The Care Quality Commission
  • Organisation
  • SERVICE PROVIDER

University Hospitals of Morecambe Bay NHS Foundation Trust

This is an organisation that runs the health and social care services we inspect

Overall: Requires improvement read more about inspection ratings
Important: Services have been transferred to this provider from another provider

All Inspections

4 & 5 April 2023 and 15 - 18 May 2023

During a routine inspection

The University Hospitals of Morecambe Bay NHS Foundation Trust (UHMBT) provides hospital services across the Morecambe Bay area - an area covering a thousand square miles in south Cumbria and north Lancashire.

It operates from three main hospitals - Furness General Hospital (FGH) in Barrow, the Royal Lancaster Infirmary (RLI), and Westmorland General Hospital (WGH) in Kendal.

FGH and the RLI have a range of general hospital services, with full emergency departments, critical/coronary care units and various consultant-led services. WGH provides a range of general hospital services, together with an urgent treatment centre.

All three hospitals provide a range of planned care including outpatients, diagnostics, therapies, day case and inpatient surgery. In addition, a range of local outreach services and diagnostics are provided from community facilities across Morecambe Bay.

We carried out an unannounced inspection of the medical care core service at Royal Lancaster Infirmary and the maternity core services at Royal Lancaster Infirmary and Furness General Hospital.

Following our previous inspection, under Section 31 of the Health and Social Care Act 2008, we imposed urgent conditions on the registration of the provider in respect to the regulated activities of diagnostics and screening and treatment of disorder, disease and injury for both medical and maternity services.

The trust made an application for the conditions to be removed in March 2023. The trust was inspected to assess whether the required improvements, had been made and sustained.

As a result of the evidence submitted by the trust and gathered during our inspections of the core services, we agreed to remove the conditions in June 2023.

20 April to 14 May 2021

During a routine inspection

We carried out an unannounced inspection of urgent and emergency care services, surgery and maternity core services of the (acute) services provided by this trust because at our last inspection we rated the trust overall as requires improvement and we had concerns about the quality and safety of some services.

During our inspection we became aware of concerns about the stroke pathway for patients and did a further unannounced responsive inspection of this service at Royal Lancaster Infirmary and Furness General Hospital.

Overall, we rated the trust and each location as requires improvement. We also inspected the well-led key question for the trust overall. We rated three out of the ten services inspected as good, three as requires improvement and two as inadequate.

Following this inspection, under Section 31 of the Health and Social Care Act 2008, we imposed urgent conditions on the registration of the provider in respect to the regulated activities; Diagnostics and Screening and Treatment of Disorder, disease and Injury. We took this urgent action as we believed a person would or may be exposed to the risk of harm if we had not done so. Imposing conditions means the provider must manage regulated activities in a way which complies with the conditions we set. The conditions related to the stroke services at Royal Lancaster Infirmary and Furness General Hospital. In light of this, we suspended the ratings for Medical care including care for older people.

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

Safe

  • Not all staff supporting children had completed paediatric advanced life support training. Not all staff, at the trust, had completed safeguarding level three training.
  • Patients identified for the stroke pathway did not always receive care and treatment in line with national guidance or trust policies.
  • There was not always sufficient staff with the right qualifications, skills, training and experience to provide care and treatment for children in the urgent and emergency departments and sufficient staff to care for women in maternity services.
  • Staff did not always adhere to trust and national infection prevention and control guidance with regards to social distancing and wearing of personal protective equipment in urgent and emergency services.
  • Controlled drugs were not always stored, administered and recorded safely. The Trust process for the administration of medicines following Patient Group Directions (PGD’s) had been reviewed and updated but had not been implemented effectively in some locations.
  • The escalation plan for caring for patients in the corridor was not always adhered to.
  • Women receiving maternity care, who were assessed as at risk of sepsis, did not always receive care and treatment in line with national guidance. Risk assessments were not always completed for women or for patients identified with mental health concerns.
  • It was not clear if national early warning scores were always assessed and used to identify any signs of deterioration as they were not always documented in patient records. It was not always clear if all risks to women in labour were assessed, including when risk levels changed from low to high, with a need to escalate care safely.
  • Although harm grading guidance was available, we were not assured that all incidents were graded appropriately to reflect the level of harm.

