility in their clinical areas.
• Audits of the WHO surgical safety checklist showed completion of the checklist had been inconsistent and had not been completed for every patient;
• The foundation school had identified concerns about the adequacy of the training and experience of foundation programme doctors within surgery; the trust had developed a comprehensive improvement plan in response.
• There was a large number of maternity guidelines within the maternity service which were not in date, although there was an action plan in place to recover this position.

However:

• Staff worked hard to deliver the best care they could for patients. Patients were supported by staff who were kind and compassionate despite being under pressure.
• Patients were positive about the care they received and staff proactively involved patients and their family to consider all aspects of holistic wellbeing.
• Staff confidently reported incidents and the division had made considerable efforts to reduce patient harms from falls and pressure ulcers.
• Ward environments were clean and staff used personal protective equipment appropriately to protect themselves and the patient from infection exposure.
• Patient outcomes in many national audits were good and there had been some reported improvements in others.
• Multidisciplinary team working across the services was integrated, inclusive and progressive.
• The trust had introduced a composite workforce model through the recruitment of trainee advanced clinical practitioners and physician associates to support the medical workforce within surgery;
• Discharges were managed during daily and weekly ward meetings and multidisciplinary team meetings on wards and staff worked with the discharge liaison team;
• Improving referral to treatment times had been set as a priority within the surgical division and at the time of inspection, national data showed referral to treatment times had improved for all surgical specialities;
• Services for children and young people had taken appropriate action in response to issues identified at the previous inspection. There were sufficient medical and nursing staff to ensure children were safe, and appropriate mitigation in place to manage staffing pressures. The service met relevant standards recommended by the Royal College of Paediatrics and Child Health.

Updated 22 November 2018

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

• Registered nurse staffing shortfalls and registered nurse vacancies persisted on all divisional wards. Several registered nurse shifts remained unfilled despite escalation processes. Medical staffing cover was poor and locum cover was significant.
• Additional support was not always available for wards with more complex patient need, such as one to one support due to behavioural problems or aggressive tendencies.
• The electronic systems for recording staffing levels and patient acuity was not used appropriately or consistently.
• There were frequent difficulties recording and retrieving patient observations due to fluctuating WiFi signal on the ward.
• Prescribing policies were not followed and staff had difficulty following controlled drug procedures due to limited staffing. Intravenous fluids were not always secured as per the trusts medicines policy.
• Staff confirmed learning opportunities and access to professional development was variable and appraisal quality was said to be poor at ward level.
• There were excessive numbers of bed moves after 10pm which were without a medical reason for doing so and there remained many medical outliers being cared for on non-medical wards.
• The divisional risk register did not correlate with top risks identified by divisional leads. Risk ratings were confusing and detail of actions taken against the risks were limited.
• Staff morale was variable and junior doctors resented the perceived shift of onus onto them to take responsibility for covering gaps in the junior doctor medical rota.
• We saw that although sepsis screening and the number of patients receiving treatment within one hour had greatly improved, there was room for further improvement.
• Staff had a variable understanding and awareness of consent issues, the Mental Capacity Act and Deprivation of Liberty Safeguards.
• We were not assured that safeguarding training was delivered in accordance with Adult and Children Safeguarding Levels and Competencies for healthcare, intercollegiate guidance (2016).
• Governance systems varied from ward to ward in terms of quality and quantity. The risk register appeared unreliable, duplicating many common themes and lacking detail in terms of actions taken and progress over the period of time since the risk was identified. There were several examples of wards not knowing what the risk register was. Additionally, ward managers were unable to voice what risks were on it.
• The division had not fully embedded seven-day working across all areas.
• Senior leaders lacked visibility.

However:

• Staff confidently reported incidents and the division had made considerable efforts to reduce patient harms from falls and pressure ulcers.
• Ward environments were clean and staff used personal protective equipment appropriately to protect themselves and the patient from infection exposure.
• The division was actively involved in local and national audits which provided a strong evidence base for care and treatment.
• Patient outcomes in many national audits were good and there had been some reported improvements in others.
• Multidisciplinary team working across the divisional wards was integrated, inclusive and progressive.
• Patients were positive about the care they received. Staff interactions with patients were compassionate, kind and thoughtful. Staff proactively involved family and considered all aspects of holistic wellbeing.
• The division had developed new services, extending the remit of existing services, appointed specialist practitioners and collaborated with neighbouring trusts in service development.
• The division had a clearly defined strategy and vision which was aligned to organisational aims and wider healthcare economy goals.
• Governance processes across the division were clinician driven and quality measures were monitored.
• Cultural improvements had been made.
• We were notified, post inspection, that a recent WiFi upgrade had significantly improved coverage and performance and on 31 July, the e-observations software was upgraded to NEWS2.

