Cumberland Infirmary

Updated 20 November 2023

North Cumbria Integrated Care NHS Foundation Trust (NCIC) was created in October 2019 following an acquisition of North Cumbria University Hospitals NHS Trust (NCUH) by Cumbria Partnership Foundation Trust (CPFT).

The trust provides a range of acute hospital services based at the Cumberland Infirmary in Carlisle (CIC)

The trust serves a population of approximately 320,000 in the west, north and east of Cumbria, in the districts of Allerdale, Carlisle, Copeland, Eden Valley and South lakes and Furness for some community services. It also provides services to parts of Northumberland and Dumfries & Galloway. The community is spread over a large geographical area, with 51% of residents living in rural settings. Over 65s make up a larger proportion of the population than the national average. Deprivation is similar to the England average and about 11,700 children (14.5%) live in poverty.

Updated 20 November 2023

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 September 2023

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 20 November 2023