However;

  • Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The trust controlled infection risk well.
  • In surgery there was enough staff to care for patients and keep them safe.

Effective

  • Current policies were not always available for staff to access during care and treatment of patients.
  • The trust did not always submit information for audits, including national audits, and not all services were included in the audit programme.
  • The trust did not always manage patient pain effectively including reassessing pain scores in line with trust policy.
  • There was not always effective multidisciplinary working in the trust to benefit patient care, treatment and outcomes.

However;

  • Staff provided good care and treatment, gave patients enough to eat and drink. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.

Caring

  • The trust did not always maintain patients’ privacy and dignity, specifically when needing to be cared for in a corridor in the urgent and emergency department.

However;

  • Staff treated patients with compassion and kindness and took account of their individual needs and helped them understand their conditions. They provided emotional support to patients, families and carers.

Responsive

  • The trust did not always manage the flow of patients, in the urgent and emergency care department with patient spending long periods waiting for an in-patient bed.
  • The length of stay for patients receiving care for trauma and orthopaedics was longer than the national average.

However;

  • The trust planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback.

Well-led

  • Although the trust had an overall vision and strategies, not all services had their own vision and strategy.
  • Trust governance processes were not robust or always effective. Risks were not always identified correctly with appropriate mitigations put in place.

However;

  • Most staff felt respected, supported and valued. 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 trust engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

You can find further information about how we carry out our inspections on our website: www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

14 Nov to 14 Dec 2018

During a routine inspection

Our rating of the trust went down. We rated it as requires improvement because:

We rated safe, responsive and well led as requires improvement and effective and caring as good. The safe and effective ratings remained the same as our inspection in 2016. However, caring went down from outstanding to good and well-led and responsive went down from good to requires improvement.

  • In rating the trust, we took into account the current ratings of the services that we did not inspect during this inspection but that we had rated in our previous inspection.
  • We rated well led for the trust overall as requires improvement. This was not an aggregation of the core service ratings for well led

Our full inspection report summarising what we found and the supporting evidence appendix containing detailed evidence and data about the trust is available on our website – www.cqc.org.uk/provider/RTX/reports.

11-14 October 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 this trust in July 2015, we rated services as requires improvement. We rated safe, effective, responsive and well led as requires improvement. We rated caring as good.

There were seven breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations. These were in relation to staffing, supporting staff, safety and suitability of premises, safe care and treatment, and assessing and monitoring the quality of service provision.

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 signifcantly improved and rated it as good overall, with caring rated as outstanding and safe rated as requires improvement.

Our key findings were as follows:

  • There had been significant improvements across most services in the trust since our last inspection in July 2015. This was particularly demonstrated in maternity and gynaecology, and end of life services.
  • In medical, critical care, and end of life care services, there were a number of outstanding examples of compassionate care and emotional support shown by all levels and disciplines of staff, who did not hesitate to go the extra mile to make a difference for patients and their loved ones.
  • Leadership across the trust was good, managers were available, visible, and approachable; staff morale had improved significantly and they felt supported. Staff spoke positively about the service they provided for patients.
  • Cross bay working as well as joint working between services had been significantly strengthened since the last inspection.
  • There were good levels of staff engagement across the trust. Staff were proud of the organisation as a place to work. The NHS Staff Survey 2016 demonstrated many areas of improvement.
  • The investment in leadership programmes was good, particularly at middle management level.
  • Senior leadership was stable and had been strengthened since the last inspection.
  • The trust valued and encouraged public engagement. There were many examples of good public engagement, particularly in maternity services.
  • Staff knew the process for reporting and investigating incidents using the trust's reporting system. They received feedback from reported incidents and felt supported by managers when considering lessons learned.
  • The trust had infection prevention and control policies in place, which were accessible, understood and used by staff. Patients received care in a clean, hygienic and suitably maintained environment.
  • The trust reported no incidences of Methicillin Resistant Staphylococcus Aureus (MRSA) infection between September 2015 and May 2016. Eight cases of clostridium difficile were reported in the same period.
  • Nursing and medical staffing numbers had improved since the last inspection. However, there were still a number of nursing and medical staffing vacancies across the trust, especially in medical care services and the emergency departments. The trust had robust systems in place to manage staffing shortfall as well as escalation processes to maintain safe patient care.
  • The trust had improved compliance with mandatory training and appraisal targets in most services. Local support and supervision of junior staff had improved, and many areas had developed their own unit-specific competencies for training and development purposes.
  • There had been an improvement in record-keeping standards across the trust, however, we identified some ongoing areas for improvement around legibility and trigger levels for early warning of deterioration, particularly in medical care services and the emergency department.
  • 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%.
  • Access and flow, particularly in the emergency departments and medical care services, remained a challenge. The emergency department performance had deteriorated over the last 12 months. The Department of Health’s standard for emergency departments is that 95% of patients should be admitted, transferred or discharged within four hours of arrival in the A&E. The trust breached the standard between October 2015 and September 2016. Lack of beds in the hospital resulted in patients waiting longer in the emergency department. Delays in obtaining suitable community care placements were causing access and flow difficulties, particularly in medical care services.