Updated 22 November 2018

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

• Services for children people had taken appropriate action in response to issues identified at the previous inspection. There were sufficient medical and nursing staff to ensure children were safe, and appropriate mitigation in place to manage staffing pressures. The service met relevant standards recommended by the Royal College of Paediatrics and Child Health.
• The leadership, governance, and culture promoted the delivery of high quality person-centred care. Medical and nursing staff spoke positively about leadership at ward, service and care group level. There was a good culture and most staff told us they felt valued and respected by peers and managers.
• There was a clear vision and strategy and managers worked collaboratively with stakeholders to develop an integrated model of care. Implementation of the strategy had resulted in the development of short stay paediatric assessment units at both sites, and the service was in the process of developing closer links between maternity and the special care baby unit.
• Staff protected children and young people from avoidable harm and abuse. There were systems and processes to safeguard children and young people. Staff took a proactive approach to safeguarding and focused on early identification.
• Medical and nursing staff delivered compassionate and sensitive care that met the needs of children, young people, and families. Feedback from patient surveys and the NHS Friends and Family Test was positive and staff created a strong patient and family-centred culture.
• Managers and staff planned and delivered services to meet the needs of children and young people, and worked collaboratively with partner organisations and other agencies.
• All areas were visibly clean and hand hygiene audits consistently achieved 100%. There were no cases of Clostridium difficile (C.difficile), MRSA, or methicillin sensitive Staphylococcus aureus (MSSA) in the previous 12 months prior to the inspection.
• Children’s services participated in national audits and there was evidence on ongoing improvement, particularly in relation to diabetes.
• Nursing and medical staff were qualified and had the skills they needed to carry out their roles effectively and in line with best practice. Staff had received an annual appraisal and received support and personal development.
• Children and young people were able to access the right care at the right time and referral to treatment times (RTT) were consistently 98% and above.
• There was an open and transparent approach to handling complaints. Information about how to make a formal complaint was available however; families tended to contact the service directly when they had a concern.

However:

• Safeguarding level three training did not meet the standards recommended by Royal Collage of Paediatrics and Child Health intercollegiate document.
• Not all guidelines and policies, which were accessible via the trust internet, were up to date. This included the safeguarding children supervision guideline, and guidelines for hypoglycaemia and meningitis.

Updated 29 March 2017

During our previous inspection of CIC, in July 2015, we rated critical care services as ‘good’ overall, with safe as ‘requires improvement’, due to concerns about nurse and medical staffing levels. Effective, caring, responsive and well-led were rated as ‘good’. We rated the service as ‘good’ overall, after our comprehensive announced and unannounced inspection visit in December 2016, with evidence of ongoing improvement in the unit:

• There was ongoing progress towards a harm free culture. Incident reporting was understood by the staff we spoke with and improvements in reporting culture had been noted by the critical care team. There was a proactive approach to the assessment and management of patient-centred risks and staff had a good understanding of the trust position related to learning from incidents, serious incidents, and Never Events.
• There had been no Never Events in critical care and no reportable serious incidents at the CIC site. There had been ten NRLS reported incidents, and themes were monitored closely by grade and seriousness of harm.
• A 24/7 Critical Care Outreach Team (CCOR) was well established. We observed good practice for recognition and treatment of the deteriorating patient. One hundred percent of patients received follow-up care once discharged from the unit. Practice was in line with GPICS (2015), NICE CG50 and against the seven core elements of Comprehensive Critical Care Outreach, (C3O 2011) ‘PREPARE’; 1. Patients track and trigger, 2. Rapid response, 3. Education and Training, 4. Patient safety and governance, 5. Audit and evaluation (monitoring patient outcome), 6. Rehabilitation after critical illness and 7. Enhancing service delivery.
• Nurse staffing was good with sufficient staffing levels for provision of critical care. There was provision of a supernumerary coordinator and practice educator in line with Guidelines for the Provision of Intensive Care Services (GPICS) (2015).
• Supernumerary induction for new nursing staff was good with an organised approach to nurse appraisal and nursing achievement of competence in critical care skills.
• Medical staff we spoke with described good anaesthetic staffing levels and continuity for rotas and out-of-hours cover, however, this was achieved with 35% use of locum consultant staff at CIC, as sickness and vacancy rates for anaesthetic cover were greater than average for 2015/16.
• The policy and activity around critical care patient transfer to other hospitals when required were good. The arrangements for the small numbers (17 in 2015/16) of paediatric admissions for stabilisation for hours prior to transfer were also good, this included levels of staff training and competence and storage and checking of essential equipment. The unit was part of the ‘North East Children’s Transport and Retrieval’ (NECTAR) new transport service.
• The emergency resuscitation equipment and patient transfer bags for both adults and children were checked daily with a good system in place as per trust policy. There was good provision of equipment in critical care, good storage, and robust systems for medical device training.
• The unit was visibly clean; standards of IPC were in line with trust policy. One isolation room was available with a ventilated lobby area, in line with Health Building Note HBN 04-02. Staff we spoke with told us that isolation of patients was risk assessed and documented. Liaison with the infection control team supported assurance that patients with infections received best practice.
• The team in the unit had invested in and implemented an electronic patient record and prescription system specific to intensive care, which we observed to be comprehensive and well understood by staff. All records checked in the system were complete, and the risk assessment and patient review process was good.
• Patients were at the centre of decisions about care and treatment. We reviewed consistent positive survey feedback and comments, which gave evidence of a caring and compassionate team. The team had established a memorial service for relatives of patients who had died in the unit, and this was well attended in the local community. There was evidence of well-attended support groups for patients in the local community. Staff whom we observed and spoke with were positive and motivated and delivered care that was kind and promoted dignity, and that focused on the individual needs of people. The improvements made towards the rehabilitation of patients after critical illness since our last inspection were comprehensive.
• The team members in critical care services spoke highly of their local leadership and felt supported by matrons, consultants, and senior matrons. A culture of listening, learning, and improvement was evident amongst staff we spoke with in the unit. Staff we spoke with across the team were positive about their roles and clear about governance arrangements, despite frequent changes in the senior team over the preceding five years. Staff expressed desire for a period of stability in the senior and executive team.

• We found that Intensive Care National Audit and Research Centre (ICNARC) data showed that patient outcomes were comparable or better than expected when compared with other units nationally, this included unit mortality. ICNARC data had been collected and submitted consistently at CIC for around three years, since the appointment of a dedicated member of the team. The data was available to the team and, during our inspection, we were able to review consistent annual reports. However, we reported to the critical care team that, although its data was published on the ICNARC website, this was only for one unit. Staff we spoke with were not aware of this and could not explain why data for the other unit was not published.

• Plans were in place to provide multidisciplinary follow-up clinics across both units for rehabilitation of patients after critical illness, as recommended by NICE CG83 and GPICS (2015). These were for those patients who had experienced a stay in critical care of longer than four days. A small, dedicated team was being recruited to deliver this standard, and progress was good. Support groups had been well attended in the local community, with staff organising a range of supportive and educational opportunities. The use of patient diaries had been embedded in practice.
• Patients received timely access to critical care treatment and consultant-led care was delivered 24/7. Readmissions to the unit were monitored closely by the consultant and CCOR team and were below national average. Patients were not transferred out of the unit for non-clinical reasons. We found that patients were not cared for outside of the critical care unit when Level 2 or 3 care was required, and we did not see examples of critical care outliers in theatre recovery or ward areas.
• Patients in the critical care unit were discharged to the wards within eight hours once a decision to discharge was made, as per GPICS (2015). ICNARC data indicated a position that was much better than national performance against this target. Almost all patients were discharged within four hours of being ready for discharge. There were no single sex breaches and low numbers of out-of-hours discharges (0.8%).

