Archived: West Cumberland Hospital

Updated 22 November 2018

West Cumberland Hospital (WCH) 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. WCH is a provider of acute hospital services serving mainly the Whitehaven and West Cumbria areas.

It underwent phase one of a £90 million redevelopment, with the new building opening in October 2015. Phase two of the redevelopment is underway. It is a general hospital providing 24-hour A&E, a consultant-led maternity unit and special care baby unit, a range of specialist clinical services and outpatient clinics. It has 239 beds (191 of which are inpatient).

The consultant-led emergency department at West Cumberland Hospital, Whitehaven is open 24 hours a day, seven days a week to provide an accident and emergency service for children and adults. In the year April 2016 to March 2017, 92,105 patients attended the trust’s EDs. 37,001 of these patients attended ED at WCH. Paediatric attendances (children age 0 to16) represented approximately 18% of patients who attended ED across the trust. The hospital was not a designated trauma unit, but accepts trauma patients for stabilisation only prior to transfer to the Cumberland Infirmary. The major’s area was comprised of six cubicles and the minor’s area of eight cubicles, including an observation area for observation of patients with mental health needs. Three rooms were designated for “see and treat” and one rooms was situated adjacent to the paediatric area, providing flexibility for both adult and paediatric patients. The paediatric area included a separate waiting room. A spacious resuscitation area contained three bays, one of which was also equipped for paediatric patients. The department also housed a relatives’ room, and an ambulatory care area with two beds and seating. Emergency care was situated adjacent to the radiology department.

The medical care service at the trust provided care and treatment at the West Cumberland Hospital (WCH) situated in Whitehaven. The medical care service was managed by a single management team covering both sites under the division for medicine and emergency care (“care group”). The trust provided 111 medical inpatient beds and 50 day-case beds located across 6 wards.

The West Cumberland Hospital (WCH) provided elective surgical services for general surgery, head and neck, ENT, orthopaedics, gynaecology and ophthalmology. There was one large ward, an operating suite, a day-case unit, and recovery area. Patients requiring emergency surgical intervention were transferred to the Cumberland infirmary. In total, the surgical division had 80 day case and 157 inpatient beds.

The trust has a total of 15 adult critical care beds and the Intensive Care National Audit and Research Centre (ICNARC) data indicates that there are around 1150 admissions a year, with 300 at the WCH site. Across two sites there are 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 and this includes care for those ‘stepping down’ from level 3 care. Beds are used flexibly with the resources to increase and decrease the numbers of either ITU or HDU admissions.

West Cumberland Hospital (WCH) in Whitehaven provided care and treatment for maternity gynaecology patients in the West Cumbria area. The maternity services comprised outpatient clinics, a day ward, a ward for post-natal and ante-natal care and a delivery suite. Community midwifery services were provided by midwives employed by the trust. For gynaecology patients there was a women’s outpatients department, and inpatient beds on a surgical ward.

There were 13 maternity beds located across three wards for antenatal and postnatal care. Services for children and young people at WCH included a 14-bed children’s ward and there was a special care baby unit (SCBU) with 9 commissioned cots.

The children’s outpatient department was situated within the main outpatient department. The Specialist Palliative Care Team (SPCT) service at NCUH Palliative care is commissioned by Cumbria Clinical Commissioning Group and is delivered in the Trust by staff from Cumbria Partnership Trust. The Specialist Palliative Care Team (SPCT) at WCH comprised of one 0.8 whole time equivalent (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 nurse. An End of Life Care team was established at NCUH and consisted of a Lead Bereavement Nurse, 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 Cumberland Infirmary and WCH. Clinics were held in the main outpatient department and departments such as Ophthalmology. WCH had been in the newly built outpatient department for around 12 months at the time of our inspection. Most outpatient clinics had moved to the newly built unit, however there were a small number of clinics still offered in the previous building. Diagnostic imaging services were mainly provided from two locations: Cumberland Infirmary and West Cumberland Hospital with a limited service at Workington Community Hospital, Penrith Hospital and Cockermouth Community Hospital. Diagnostic imaging at WCH provided plain film x-rays, ultrasound, CT, MRI, and interventional treatments. The acute clinical work including fluoroscopy was concentrated at the two main sites; Cumberland Infirmary and West Cumberland Hospital that offered a range of diagnostic imaging, image intensifiers in theatres, and interventional procedures.