We saw several areas of outstanding practice including:

  • The Listening into Action programme had delivered clear, effective, and significant quality improvements for the organisation and for patients across the hospital.
  • There were many examples of public engagement in the development and delivery of maternity services, such as co-designing the new maternity unit, interviews for the recruitment of new staff, including midwives and matrons, and the development of guidelines and strategies.
  • The service was one of three trusts which were successful in securing funding to pilot a maternity experience communication improvement project. This was a patient-based training tool for multi-professional groups in maternity services. The project had the potential to be adopted nationally if learning outcomes and measurable improvements could be made for women who were using maternity services.
  • The bereavement team, Chaplaincy, and specialist palliative care (SPC) team worked together to promote compassionate care at the end of life. A particular innovation relating to this had been the development of death cafés. A death café provided an opportunity for people to talk more openly about death and dying. The trust had held death cafés for the public as part of ‘dying matters’ week, and also had used them to support staff to talk more openly about death, and to promote better communication with patients and relatives at the end of life.
  • There were a number of innovations relating to compassionate care for patients at the end of life. This included the use of canvas property bags with dragonfly symbols, so staff knew that thosecollecting the property had been recently bereaved. In addition, bereavement staff sent out forget-me-not seeds to family members following the death of a loved one. Families were also able to get casts of patients' hands. This was a service provided by an external organisation, with funding provided by the trust.
  • The trust had adopted the dragonfly as the ‘dignity in death’ symbol. This was used as a sign to alert non-clinical staff to the fact that a patient was at the end of life or had died. A card with the symbol was clipped to the door or curtain where the patient was being cared for. By alerting all staff this meant that patients and family members would not have to face unnecessary interruptions and non-clinical staff knew to speak with clinical staff before entering the room. An information card had been produced for non-clinical staff explaining the difference between the dragonfly symbol (dignity in death) and the butterfly (dementia care).
  • A remembrance service was held by the Chaplaincy every three months for the bereaved. We were also told that ‘shadow’ funeral services had been delivered within the trust when patients had been too unwell to attend funerals of loved ones.
  • Relatives were sent a condolence letter by the bereavement service a few weeks after the death of a loved one,; and support was offered at this time.

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

Importantly, the trust must:

In urgent and emergency care services:

  • Monitor performance information to ensure 95% of patients are admitted, transferred or discharged within four hours of arrival in the emergency departments across the trust.
  • Ensure patients do not wait longer than the standard for assessment and treatment in the emergency departments across the trust.

In services for children and young people:

  • Ensure there are sufficient nursing staff at Royal Lancaster Infirmary (RLI) to comply with British Association of Perinatal Medicine (BAPM) and Royal College of Nursing (RCN) guidance.

Professor Sir Mike Richards Chief Inspector of Hospitals

14-17 July 2015

During an inspection looking at part of the service

University Hospitals of Morecambe Bay NHS Foundation Trust is a large acute hospital provider serving the population of South Cumbria and North Lancashire. The trust was established in 1998 and gained teaching status in January 2006. It has been a foundation trust since 2010. Services provided at the trust are commissioned by two clinical commissioning groups based in Lancashire and Cumbria.