However:

• Although substantive and establishment nurse staffing were good in critical care, with low vacancies and sickness rates, staff (including members of the CCOR team) were moved frequently to support shortfalls in staffing in other wards and departments. We spoke with staff who felt that this affected the morale of nursing staff in the unit. Nonetheless, patient safety was not compromised, and we did not see evidence that patient-to-nurse ratios were compromised, as we had found that they had been during previous inspections. We also noted that it was not possible to protect the supernumerary coordinator role when staff were moved.
• The role of the supernumerary clinical educator was embedded and valued. However, this role was provided in a 0.8 WTE post, and the post-holder had commitments to deliver nasogastric (NG) education across the trust in response to trust-wide serious incidents. Although this training was valuable it meant that the clinical educator was only able to provide a part time service in the CIC unit and was unable to provide a service across the trust.
• The number of pressure sores recorded in the incident reporting system had not shown improvement since our previous inspection, and staff reporting of pressure ulcer grading and level of harm was inconsistent.
• The critical care pharmacist provision was well below GPICS (2015) standards. We spoke with staff in the unit who did not report any issues with management of medicines and pharmacy support. However, pharmacists were not able to fulfil the critical care role, join ward rounds, or deliver improvements in practice, with only 0.2 WTE dedicated hours.
• In 2015 we reported that the unit had limits in storage and patient bed space, and, during this inspection, we noted again that, although the unit was modern in design, it would not meet current national standards for new buildings and environment. (HBN 04-02). The senior team had submitted proposals which outlined plans for unit upgrade and expansion. 

Updated 29 March 2017

During our previous inspection of End of Life Care Services at Cumberland Infirmary, in April 2015, we rated the service as ‘requires improvement’ overall. During this inspection there was evidence of ongoing improvement. We have rated the service as ‘good’ overall, with effective as ‘requires improvement’ because:

• Staff delivering end of life and specialist palliative care understood their responsibilities with regard to reporting incidents. Staff we spoke with told us that when an incident occurred it would be recorded on an electronic system for reporting incidents.
• We viewed mortuary protocols and spoke with mortuary and porter staff about the transfer of the deceased. Staff told us that the equipment available for the transfer of the deceased was adequate, and we saw that this included bariatric equipment.
• The trust had developed a care of the dying patient (CDP) care plan that provided prompts and guidance for ward-based staff when caring for someone at the end of life. We observed the use of these and saw that information was recorded and shared appropriately and that the plans were completed.
• We saw that specialist palliative care nurses worked closely with medical staff on the wards to support the prescription of anticipatory medicines. The guidance that the specialist nurses provided was in line with end of life care guidelines and was delivered in a way that focused on developing practice and confidence in junior doctors around prescribing anticipatory medicines.
• The palliative care end of life communication training (Sage and Thyme) was part of the mandatory training for all staff at CIC.
• We observed the use of McKinley syringe drivers on the wards and saw that regular administration safety checks were being recorded. Ward staff told us that syringe drivers were available when they needed them.
• The trust had also introduced a “Care after Death” document. The document provided a standard operating procedure for healthcare staff to understand that end of life care extends beyond death, to provide care for the deceased person and support to their family and carers.
• An early warning scoring system was in use throughout the trust to alert staff to deteriorations in a patient’s condition. Patients recognised as being at the end of life had their care plan transferred to the CDP framework when they were expected to die within a few days.
• The Trust had an organ donation policy which adhered to national guidelines. The framework process made reference to specialist nurses, clinicians, and nursing staff supporting the family throughout the process.
• Staffs were able to demonstrate compassion, respect, and an understanding of preserving the dignity and privacy of patients following death. Mortuary staff told us there was always a member of staff on call out-of-hours. This service was available for families who wanted to visit during an evening or a weekend.
• Porters had face-to-face mortuary training that included the transfer of the deceased, promoting dignity and respect, and an understanding of bereavement.
• The chaplaincy service provided spiritual support for patients and their families, together with the Bereavement Nurse Specialist
• The trust ensured that there was timely identification of patients requiring end of life care on admission. Systems were in place so that when a patient who was known to the palliative care team was admitted that team would be alerted.
• We observed staff caring for patients in a way that respected their individual choices and beliefs, and we saw that records included sections to record patient choices and beliefs so that these were widely communicated between the teams.
• An Integrated End of Life and Bereavement group was in operation. This was headed by the Deputy Director of Nursing, and the members of the group included the SPCT, the chaplaincy, the bereavement lead, education and training staff, and consultant medical staff.
• The trust had developed “Welcome to Hospice at Home – West Cumbria” initiative. This service included the provision of daytime and night nursing care, respite care during the day, evening, or night, and volunteer support in the home The service could also refer patients to other services within the organisation, including complementary therapies for patients, carers, and those bereaved, one-to-one or group support, bereavement support, and Lymphedema support. All services provided were free of charge
• The SPCT had developed a care pathway tool for patients in all areas of the hospital. This was to ensure that patients who required end of life care were identified at the earliest opportunity, and to facilitate the most appropriate care in the most appropriate place for each patient.
• A clear vision had been established, providing that ‘All people who die in Cumbria are treated with dignity, respect and compassion at the end of their lives, and that, regardless of age, gender, disease, or care setting they will have access to integrated, person-centred, needs-based services to minimise pain and suffering and optimise quality of life’.
• The vision’s aim was to provide a framework for the delivery of services allowing all adults in Cumbria who were approaching the end of their lives, “to live as well as possible until they die,” in accordance with their own wishes and preferences.
• The lead bereavement nurse and the chaplain had leadership roles in terms of end of life care and raising awareness of aspects of their service across the trust. This involved attending meetings and working collaboratively across services and departments to raise awareness of end of life care issues.
• There was a commitment at all levels within the trust to raise the profile of death, dying, and end of life care. This included improving ways in which conversations about dying were held and engaging with patients and their families to ensure their choices and wishes were achieved.
• Discharge coordinators were available to support the process of rapid discharge at the end of life, and the trust had recently implemented a community service where patients could be supported by trust staff in their own homes should care packages be difficult to access in the community.

