The Care Quality Commission
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Westmorland General Hospital

Overall: Requires improvement read more about inspection ratings

Burton Road, Kendal, Cumbria, LA9 7RG (01539) 716689

Provided and run by:
University Hospitals of Morecambe Bay NHS Foundation Trust

All Inspections

20 April to 7 May 2021

During a routine inspection

Westmorland General Hospital is a part of the University Hospitals of Morecambe Bay NHS Foundation Trust. It has an urgent treatment centre and a midwifery-led maternity unit and provides elective surgery and out -patient services.

We visited Westmorland General Hospital as part of our unannounced inspection from 20 to 22 April 2021.

Our inspection was unannounced (staff did not know we were coming) to enable us to observe routine activity.

We visited urgent and emergency care and maternity core services as part of the inspection.

The Urgent Treatment Centre (UTC is staffed by GPs, doctors, emergency nurse practitioners and nurses.

The UTC became part of University Hospitals of Morecambe Bay Foundation Trust in April 2018. Prior to this is it was managed by a different foundation trust. The UTC was initially a Primary Care Assessment Service. It was then reclassified to an UTC in line with national guidance.

The UTC is designed to treat patients with minor illnesses and injuries. Patients with more serious conditions such as chest pains, strokes, serious illness or serious injuries attend the nearest Accident and Emergency department in Lancaster. If a patient attends with these more serious conditions, then the trust arranges for transfer to the nearest emergency department whilst maintaining the patients care and safety within the unit capabilities.

The UTC operates between 0800 and 2200 seven days a week.

Helme Chase is a midwife-led unit, based at the Westmorland General Hospital. A midwife-led unit means there are no doctors present. Women can give birth at Helme Chase 24 hours a day, seven days a week, supported by a midwife.

Women who have been identified with an uncomplicated pregnancy, i.e. they are unlikely to develop any complications during pregnancy, whilst giving birth, or after their baby is born, can choose to give birth at Helme Chase.

Community midwifery services provide antenatal, intrapartum and postnatal care including birth at home.

Between April 2020 and March 2021 there have been 15 babies born at Helme Chase. The birth rate prior to the COVID-19 pandemic was reported as 10 to 12 births per month including home births.

We were not able to observe care and treatment as no one was using the service during our site visit.

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

  • Across both services, staff did not always feel supported by the executive leadership team and reported they were not visible.

Maternity care

  • There was not always enough staff to care for women and keep them safe. Concerns were identified in relation to cleaning the birthing pool. The design, maintenance and use of facilities, premises and equipment in maternity services were not managed well to keep people safe. Maternity staff did not always complete and update some risk assessments for each woman nor take action to remove or minimise risks. Staff did not always identify and quickly act upon women at risk of deterioration. The maternity service did not always have enough staff with the right qualifications, skills, training and experience to keep women safe from avoidable harm and to provide the right care and treatment. The maternity service did not always manage safety incidents well.
  • The service did not always provide care and treatment based on national guidance and evidence-based practice. Managers did not check to make sure staff followed guidance. There was a lack of clear information to evidence how the service monitored the effectiveness of care and treatment. The service could not demonstrate how they used findings to make improvements and achieve good outcomes for patients. The service did not always make sure staff were competent for their roles.
  • The service did not plan and provide care in a way that met the needs of local people and the communities served. Women could not always access the service when they needed it nor receive the right care promptly.
  • The service did not run services well using reliable information systems or always support staff to develop their skills. Leaders did not operate an effective governance process and not all relevant risks and issues were identified and escalated with actions identified to reduce their impact. It was unclear what the vision was for the service.

However:

  • Across both services, staff had training in key skills, understood how to protect patients from abuse, and managed safety well. Staff kept good care records and managed medicines well.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.

Urgent and emergency care

  • The service had enough staff to care for patients and keep them safe. The service controlled infection risk well. Staff assessed risks to patients, acted on them and safety incidents well and learned lessons from them.
  • Staff provided good care and treatment. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients. Patients were advised on how to lead healthier lives and supported them to make decisions about their care. Key services were available seven days a week.
  • Urgent and emergency services had improved and planned towards care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. We saw information about how patients could give feedback throughout the centre. People could access the service when they needed it and did not have to wait too long for treatment.
  • Local leaders ran the urgent treatment centre well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service had improved since the last inspection and engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

Maternity care

  • Patients and women were given enough to eat and drink, and pain relief when they needed it.