The trust provides services from three principal sites to a population of 365,000, covering South Cumbria, North Lancashire and surrounding geographical areas. The hospital sites we inspected were: Furness General Hospital in Barrow; Royal Lancaster Infirmary in Lancaster and Westmorland General Hospital in Kendal.

We carried out this inspection to follow up on the improvements required in response to the findings of our inspection in February 2014. At the time of our February 2014 inspection we had significant concerns regarding the trust’s ability to assure safe and well managed services for patients. There were particular concerns relating to medical services and critical care services as well as significant concerns regarding the trusts strategic approach to service provision, its leadership capacity and its governance systems. The safety and well led domains were rated as inadequate.

Our inspection findings led to a recommendation that the trust be placed in ‘special measures’. Special measures is a status applied by regulators of public services in England to providers who fall short of acceptable standards. In response an improvement director was appointed by Monitor to support the trust in making the required improvements. The trust developed a detailed action plan to address the identified shortfalls. Since that time we have worked closely with the trust and Monitor regarding the implementation of the required improvements.

We carried out a further inspection between July 14 and July 17 2015 (inclusive) to assess and evaluate the impact of the improvements made on the safety and quality of services provided to patients, and to evaluate how well the trust was led and managed. We looked at all the core services provided by the trust which are;

  • Accident and emergency
  • Medical care (including older people’s care)
  • Surgery
  • Critical care
  • Maternity and family planning
  • Services for children and young people
  • End of life care
  • Outpatients.

We also looked at the progress the Trust had made in implementing the recommendations made by Public Health England (PHE) following a review of the Breast Screening Service undertaken in response to concerns raised by staff. In addition, we reviewed the progress the trust was making in implementing the recommendations made following the enquiry in to maternity services by Dr Bill Kirkup.

The trust had made progress in all the areas we identified in our inspection in February 2014. However, there were still a number of areas that required further and ongoing improvement. Key concerns related to the recruitment of nursing and medical staff. There were also a number of midwife vacancies. The trust acknowledged that further work was required and there were plans and initiatives in place to secure additional staff at the time of our inspection.

Our key findings were as follows;

Leadership and staff engagement

The Executive Team had stabilised and was working well together to secure service improvements, a new Chief Operating Officer had been appointed. Senior managers were more visible and accessible to staff and staff were positive about this development.

The trust had approved its Quality Improvement Plan 2014-2017, ‘Better Care Together’. This document detailed clear objectives with expected outcomes and indicators for the improvement trajectory.

To support the delivery of ‘Better Care Together’ and staff engagement overall, the trust had commenced the ‘Listening into Action’ programme. The first year of Listening into Action (LiA) resulted in clinical teams leading 16 quality improvement schemes through a 20 week improvement cycle. A further 13 teams are now being supported through the next improvement cycle and 10 priorities have been identified for accelerating LiA as the key approach for engagement and improvement in 2015/16 onwards.

The trust had also appointed a ‘freedom to speak up guardian’ in response to the Freedom to Speak Up Review into whistleblowing in the NHS. The intention was to support staff so they could raise concerns in the public interest with confidence that they would not suffer detriment as a result. This work was in progress at the time of our inspection.

However, there were areas regarding staff engagement and support that still required improvement. One area of particular concern was the Workforce Race Equality Standard (WRES) submission which highlighted that BME staff had a disproportionate employee experience compared to non-BME colleagues. These views were confirmed in our meetings and focus groups with BME staff. Some staff felt they were very well supported, however others alleged a bullying culture where they felt marginalised and unable to raise concerns without there being repercussions. We raised this matter with the trust who confirmed that they were aware of the issues and, in response, had met with BME staff representatives to hear their concerns and had committed to working with staff to agree what actions needed to be taken to improve this. The trust had reviewed its leadership on diversity and inclusiveness, and as a result had appointed a designated Board lead and leads for both workforce and service issues. There were plans in place to involve and include staff from a BME background in all of the work streams intended to secure improvements and promote an open and just culture.

However, there were concerns regarding the culture in the paediatric service in Furness General Hospital. Senior clinicians reported a bullying culture where concerns were slow to be heard and addressed.