However:

• For patients who did not have mental capacity, DNACPR forms we viewed at this inspection were inconsistently completed. We saw DNACPR forms that did not provide evidence of a best interest decision or a mental capacity assessment being undertaken and recorded. In a letter to CQC the trust formally acknowledged our concerns and outlined actions to be taken to address this issue.

• The trust had not achieved two clinical indicators and three organisational indicators in the End of Life Care Audit: Dying in Hospital in 2016.
• The trust had not produced an action plan with key responsibilities and timelines for achievement to address areas where performance was lower than the England average at the time of our inspection.
• The trust could not provide us with the number of referrals to the SPCT.
• Both the SPCT and staff on general wards supported patients in their endeavours to die in their preferred location. However, the trust did not collate or hold the data that would demonstrate the percentage of patients who had done so. This information was held by the Clinical Commissioning Group and could not be provided by the trust.
• There was no regular audit of the CDP.
• Specialist palliative care was not provided across a seven day service.
• The trust did not have formal contract meetings with members of the Cumbria Healthcare Alliance to monitor the service being commissioned and provided, and so could not demonstrate that the service was of an appropriate standard in terms of quality and meeting patient need. 

Updated 22 November 2018

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

• The trust had recruited three long term consultant paediatrician locums to meet RCOG guidelines. However, managers had been able to recruit sufficient locum doctors to mitigate risks and meet minimum standards for delivery of safe care.
• Midwives had undertaken training as midwife advocates and provided supervision and support to registered midwives working in the service.
• New leadership was in place with a new clinical director and associate director of midwifery both recruited in early 2018. Leaders were respected by staff at all levels but had not yet been able to fully embed changes in practice.
• There had been some significant improvement in cross site working between medical staff and senior midwife managers. Managers worked across all sites. However, staff continued to work at separate sites with shared processes and functions. Cohesiveness of the team across the two main hospital sites for maternity services was beginning to form. Staff at all levels were confident in reporting any poor practice they came across, although not all staff felt this would be acted upon.
• There was improvement in governance processes with risk and governance leads for clinicians and midwives. There had been improvements in action plans and follow up of actions from audits
• Not all staff in the service felt engaged in the reconfiguration of maternity services and some felt their opinions were not listened to.
• Staff understood their responsibilities to raise concerns, to record safety incidents and near misses. Nursing and midwifery staffing levels were better than the national recommendations for the number of babies delivered on the unit each year. There were sufficient medical staff to cover the obstetric rota.
• Women were positive about their treatment by clinical staff and the standard of care they had received. They were treated with dignity and respect.
• Services were planned, delivered and co-ordinated to take account of women with complex needs, there was access to specialist support and expertise.
• Midwifery and medical staff worked together ensuring women received care which met their needs.