14 Nov to 14 Dec 2018

During a routine inspection

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

  • Staff were well supported to improve quality and continuously develop. Staff were encouraged to contribute and work collaboratively to provide innovative ways to deliver more joined up care.
  • Consent practices were strong, and patient focussed including the accommodation of individual needs. People who use services were involved in the development of tools and support to aid informed consent.
  • Staff morale was high. Teams supported each other well and we saw examples of good teamwork. We saw staff from different professions working well together and staff told us they were proud of their work.
  • Infection control measures were effective. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection.
  • Patient records across the trust were of a good standard, up to date, legible and accessible.
  • Feedback for the service was good and there were very few complaints. The culture was very person-centred and promoted kindness and dignity. People’s needs, and preferences were respected. The emotional needs of patients were in the forefront of the minds of staff and they worked with patients to develop better ways to encompass these.
  • There were escalation policies, guidance and care pathways for deteriorating patients. Staff completed and updated risk assessments for each patient. They kept clear records and asked for support when necessary.
  • Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
  • Staff involved patients and those close to them in decisions about their care and treatment. Patients confirmed that staff treated them well and with kindness, providing emotional support to minimise their distress.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness. Staff used the World Health Organisation (WHO) surgical safety checklist, ‘Five Steps to Safer Surgery’. National and local safety standards for invasive procedures incorporated the contents of the WHO surgical safety checklist.
  • Managers checked to make sure staff followed guidance, monitored the effectiveness of care and treatment and used the findings to improve them. They compared local results with those of other services to learn from them.

However:

  • Staff were not up to date with mandatory training and other important training such as safeguarding vulnerable adults and children. Safeguarding processes were not robust. Additionally, staff had not undergone regular appraisals and did not feel competent to manage some of the patients who attended the department. As a result, we had concerns about the safety of the department.
  • The department did not have a suitable safe place for patients living with a mental health condition.
  • Some patients experienced delays in receiving some test results and often experienced delays being transported to other care settings; transport delays were outside of the influence of the trust. This was a potential risk to patients.
  • The UTC did not have embedded governance systems in place and had only recently introduced clinical audit as a way of assuring quality. Patient outcomes had not been monitored and managed in a robust way.
  • The UTC had undergone a series of changes. As a result, governance and leadership processes were not fully embedded in the department. Therefore, at the time of the inspection, despite there being plans in place for the department, we were not assured the department was able to demonstrate that it was well led.
  • Not all staff were not up to date with mandatory training and other important training such as safeguarding vulnerable adults and children. Safeguarding processes were not always robust in UTC. Additionally, staff had not undergone regular appraisals and did not feel competent to manage some of the patients who attended the department. As a result, we had concerns about the safety of the department.

11-14 and 26 October 2016

During an inspection looking at part of the service

We carried out a follow up inspection between 11 and 14 October 2016, to confirm whether University Hospitals of Morecambe Bay NHS Foundation Trust (UHMB) had made improvements to its services since our last comprehensive inspection, in July 2015. We also undertook an unannounced inspection on 26 October 2016.

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

When we last inspected Westmorland General Hospital in July 2015 we rated services as 'good' overall, although surgical services were rated as 'requires improvement' for being responsive to people’s needs, and outpatients and diagnostic imaging services were rated as 'requires improvement' for safe.

There were two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations. These were in relation to referral to treatment times (RTT) n surgical specialities and suitability of premises within the outpatient department (OPD).

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

We found that the trust had made the required improvements and rated WGH as 'goo' overall.

Our key findings were as follows:

  • Staff knew the process for reporting and investigating incidents using the trusts reporting system. They received feedback from reported incidents and felt supported by managers when considering lessons learned.
  • Patients were treated with compassion, dignity, and respect.
  • Wards, outpatients, and theatre nurse staffing skill mix was variable during shifts, but measures were in place to ensure the safety of patients. Generally, on surgical wards, nursing staff to patient ratio was one to eight. We reviewed the nurse staffing levels on all wards and theatres, and found that numbers and skill mix appropriate at the time of inspection.
  • Medical staffing was provided by consultants and doctors for elective activity between 08:00 and 18:00, Monday to Friday. All surgery was supported by a resident medical officer on a 24 hour basis.
  • The hospital had an escalation policy and procedure to deal with busy times, and staff attended bed meetings in order to monitor bed availability on a daily basis.
  • There had been no cases of clostridium difficile or Methicillin Resistant Staphylococcus Aureus (MRSA) in the surgical division at WGH between October 2015 and September 2016 .
  • The hospital had infection prevention and control policies in place, which were accessible, understood, and used by staff. Patients received care in a clean and hygienic environment.
  • Allied health professionals (AHPs) worked closely with ward staff to ensure a multi-disciplinary team (MDT) approach to patient care and rehabilitation.
  • We saw that patients were assessed using a nutritional screening tool, had access to a range of dietary options, and were supported to eat and drink.
  • The trust’s referral to treatment time (RTT) for admitted pathways for surgery services had improved since the last inspection. Information for September 2016 showed an improvement in the trust’s performance, with 75% of this group of patients treated within 18 weeks against the England average of 75%.
  • In outpatients, the overall environment had improved. We noted that space was still limited in some areas.
  • In outpatients, there remained a shortage of some staff groups including occupational therapists, radiographers, and radiologists.
  • Leadership across the hospital was reported as good, staff morale had improved, and staff felt supported. All staff spoke positively about the service they provided for patients.

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

The trust should:

In surgery:

  • Continue to sustain improvement in hand hygiene audit result.
  • Continue improving venous thromboembolism (VTE) assessments.
  • Continue improving Referral to Treatment Times (RTT) for patients and continue to implement trust-wide initiatives to improve response.
  • Increase medical/orthogeriatricians input on surgical wards
  • Ensure all transfers between locations are performed in line with best practice guidance and policy. Where practice deviates from the guidance, a clear risk assessment should be in place.
  • Continue with staff recruitment and retention.

In maternity and gynaecology:

  • Ensure that outcome measures are developed to monitor the effectiveness of the strategic partnership with Central Manchester University Hospitals NHS Foundation Trust and Lancashire Teaching Hospitals NHS Foundation Trust.

In outpatients and diagnostic imaging:

  • Continue to ensure sufficient numbers of suitably qualified, competent, skilled, and experienced persons are deployed in order to meet the needs of the patients. This is particularly in relation to radiology, ophthalmology, and allied health professionals.
  • Continue work started to ensure that all premises used by the service provider are suitable for the purpose for which they are being used, properly used, properly maintained, and appropriately located for the purpose for which they are being used. This is particularly in relation to the macular clinic.
  • Ensure that it meets RTT targets in outpatient clinics, and that it addresses backlogs in follow-up appointment waiting times.

Professor Sir Mike Richards

Chief Inspector of Hospitals

17 July 2015

During an inspection looking at part of the service

Westmorland General Hospital is one of three locations providing care as part of University Hospitals of Morecambe Bay NHS Foundation Trust. The hospital provides elective surgical services, a midwifery led maternity service and outpatient and diagnostic services including pathology, radiology and endoscopy, and allied health services such as physiotherapy, occupational therapy, dietetics and pharmacy services. The hospital does not provide Accident & Emergency services, critical care or services for children and young people. However the hospital does hold paediatric clinics in the outpatients department.

University Hospitals of Morecambe Bay NHS Foundation Trust provides services for around 360,000 people across North Lancashire and South Cumbria with over 700 beds. In total, Westmorland General Hospital has 43 beds.

We inspected University Hospitals of Morecambe Bay NHS Foundation Trust as part of our comprehensive inspection programme in February 2014. Following our inspection in February 2014 we rated Westmorland General Hospital as ‘good’ overall. We judged the hospital as ‘good’ for safe, effective, caring, and responsive. Surgery and maternity were rated as ‘good’, however outpatients and diagnostic imaging was rated as ‘requires improvement’. This was because of long waiting time appointments in some departments and difficulties in securing case notes and test results for patient appointments.

At this inspection, we rated Westmorland General Hospital as ‘good’. We have judged the service as ‘good’ for safe, effective, caring, responsive and well-led care. Surgery, maternity and outpatient and diagnostic imaging were rated as ‘good’.