Leadership development

The trust had a Leadership Development Strategy that was approved on the 24 June 2015. This document described the trust’s strategic approach and included values-based leadership, staff engagement/Listening into Action, Human Factors and alignment with the NHS Healthcare Leadership Model. A scoping exercise for Clinical Leadership Development was planned for the summer, to complement the Kirkup recommendations on reviewing clinical leadership training. A bespoke development programme for ward and clinical team leaders had been commissioned, with the second cohort now undertaking this programme.

Governance and risk management.

Governance and risk management systems had improved considerably since our last inspection. A comprehensive Risk Management Strategy (2015-16) was in place that set out the roles and responsibilities for risk management. The appendices of the strategy gave clear guidance on how to undertake a risk assessment for inclusion on the risk register.

The Board Assurance Framework (BAF) had been reviewed in relation to its structure and appropriateness for the organisation. The BAF was reviewed and presented to the board at the April 2015 Board meeting. The framework was aligned to the trust vision, values, objectives and priorities. Controls, mitigation, assurance, gaps in assurance, rating and rationale for rating were clearly documented. The BAF linked to the corporate risk register identified appropriate risks and there was evidence of the Board reviewing corporate risks in both January and April 2015. This was an improvement since our last inspection.

Nurse staffing

Nurse staffing levels had improved. Ward staffing establishments were calculated using a recognised dependency tool and regularly reviewed. There were minimum staffing levels set for all wards and departments. The ‘red rules for safety’ initiative was being implemented across all wards and departments.

The principals of this initiative included one registered nurse should deliver care to no more than eight patients and the minimum skills mix on a ward should be 60% registered nurses to 40% health care assistants.

The staffing issues in the High Dependency Unit had been comprehensively addressed and there was sufficient numbers of nurses to meet the needs of patients at all times. In other wards and departments throughout the trust staffing levels met the needs of the patients at the time of our inspection; however, the skill mix on ward 39 and ward 20 at Royal Lancaster Infirmary was still variable and did not always meet the ‘red rules’ requirements of one registered nurse to eight patients. E-rostering data excluded bank and agency. Safer staffing data demonstrated that ward 39 and ward 20 had sufficient staffing for the month of June 2015. There were times when skill mix had been reduced this was due to additional health care support staff being employed to support dependent patients on these wards. The data demonstrated that staff were used flexibly over a 24-hour period. In Furness General Hospital staffing levels met the needs of the patients at the time of our inspection, however, on reviewing staffing rotas over the previous month there were concerns regarding the staffing levels and skill mix on some wards. It was evident that there were still nurse vacancies in some specialities. There was an escalation process in place for managers to respond to staffing challenges, however there were times when wards were not always appropriately staffed.

In May 2015 the trust reported a registered nurse vacancy rate of 13.1%. The trust was engaged in the ongoing recruitment of staff at the time of our inspection.

The trust also continued to develop additional solutions to respond to staff shortages, including Physician’s Assistants, Advanced Practitioners and Non-Medical Consultant roles. In addition, the trust had successfully appointed a cohort of 36 Apprentices in Clinical Healthcare and was currently advertising for a further 36 apprentices to commence in September 2015. The trust continued to work with external recruitment agencies to undertake bespoke recruitment overseas.

Medical Staffing

There were a number of concerns regarding medical staffing including middle grade cover in surgery at Westmoreland Hospital; In addition there were concerns regarding the sustainability of the paediatric consultant on call cover and lack of junior doctor cover in the service for children and young people. There were ongoing challenges in addressing the concerns within the breast screening unit and there were consultant vacancies within End of Life Care with no post at Furness General Hospital.

The trust however performed within expectation for 11 categories out of 13 in the GMC National Training Scheme survey.

Incident reporting

The trust was actively reporting patient safety incidents. The most recent NRLS report (March 2015) detailed a ratio of 43.49 patient safety incidents reported per 1000 bed days. The average for all acute trusts is 35.1. This indicates good performance by the trust in this regard.

The trust had a process for the management of serious incidents and held a weekly ‘Patient Safety Summit’ to review all incidents causing moderate harm or above, alongside any significant near misses. The weekly summit had the responsibility of identifying trends that were then allocated to task and finish groups, completing root cause analysis investigations and providing a quarterly summary to the ‘SIRI Panel’. The SIRI Panel provided a quarterly report to the Quality Committee. The Quality Committee in turn reported to the Board.