However:

• Mandatory training rates continued to miss the trust target for both midwifery and medical staff.
• Training compliance for safeguarding level three was below the trust target for those required to be trained to that level.
• Despite staffing levels being better than the national recommendations we found that 10% of women did not receive one to one care in labour.
• Routine requests for doctors to see women on the ward were not always answered in a timely manner.
• We found some boxes containing drugs were not dated since being removed from refrigerated stock. Therefore, staff did not know how long they had been out of a monitored temperature range.
• There were many maternity guidelines which were not in date, although there was an action plan in place to recover this position.
• There was no formal strategy for the future of maternity services due to the review of the Cumbria wide provision of maternity care. However, managers were working on two possible options for provision of care.

Updated 29 March 2017

We rated this service as ‘good’ because:

• An electronic incident reporting system was in place. Staff we spoke with could describe how they would report incidents.
• The environment was suitable, clean, and tidy. Hand gel dispensers were available for use in all areas visited, and staff adhered to the ‘bare below the elbow’ policy in services that we visited.
• We found that equipment had been checked appropriately, and medicines that we checked were found to be in date and securely stored. Medical records availability had been identified as an issue at previous inspections, and we found improvements had generally been maintained.
• Staffing levels and skill mix were ascertained by the department managers. Actual staffing levels were mostly in line with the planned staffing levels in most areas.
• Staff used evidence-based guidance and followed national guidance. We found that a number of staff members had undertaken additional courses and training to enhance their competency. Staff had access to the systems and information they required for their role.
• Care was planned and delivered in a way that took account of patients’ needs and wishes. Patients attending the outpatient and diagnostic imaging departments received effective care and treatment.
• Staff provided compassionate care and ensured patient privacy and dignity was respected whilst using the services. Patient feedback was positive about the services. Diagnostic services were delivered by caring, committed, and compassionate staff.
• The service offered clinics throughout the week and on weekends to ensure that patients were seen and to meet demand. Additional clinics were added to manage demand for the services. Interpreter services were accessible and available if required.
• Management could describe the risks to the service and the ways in which they were mitigating these risks. However, we found that not all risks identified were on the risk register.
• Staff were mostly positive about their roles, local leadership, and team work. Daily huddles in the outpatient department had increased information sharing between staff and were found to be useful.

However:

• Mandatory training completions had not achieved the trust target of 95%.
• There were staff shortages in the orthopaedic practitioner staff group and oncology outpatients.
• There was no formal clinical supervision in main outpatients or ophthalmology outpatients.
• There was no current strategy for outpatients. However, staff told us that they were developing one.
• Performance measurement information was limited.
• The trust did not measure how many patients waited over 30 minutes to see a clinician in outpatient departments.
• Turnaround times for inpatient plain film radiology reporting did not meet Keogh standards, which require inpatient images to be reported on the same day.

Updated 22 November 2018

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

• Environmental audits showed results of 97% compliance;
• The division had systems and processes in place to support staff in wards and theatres to assess and respond to patient risk;
• Patient observations were recorded appropriately on the electronic system and concerns about deteriorating patients were escalated in accordance with guidance;
• Staffing levels were reviewed across the trust as a whole based on staffing numbers, the use of an acuity tool and professional judgement;
• The trust had introduced a composite workforce model through the recruitment of trainee advanced clinical practitioners and physician associates to support the medical workforce within surgery;
• From June 2017 to May 2018, the trust did not report any never events at Cumberland Infirmary for surgery.
• All patients had a similar expected risk of readmission for elective admissions when compared to the England average;
• The trust had introduced a full time orthogeriatrician and the ‘consultant of the week’ working model which had improved co-ordination, review and consistency of care;
• Mental health colleagues confirmed staff had a good understanding of the Mental Capacity Act.
• National data (NHS England, June 2018) showed 97% of respondents recommended surgical services;
• The average length of stay for all elective patients at Cumberland Infirmary was 3.4 days compared to the England average of 3.9 days;
• The average length of stay for all non-elective patients at Cumberland Infirmary was 4.4 days compared to the England average of 4.9 days;
• Discharges were managed during daily and weekly ward meetings and multidisciplinary team meetings on wards and staff worked with the discharge liaison team;
• Improving RTTs had been set as a priority within the division and at the time of inspection, national data showed referral to treatment times had improved for all specialities;
• The senior management team had a clear and comprehensive understanding of the current risks, challenges and pressures impacting on service delivery and patient care;
• There was an established structure of management and governance meetings in the surgical division;
• The electronic patient record enabled staff to ask and record patients’ information and communication needs.