Our key findings were as follows:

Cleanliness and infection control

  • The trust had infection prevention and control policies in place which were accessible to staff.
  • We observed good practices in relation to hand hygiene and ‘bare below the elbow’ guidance and the appropriate use of personal protective equipment, such as gloves and aprons, while delivering care.
  • ‘I am clean’ stickers were used to inform staff at a glance that equipment or furniture had been cleaned and was ready for use.
  • Patients received care in a clean, hygienic and suitably maintained environment. Staff were aware of and applied infection prevention and control guidelines.
  • Between April 2014 and February 2015 there had been no cases of Clostridium Difficile in the surgical division at Westmorland General Hospital.

Nurse staffing

  • Care and treatment were delivered by committed and caring staff who worked hard to provide patients with good services.
  • The nursing staff vacancy rate was 18.8 whole time posts in May 2015. There had been no use of agency staff as staff had been made available from the elective orthopaedic unit which had been closed for two months.
  • The nursing staff ratios were calculated separately in each area to determine safe staffing levels dependent on the activity for the day.
  • Numbers of staff on duty met with the NICE guidelines “Safe staffing for nursing in adult inpatient wards in acute hospitals” in the ratio of one nurse to eight patients. This was maintained with clinical support workers providing additional assistance.
  • The service met the national benchmark for midwifery staffing set out in the Royal College of Obstetricians and Gynaecologists (RCOG/RCM) guidance (Safer Childbirth: Minimum Standards for the Organisation and Delivery of Care in Labour) with a ratio of 1 midwife to 25 births compared to the RCOG recommendation of 1 midwife to 28 births.

Medical staffing

  • The number of medical staff employed to work solely at Westmorland General Hospital was 4.4 doctors. There was a vacancy of 1.4 doctors and recruitment was underway.
  • Consultants completed operations for their speciality at this hospital at booked session times. If there were low numbers of permanent staff in that speciality, for example urology, then locum medical doctors would carry out the procedures.
  • There was a resident medical officer who was on- call at all times, including nights and weekends. They visited the inpatient wards every morning, midday and evening seven days per week and were available to visit during the night if required.
  • In maternity services, there were two consultant led antenatal clinics per week.
  • There were vacancies for radiologists. The trust was actively recruiting for these posts and had introduced the use of extended roles for advanced practitioners to help manage caseloads.

Mortality rates

  • The trust was highlighted as a ‘risk’ for the in-hospital mortality indicator - Cerebrovascular conditions in the CQC Intelligent monitoring report May 2015.
  • Mortality and morbidity meetings were held weekly or monthly at the other trust sites and were attended by representatives from all teams within the relevant divisions from this hospital. As part of these meetings, attendees reviewed the notes for patients who had died in the hospital within the previous week. Any learning identified was shared and applied.

Nutrition and hydration

  • Patients had a choice of nutritious food and an ample supply of drinks during their stay in hospital. Patients with specialist needs in relation to eating and drinking were supported by dieticians and by the speech and language therapy team.
  • The patient records we reviewed included an assessment of patients’ nutritional requirements based on the malnutrition universal screening tool (MUST).
  • Where patients were identified as being at risk, there were fluid and food charts in place..

There were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • Ensure that all premises used by the service provider are clean, secure, suitable for the purpose for which they are being used, properly used, properly maintained and appropriately located for the purpose for which they are being used. This is particularly in relation to services provided in outpatients.

In addition the trust should:

In surgical services:

  • Ensure that there are systems and process in place to for staff to be made aware of any learning and change of practice from audit programmes.
  • Review written consent being obtained on the day of surgery.
  • Ensure that the 5 steps to safer surgery process is audited to monitor that it is being used appropriately, particularly in surgical care.

In maternity and gynaecology services:

  • Ensure that the actions of the Kirkup recommendations are implemented within timescales and embedded across the trust.
  • Ensure that a practical test of the child and infant abduction policy is completed every 12 months in line with trust policy.
  • Ensure safeguarding records always record outcomes of meetings with social workers.
  • Ensure that staff act in accordance with the requirements of the Mental Capacity Act 2005 and associated codes of practice.

In outpatients and diagnostic imaging:

  • Ensure that staff act in accordance with the requirements of the Mental Capacity Act 2005 and associated codes of practice.

Professor Sir Mike Richards

Chief Inspector of Hospitals

4-6 February 2014

During a routine inspection

Context

University Hospitals of Morecambe Bay NHS Foundation Trust became a Foundation Trust on 1 October 2010 and provides a comprehensive range of acute and support hospital services for around 350,000 people across north Lancashire and south Cumbria with over 740 beds.