Paediatric medical staff remained concerned about their lack of involvement in the ‘rapid review process’ in relation to Serious Incidents Requiring investigation (SIRI) and felt excluded from the process in incidents relating to babies referred from maternity services.

Implementing recommendations and securing improvement.

Public Health England (PHE) had undertaken a review of the Breast Screening Service in response to concerns raised by staff. The review concluded that film reading and clinical practice at the assessment stage in the breast screening service was currently operating within national minimum standards, however the working environment within the service was extremely poor and if not addressed urgently the service would be unlikely to be able to continue to provide a safe service.

The trust had made progress in implementing the technical and recording recommendations made in response to the PHE review. However, the pace at which the required management changes were being implemented was slow and had become very protracted. It was acknowledged that the trust did have some complex staffing issues to address, however the pace of change meant that professional relationships and the culture within the Breast Screening Unit remained a cause for concern.

The trusts maternity service had been subject to an independent enquiry established to review the management, delivery and outcomes of care provided by the maternity and neonatal services between January 2004 and June 2013. (Kirkup Enquiry). The trust had developed a comprehensive plan to respond to the recommendations made in the report and there was evidence that the trust was making progress in this regard. However, there was still work to do, in particular, embedding the improved governance and risk management systems, improving the maternity dash board and aligning investigation processes. Joint working across the maternity and paediatric services had improved; however, there was still work to be done to assess the impact of the improved arrangements on the functionality of teams.

Importantly, the trust must:

  • Ensure that all premises used by the service provider are suitable for the purpose for which they are being used and properly maintained. This is particularly in relation to physiotherapy services and medical care services provided from medical unit one.
  • Ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed in order to meet the needs of the patients.
  • Staff should receive appropriate support, training and appraisal as is necessary to enable them to carry out their role.
  • Ensure that staff understand their responsibilities under and act in accordance with the requirements of the Mental Capacity Act 2005 and associated code of practice.
  • Ensure that staff follow policies and procedures around managing medicines, including intravenous fluids particularly in medical care services and critical care services.
  • Ensure referral to treatment times in surgical specialities meet the national target.
  • Ensure that the resuscitation trolleys on the children’s ward are situated in areas that make them easily accessible in an emergency. All staff must be clear on who has responsibility for the maintenance of the resuscitation trolley on the delivery suite.
  • Ensure that they maintain an accurate, complete and contemporaneous record in respect of each service user.

It is apparent that the trust is on a journey of improvement and progress is being made both clinically and in the trust’s governance structures. I am therefore happy to recommend that University Hospitals of Morecambe Bay NHS Foundation Trust is now taken out of special measures. This is subject to establishing a partnership arrangement with another provider specifically to support the ongoing improvement required in maternity services.

Professor Sir Mike Richards

Chief Inspector of Hospitals

4-6 and 16 February 2014

During a routine inspection

University Hospitals of Morecambe Bay NHS Foundation Trust is a large acute hospital provider serving the population of south Cumbria and north Lancashire. The trust was established in 1998 and gained teaching status in January 2006. Services provided at the trust are commissioned by two clinical commissioning groups based in Lancashire North and Cumbria.

The trust provides services from three principal sites to a population of 365,000, covering south Cumbria, north Lancashire and surrounding geographical areas. The sites are: Furness General Hospital in Barrow; Royal Lancaster Infirmary in Lancaster and Westmorland General Hospital in Kendal. The trust also provides outpatient services at Queen Victoria Hospital in Morecambe, at Ulverston Health Centre and in a range of community-based facilities. The trust has approximately 5,000 staff. In 2012/13 the trust had an income of £280 million.

Furness General and the Royal Lancaster Infirmary have a range of general hospital services, with full A&E departments, critical/coronary care units and consultant-led beds. Westmorland General Hospital provides a range of general hospital services, together with a Primary Care Assessment Service (PCAS) with GP-led inpatient beds, operated by the Cumbria Partnership NHS Foundation Trust.

All three sites provide a range of planned care, including outpatients, diagnostics, therapies, day-case and inpatient surgery. In addition a range of local outreach services and diagnostic services are provided from a number of community facilities across the community.

Governance, strategy and leadership

The trust had a long history of turbulence, including a high turnover of senior leadership. 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.