However:

• The trust target (95%) was not met for most mandatory training modules for qualified nursing staff and for medical staff.
• The trust target (95%) was not met for any of the safeguarding training modules for which qualified nursing staff or for which medical staff were eligible;
• We were not assured that safeguarding training was delivered in accordance with ‘Adult Safeguarding Levels and Competencies for Healthcare, Intercollegiate guidance (2016)’;
• Audits of completion of the WHO surgical safety checklist showed completion of the checklist had been ‘poor’ and had not been completed for every patient;
• There was inconsistent practice across wards regarding the management of medicines, maximum and minimum temperatures were not recorded on wards.
• General surgery patients had a higher expected risk of readmission for elective admissions when compared to the England average;
• General surgery patients had a higher expected risk of readmission for non-elective admissions when compared to the England average;
• The trust target (95%) was not met for staff who had an appraisal;
• There were no patient information leaflets available in different languages on wards;
• The trust’s referral to treatment time (RTT) for admitted pathways for surgery was consistently worse than the England average;
• Although the senior management team informed us that recruitment had recently been made, they acknowledged the difficulties in covering the anaesthetic rota at West Cumberland Hospital;
• The foundation school had identified concerns about the adequacy of the training and experience of foundation programme doctors in surgery; the trust had developed a comprehensive improvement plan in response.

Updated 22 November 2018

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

• Patients had an initial assessment on arrival to the department. However, this was not always within the 15 minute handover or initial assessment target.
• There had been a number of serious incidents where patients had suffered harm as a result of missed diagnosis, late escalation of deterioration or delay in receiving treatment. Some of the harm was severe.
• Staff recording of deterioration and escalation needed to improve to ensure patients received the correct treatment in a timely manner.
• The emergency department had a designated mental health assessment area that did not meet best practice guidance for a safe metal health assessment room. It contained inappropriate equipment and a number of ligature risks. However, the department took action quickly to change the room and make it safer. Mental health patients also experienced long waits in the department as they waited to see mental health specialists from the local mental health trust.
• Mandatory training was not always completed by medical or nursing staff in a timely manner and compliance with mandatory training targets was poor for both nursing and medical staff.
• Infection control procedures were not always followed in relation to hand hygiene, cleaning of toys and cleaning of storage trolleys.
• Patients experienced long waits in the department once a decision had been made for them to be admitted. This was because of bed shortages throughout the trust but the impact was felt within the emergency department (ED).
• National and local guidelines were not fully embedded, national audit results were poor and the department was not meeting most of the audit standards. Some local audit work was underway to ensure that audit compliance improved.
• The emergency department had no vision or strategy at the time of the inspection.
• Senior clinical leadership was not visible in the department during our inspection and did not attend the department to support staff during our inspection visit to CIC.
• Although data was collected and used to manage performance against local and national standards, we had some concerns about the validity and robustness of the data because it contradicted some of what we observed during our inspection.

However:

• Staff worked hard to deliver the best care they could for patients. Patients were supported by staff who were kind and compassionate despite being under pressure.
• The safeguarding process for identifying children at risk of harm was robust.
• Staff newly qualified or newly employed by the department were supported through preceptorship and mentorship during their first six months in the department.
• Patients and families were involved in the decision making about their care in a way that they understood.
• The department achieved compliance with appraisal rates in the department however these had been rated as amongst the worst 25% of trusts nationally for quality of appraisal, however staff we spoke with did not express any concerns.
• Services were planned in a way to meet the individual’s needs. Patients could access emergency services appropriate for them, and their individual needs were supported.
• Complaints were managed in line with the trust’s policy.
• There was a sense of teamwork within the department and operational staff worked together in partnership to provide care and treatment for patients.