The trust operates from three main hospital sites at the Furness General Hospital in Barrow, the Royal Lancaster Infirmary, and the Westmorland General Hospital in Kendal. The Queen Victoria Hospital in Morecambe provides outpatient services and Ulverston Community Health Centre provides nutrition, dietetics and breast screening. This inspection will focus only on the acute services provided at Royal Lancaster Infirmary, Furness General Hospital and Westmorland General Hospital.

There have been significant changes to the trust board since 2012. The entire board of Directors has changed since 2012 with 14 new appointments made, including the Chief Executive. In the seven months prior to our inspection four executive directors had taken up post.

University Hospitals of Morecambe Bay NHS Foundation trust has been selected as one of the early trusts to be inspected under CQC’s revised inspection approach. The trust was selected for inspection as a trust where there were known risks to service delivery.

Overall inspection findings at Westmorland General Hospital

We found that staff at the hospital were committed to providing safe and effective care for patients. There were good examples of compassionate and person-centred care cross all the services provided.

The hospital was clean throughout and there was an ample supply of hand washing facilities and hand gels to prevent and control infection risks. The entrance to the hospital had recently been upgraded and patient facilities had been improved.

Surgical services were well managed and patients were very complimentary about the care and treatment they received at the hospital. The Midwife led maternity service was well managed and was valued by the women using the service.

The midwife-led service provided at Helm Chase maternity service was well managed and highly valued by the women who used the service.

Although performance had improved over the last year the trust is still experiencing some difficulties in outpatients in relation to appointments and the availability of patient records. The trust were working hard to improve this element of the service.

Although performance had improved over the last year the trust is still experiencing some difficulties in outpatients in relation to appointments and the availability of patient records. The trust were working hard to improve this element of the service.

15 January 2013

During an inspection looking at part of the service

In July 2011 we inspected The University Hospitals of Morecambe Bay NHS Foundation Trust in relation to concerns that were raised around Maternity Services. Following that inspection The Royal Lancaster Infirmary (RLI) and Furness General Hospital (FGH) were found to be non compliant in outcomes 1,8,10,13,16 and 21 and we served a warning notice and set compliance actions.

In July 2012 we re visited RLI and FGH to check compliance with the warning notice and to follow up compliance actions from the 2011 inspection. In 2011 we did not find any areas of non compliance specific to the Westmorland General Hospital (WGH) maternity service other than those that were shared across all three sites around the escalation of risk and medical teams not working effectively. The governance work that was completed to achieve compliance across RLI and FGH had a positive impact on the service at WGH.

Helme Chase maternity unit in Westmorland General hospital provides a midwifery led service.

The way the reports were generated in 2011 meant that it looked like Westmorland General Hospital was non compliant. This report has been generated to make sure this hospital site contains the correct information. We did not make a visit to WGH at this time but used the information that we had previously gathered in July 2011 and August 2012. For a full picture of the maternity services please refer to the reports generated for RLI and FGH published in September 2012.

18, 19, 20 July 2011

During an inspection in response to concerns

We focused during our visits upon the experiences of the women using the maternity services across the Trust and on getting their opinions on the care and support they had received. We talked with mothers, their relatives, clinicians and midwifery practitioners and people expressed a range of largely positive views. Mothers we talked with confirmed that there were good levels of information provision across all three maternity units with mothers being given choice about the kind of care available to them.

The mothers we talked to told us that they understood their care and treatment and told us they were kept up to date about what was happening and given explanations about what was happening during their pregnancies and also during labour so they could make informed decisions. All the mothers we talked with expressed satisfaction with the care and support they had received from the midwives during their stay on the maternity units. All those mothers we talked to on the post natal wards told us the midwives had 'always' asked them what they wanted during their labour and given them explanations. All those we talked to confirmed that once in established labour they had not been left on their own by midwives. We were also told that doctors and consultants spent time with them and explained why changes to their plan were needed.

One mother told us staff had been 'brilliant' and had 'acted quickly when things changed' and that 'all the options were discussed with us'. Another commented on the fact that they had felt able to ask their consultant questions 'all the way through being pregnant'.

Another mum who had been transferred between units told us 'It was a very quick response, and they (staff) explained as much as they could'.

Mothers also commented that they could see staff were busy at times during their stays and one in Furness General Hospital told us 'They were very busy when I came in, despite that they were always there for me'.