Governance systems have been strengthened by dividing clinical services into five clinical divisions and appointing substantive clinical leaders to each division.

However, there was no clear strategy for the future provision of services across the trust. The strategic plans and risks were not well known at ward or team level. There was a heavy reliance on the ‘Better Care Together ‘ strategy that was still in development to address the long standing financial, geographical and service re-configuration challenges facing the trust.

In addition, there was a lack of robust data and key performance metrics to support and underpin performance and achievements. Key performance and safety information was not collected and collated in a consistent and a systematic way. We found that the trust had systems and processes in place for governance and risk management. However, the implementation and quality of the systems was variable. Risk management required improvement in a number of services across the organisation. The risk register did not clearly set out risks, controls, gaps in controls and sources of potential assurance. The issues in relation to staffing shortfalls on the CCU/HDU was a clear example of this.

The systems for reporting incidents were not consistently followed and there was a lack of clarity in some services about the range and nature of reportable incidents. Performance information and learning from the incidents that were reported was not effectively or consistently used to drive changes and improve practice.

The trust has a higher number of reported ‘never events’ than similar trusts. A review of outcomes of investigations, including root cause analysis of serious untoward incidents, continues to suggest areas of concern where similar themes are repeated e.g. failure to follow guidelines/protocols and embedding the learning from previous incidents. Similarly the use of information from local audits was not consistently applied to secure improvement and manage risks. We found examples of local audit identifying performance and practice shortfalls that were not adequately addressed by action planning and appropriate escalation.

There was little evidence of the impact of a cultural change programme that promoted an identity of a fully merged trust. There were different cultures in all the three hospitals we inspected and staff were loyal to their ‘home hospital’. Although the clinical directors, senior medical and nursing staff within divisions were working and communicating across the three sites, the majority of other staff were not communicating with their counterparts in other hospitals. We saw little evidence of cross bay working at the time of our inspection with the exception of the productive theatre iniative.

Front line staff did not see themselves as part of the wider organisation.

Staff Engagement

Staff reported that they felt disconnected from the executive team and from the board. They felt that, with the exception of the executive nurse, the executive team and board members were not visible and communication with front line staff was poor. This sense of disconnect was evident in the NHS 2013 staff survey, which reported the following four performance indicators as being in the lowest 20% nationally:

  • The percentage of staff reporting good communication between senior management
  • The ability of staff to contribute towards improvements at work
  • Staff recommendation of the trust as a place to work or receive treatment, and
  • Staff motivation at work

Although in relation to

  • Staff recommendation of the trust as a place to work or receive treatment, and
  • Staff motivation at work

There had been an improvement on the 2012 survey.

The survey did indicate that that there had been statistical improvements in 3 indicators since the 2012 survey:

  • Effective team working
  • Support from immediate managers (although the result for this indicator remained below the national average).
  • The percentage of staff receiving health and safety training.

Staffing

In 2013, net recruitment of nursing staff (recruitment – leavers) showed a positive gain of 135 nurses. Regular updates on nurse recruitment were presented to the Board through the Risk Committee; risks were managed through the daily staffing call and the use of bank and agency staff.  However, during our inspection we identified a number of areas where staffing difficulties were having an adverse impact on patient care and safety.

We found that the nurse staffing levels in the Critical Care Unit /High Dependency Unit (CCU/HDU) at Furness General Hospital were unacceptably low and medical cover was poorly organised. We asked the trust to take immediate remedial action in this regard.

We had previously inspected the medical services provided by the trust in Ward 39 at the Royal Lancaster Infirmary in October 2013. We found that there were significant issues regarding insufficient staff to provide appropriate and safe care, and we issued a warning notice to the trust. We found at this inspection that although the trust had provided additional full time nurses there were still concerns regarding the staffing and skill mix in both Ward 39 and other medical wards within the hospital. As a result, we concluded that the trust had not yet complied with the warning notice. Our inspection found that failure to address the staffing issues in the medical wards was adversely affecting the quality of care provided to patients.

Staffing shortfalls were also identified in paediatrics and surgical services at Royal Lancaster Infirmary and in the A&E departments at both the Royal Lancaster Infirmary and Furness General Hospital. Staffing levels in the A&E department and paediatric services had been recently reviewed and business cases had been developed to secure additional staffing for these services.