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 guidelines and procedures 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.
• 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.
• Data has shown that trust wide the medical staffing cover was poor and locum cover was significant.
• 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.
• Mandatory training figures were below trust target.
• 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 was on the risk register.
• The division had not fully embedded seven day working across all areas.
• Senior leaders lacked visibility.

However:

• Ward environments were clean and staff used personal protective equipment appropriately to protect themselves and the patient from infection exposure.
• Clinical documentation, risk assessments and safety bundles were completed thoroughly.
• Ward environments were clean and staff used personal protective equipment appropriately to protect themselves and the patient from infection exposure.
• Patient outcomes in a number of 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.
• The division had developed new services, extending the remit of existing services.
• 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 has 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 the majority of 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 procedures, 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 last inspection of critical care services at WCH, in July 2015, we rated good overall, We have rated the service as good overall after a 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. Staff we spoke with understood the incident reporting system and improvement 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. The number of pressure sores recorded in the incident reporting system had shown significant improvement since our last inspection and staff reporting of pressure ulcer grading and level of harm was good.
• There had been no Never Events in critical care and one reportable serious incident at the WCH site. There had been 27 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 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.
• Medical staff we spoke with discussed good anaesthetic staffing levels and continuity for rotas and out-of-hours cover. Use of locum consultant staff at WCH for anaesthetic cover was lower than CIC (35%) at 9.4% for 2015/16. The demands of the service were very different since the move of major surgery to CIC, and this was reported as having a negative impact on recruiting new anaesthetic staff to the unit.
• The policy and activity around critical care patient transfer to other hospitals when required were good. The arrangements for the small numbers (seven in 2015/16) of paediatric admission for stabilisation for hours prior to transfer were also good, to include levels of staff training and competence and storage and checking of essential equipment. The unit were part of the ‘North East Children’s Transport and Retrieval’ (NECTAR) new transport service. All senior staff were trained in paediatric life support.
• 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, spacious and met Department of Health Building Note HBN-04.02 standards for new build units; standards of infection prevention and control were in line with trust policy. All patient rooms were large single isolation rooms as the unit was modern in design and opened in September 2015 as part of the new hospital build plan since our last inspection.
• 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 risk assessment, patient review and prompt systems and processes were 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. There was also evidence of well-attended nurse led 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, promoted dignity, and 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 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 role. Governance arrangements were clear to the staff especially in view of reporting frequent changes in the senior team over the past five years. Staff expressed that they wanted a period of stability in the senior and executive team.
• We found that 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 WCH. The data was available to the team and, during inspection, we were able to review consistent annual reports; however we reported to the critical care team that although data had been published on the ICNARC website, that data was only for one unit. Staff we spoke with were not aware of this and could not explain why data had not been published for both units.
• 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 led by the matron and senior physiotherapist and a health care assistant was 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. There was good evidence of analysis of reasons for readmission and we reviewed a summary of cases with no significant trends. Minimum numbers of patients were 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 8 hours once a decision to discharge was made as per GPICS (2015). ICNARC data indicated a position that was comparable with the national performance against this target. There was good performance for patients discharged within 4 hours of the patient being ready for discharge. There were no incidents of single sex breaches, as the unit had single room provision for patients.
• We spoke with senior staff about concerns with nurse staffing levels and the actual and potential impact on safety and staff morale created by the increase in long term sickness levels. Senior staff responded to our concerns with evidence of plans to ensure safe staffing levels and escalated recruitment plans for Band 6 and band 5 nurses. This included temporary bed closure and close monitoring of activity. Escalation policies were reissued to staff. This gave assurance that the senior team were supportive and managing the escalation of this short term staffing pressure.