Staff training

Although the trust had taken action to provide a programme of mandatory and specialist training, staff could not always access training as staffing levels meant that they were required to remain on the wards or in the departments.

Cleanliness and infection control

The hospitals were clean throughout. There were ample supplies of hand washing facilities and alcohol gels available for staff and visitors to use to minimise cross infection risks. All staff adhered to ‘bare below the elbows’ guidance. The trust had invested in a poster campaign that provided helpful guidance to staff, patients and the public regarding cross infection risks.

The trust had a prevention and control of infection policy. The majority of staff followed the guidance, however, we saw examples of poor hand hygiene in the Children’s ward at the Royal Lancaster Infirmary.

The trust’s infection rates for C.Difficile and MRSA are in an acceptable range for a trust of this size.

However, an antimicrobial audit completed by Audit North West in 2013 found poor compliance with trust policy to be a key factor in C. difficile cases, and that procedural changes made by the trust had not resulted in a demonstrated improvement. Antimicrobial prescribing was now being monitored by ward pharmacists and changes had been made to the inpatient prescription chart to try and ensure that antibiotic therapy was appropriately reviewed. Posters had been distributed to wards and there was an awareness of the need for vigilance in antibiotic prescribing initiatives among the nursing, pharmacy and medical staff we spoke with. A programme of repeat audit had been implemented; the outcomes were not available at the time of our inspection.

Medicines management

NICE (National Institute for Health and Care Excellence) recommends that pharmacists are involved in medicines reconciliation as soon as possible after admission, but pharmacy staff were not able to offer this service to every patient within the trust’s own timeframe. The trust had identified this as being due to the “limited availability of appropriately trained staff and limited opening hours”. Nurses reported that they valued the ward pharmacy service but a regular service was not extended to all wards. The pharmacy provided medicines in compliance aids if required to meet individual patient’s needs.

The trust did not have a dedicated critical care pharmacist during 2013 to ensure safe and effective drug therapy. This meant the trust did not comply with the North West core service specification for Adult Critical Care. A half-time antibiotic/critical care pharmacist was appointed in January 2014.

The trust had a delayed response to two patient safety alerts. ‘The adult patient’s passport to safer use of insulin’ (August 2012) and, ‘Reducing harm from omitted and delayed medicines in hospital’ (February 2011). We found that the trust was now taking action in relation to these issues through wider audits of omitted doses and the revision of the trust’s procedure for self-administration.

Complaints management

NICE (National Institute for Health and Care Excellence) recommends that pharmacists are involved in medicines reconciliation as soon as possible after admission, but pharmacy staff were not able to offer this service to every patient within the trust’s own timeframe. The trust had identified this as being due to the “limited availability of appropriately trained staff and limited opening hours”. Nurses reported that they valued the ward pharmacy service but a regular service was not extended to all wards. The pharmacy provided medicines in compliance aids if required to meet individual patient’s needs.

The trust did not have a dedicated critical care pharmacist during 2013 to ensure safe and effective drug therapy. This meant the trust did not comply with the North West core service specification for Adult Critical Care. A half-time antibiotic/critical care pharmacist was appointed in January 2014.

The trust had a delayed response to two patient safety alerts. ‘The adult patient’s passport to safer use of insulin’ (August 2012) and, ‘Reducing harm from omitted and delayed medicines in hospital’ (February 2011). We found that the trust was now taking action in relation to these issues through wider audits of omitted doses and the revision of the trust’s procedure for self-administration.

Patient experience

There were very mixed reviews from patients about their experiences of the services provided. Many patients we spoke with described very positive experiences of good and compassionate care from committed and professional staff. However, we spoke with a number of patients on the medical wards who informed us that although staff were very good and caring, staff shortages meant care was not provided or delivered at a good standard. This was a particular issue in medicine.

Use of resources

These reports look at how NHS hospital trusts use resources, and give recommendations for improvement where needed. They are based on assessments carried out by NHS Improvement, alongside scheduled inspections led by CQC. We’re currently piloting how we work together to confirm the findings of these assessments and present the reports and ratings alongside our other inspection information. The Use of Resources reports include a ‘shadow’ (indicative) rating for the trust’s use of resources.

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up. Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.