However:

• During our inspection we found that the team were finding it difficult to maintain nurse staffing levels in the unit due to a recent significant increase in long term sickness levels in the unit. We observed that there had been occasions were there had not been sufficient numbers of staff to provide 1:1 nursing for a long term level 3 patients, in line with intensive care standards. We escalated concern to senior staff during the inspection around the impact of a recent spike of 12% in staff sickness, which increased potential risk to patient safety. We also highlighted the lack of supernumerary coordinator in line with GPICS (2015), and the limitations and pressure on nursing staff to be able to observe patients in single rooms. A comprehensive action plan was produced by the trust after an unannounced visit which provided further assurance that these issues were being closely monitored and managed. Nurse staffing had been good prior to September 2016 with sufficient staffing levels for provision of critical care standards.
• The CCOR team had been moved frequently to support shortfalls in staffing in other wards and departments. We spoke with staff who felt that this had presented a risk to patient safety across the trust when they were unable to provide a CCOR service. It had affected the morale of team however we did not see evidence or incident at the time of inspection that patient care or safety had been compromised i.e.; increased readmission rates or late admissions to critical care. Staff we spoke with told us that more recently senior support had changed and improved. Protection of the CCOR cover had been prioritised since September 2015 and since the unit restructure under the Surgical and Anaesthetic directorate.
• There was no supernumerary clinical educator in the unit, in line with GPICS (2015). Staff provided support for training however it was recognised that the sickness in the senior, experienced team may impact on the team’s ability to provide training and support to junior staff.
• 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.
• Discharges out-of-hours, between 22.00hrs and 06.59hrs have been proven to have a negative effect on patient outcome and recovery. Critical care discharges out-of-hours were reported as 2.8% in 2015/16, against a national average of 2.0% as reported by ICNARC for 2015/16.

Updated 29 March 2017

During our last 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:

• 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.
• Records within the mortuary were comprehensive and included processes for appropriate checking.
• The palliative care end of life communication training (Sage and Thyme) is part of the mandatory training for all staff at WCH.
• An early warning scoring system was in use throughout the trust to alert staff to deteriorations in a patient’s condition. Patient’s recognised as being at the end of life had their care plan transferred to the care of the dying patient 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.
• Porters had face to face mortuary training that included the transfer of the deceased including promoting dignity and respect and an understanding of bereavement.
• Care plans for patients at the end of life included an assessment of nutritional needs and aspects of nutrition and hydration specifically relating to end of life care.
• The trust ensured that there was timely identification of patients requiring end of life care on admission. Systems were in place where a patient admitted who was known to the palliative care team would generate an alert to the team.
• 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.
• The chaplaincy team worked with ward staff and other professionals for patients receiving end of life care.
• An Integrated End of Life and Bereavement group was now in operation. This was headed by the Deputy Director of nursing the members of the group the SPCT, chaplaincy, the bereavement lead, education and training and consultant medical staff.
• Referrals to the SPCT could be made any time during a patient’s treatment. This allowed early involvement of the SPCT and time to facilitate the most appropriate care and treatment. The SPCT encouraged referrals from nursing, medical and allied health professional staff from across the trust.
• The trust had developed “Welcome to Hospice at Home – West Cumbria” initiative. All services provided are free of charge This service included the provision daytime and night nursing care, Respite Care - day, evening or night and also volunteer support in the home They can 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 Lymphoedema support. All services provided are free of charge
• The specialist palliative care team 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. Patients 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 where ‘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 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.
• Staff were consistently positive about delivering quality care for patients at the end of life.
• There was a commitment at all levels within the trust to raise the profile of death and 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 where care packages were 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 the 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.
• The trust could not provide the number of referrals to the SPCT.
• Both the SPCT and on general wards supported patient’s to die in their preferred location. However the trust did not collate or hold the data that would demonstrate the percentage of patients who died in their preferred location. This information was held by the Clinical Commissioning Group; however the trust could not provide this information.
• There was no regular audit of the CDP to demonstrate that the trust supports patient’s to die in their preferred location.
• 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 that the service being commissioned and provided is 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 still been unable to recruit to full time, substantive consultant paediatricians 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. However, data provided by the trust showed the unit was regularly overstaffed with registered midwives.
• Most 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.
• Medicines management was not always standardised across all sites and teams.
• There were many maternity guidelines and procedures 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 overall, with responsive as requires improvement, because:

• There was an electronic system to report incidents in the services. Staff were aware of how to report incidents.
• The environment of the services were visited were found to be clean and tidy and hygiene standards were good. Equipment was mostly available, except for bariatric wheelchairs and a recliner chair in the phlebotomy clinic.
• Medicines were found to be securely stores and medicines checked were in date. Data for medical records showed the improvement made previously had been generally maintained, however a recent change in the storage of the medical records had led to some challenges such as notes arriving late for clinics. Data provided by the trust showed that in September 2016, 94.38% of notes were available at the start of clinic
• Outpatient and Diagnostic services were delivered by caring, committed and compassionate staff. Patients were positive about the way staff looked after them and the care received.
• 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. Care and treatment was evidence based and followed national guidance.
• Staff had attended courses and further training to enhance competence in their services. Staff had access to the required information and systems, for example the electronic incident reporting system.
• Staff provided compassionate care and took into account the privacy and dignity of patients.
• The services had been responsive to the increasing demand for clinics by putting on addition clinics on a weekend where required. There had previously been issues with diagnostic six week waiting times; however there had been a steady trend of improvement at this inspection.
• There services had received a low number of complaints in the last 12 months.
• Outpatient managers were able to describe the risks to the services and what they action they were taking to mitigate the risks, however not all identified risks such as staffing levels were on the risk register.
• Staff were mostly positive about local leadership in the service. Staff we spoke with enjoyed their role and overall felt respected and valued by the trust. Staff described good team work and supportive teams.

However:

• Safeguarding mandatory training completion rates were below the trust target. Mandatory training completion rates were generally below the trust targets.
• The imaging department quality assurance system had been suspended when new equipment was installed and not re-introduced until eight months later. Diagnostic imaging did not carry out daily refrigerator temperature checks.
• Orthopaedic practitioner staffing levels were not at the planned levels.
• Referral to treatment time (RTT) data varied across the specialities. The service did have patients which the see by date had been breached.
• There were a number of clinics cancelled within 6 weeks of the planned clinic date across the trust, and there was no current action plan in place to address cancelled clinics in outpatients. 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

• 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 and were 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;
• All patients had a lower 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 West Cumberland Hospital was 2.2 days compared to the England average of 3.9 days;
• The average length of stay for all non-elective patients at Cumberland Infirmary was 0.9 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 five safeguarding training modules for which qualified nursing staff and for most modules 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 regarding the management of medicines, maximum and minimum temperatures were not recorded;
• From June 2017 to May 2018, the trust reported one never event at the hospital;
• Trauma and orthopaedics patients had a lower expected risk of readmission for non-elective admissions when compared to the England average;
• Urology patients had a much higher expected risk of readmission for non-elective admissions when compared to the England average;
• 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 there had been difficulties in covering the anaesthetic rota at West Cumberland Hospital previously;
• 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:

• There had been several serious incidents in which patients had suffered harm as a result of missed diagnosis, late escalation of deterioration, or delay in receiving treatment.
• Staff recording of deterioration and escalation needed to improve to ensure patients received the correct treatment in a timely manner.
• There were gaps in the process for identifying children at risk of harm and safeguarding training compliance rates for both nursing and medical staff were poor.
• The emergency department (ED) had a designated room for mental health assessment that did not meet Psychiatric Liaison Accreditation Network (PLAN) safety standards. Patients with mental health conditions also experienced long waits to see mental health specialists in the ED.
• Mandatory training for both nursing and medical staff was not always completed in a timely manner and compliance with mandatory training targets was poor for both.
• The ED achieved appraisal target rates, but staff across the trust reported that the quality of appraisals was poor.
• Patients experienced long waits in the department once a decision to admit had been made. This was due to bed shortages throughout the trust, but the impact was felt within the ED.
• National and local guidelines were not fully embedded, national audit results were poor, and the department was meeting very few audit standards. Some local work was underway to ensure that audit compliance improved.
• The ED did not have a formal vision or strategy at the time of the inspection.
• 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.

However:

• Staff worked hard to deliver the best care they could for patients.
• Staff who were newly qualified or newly employed by the ED were supported via preceptorships and mentorships during their first six months.
• Patients and families were involved in decision-making about their care in a way that they understood.
• Services were planned to meet individual needs. Patients could access emergency services appropriate for them and their individual needs were supported.
• There was a sense of teamwork within the department and operational staff worked together in partnership to provide care and treatment for patients.