All inspections: Cumberland Infirmary - Care Quality Commission

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

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

However:

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

We carried out a follow up inspection between 6 and 9 December 2016 to confirm whether North Cumbria University Hospitals NHS Trust (NCUH) had made improvements to its services since our last comprehensive inspection, in April 2015. We also undertook an unannounced inspection on 21 December 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 April 2015, we rated services as ‘requires improvement’. We rated safe, effective, responsive and well-led as ‘requires improvement’. We rated caring as ‘good’.

At Cumbria Infirmary in Carlisle (CIC) we rated services overall as ‘requires improvement’. We rated surgery, critical care and services for children and young people as ‘good’, with all other services rated as ‘requires improvement’.

There were three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations at this hospital. These were in relation to staffing, person centred care, 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 improved in some areas. However, Cumberland Infirmary (CIC) remained rated as ‘requires improvement’ overall, with caring and effective rated as ‘good’ and safe, responsive, and well-led rated as ‘requires improvement’.

Our key findings were as follows:

Nursing and medical staffing had improved in some areas since the last inspection. However, there were still a number of nursing and medical staffing vacancies throughout the hospital, especially in medical care, surgical services, and services for children and young people, including the special care baby unit.
The trust had systems in place to manage staffing shortfall as well as escalation processes to maintain safe patient care. However, a number of registered nurse shifts remained unfilled despite these escalation processes. The ‘floor working’ initiative within medical care should be reviewed in order to support safer nurse staffing.
Despite ongoing recruitment campaigns the trust had struggled to recruit appropriate clinicians in some specialities.
Compliance against mandatory training targets was an issue in some services.
Access and flow across the emergency department, medical care, surgical services, and outpatients remained a significant challenge.
For an extended period, the hospital had failed to meet the target to see and treat 95% of emergency patients within four hours of arrival and the hospital was failing to meet a locally agreed trajectory to see and treat emergency patients within the standard agreed with regulators and commissioners.
We found patients experienced overnight delays in the emergency department whilst waiting for beds to become available in the hospital.
Between 2015 and 2016 the trust cancelled 1,410 elective surgeries. Of these, 12% were not treated within 28 days.
For the period November 2015 to November 2016 CIC cancelled 573 elective surgeries for non-clinical reasons.
Referral to treatment time (RTT) data varied across specialities, particularly in surgical services.
Within the outpatients department, across the trust, several clinics had been cancelled within six weeks of the scheduled clinic date, and there were no plans in place to address this issue. Turnaround times for inpatient plain film radiology reporting did not meet Keogh standards, which require inpatient images to be reported on the same day.
Delays in obtaining suitable community care placements were causing access and flow difficulties, particularly in medical care services.
There had been an improvement in record-keeping standards throughout the hospital, however, we identified some ongoing areas for improvement around accurate completion of fluid and food charts, risk assessments, and completion of DNACPR forms, some of which did not provide evidence of a best interest decision or mental capacity assessment being undertaken and recorded where appropriate.
There was some improvement in strengthening of governance processes across the hospital, however, within some services, particularly medical care and maternity, there were gaps in effective capturing of risk issues, and in how outcomes and actions from audit of clinical practice were used to monitor quality.
Due to the review of the Cumbria-wide healthcare provision there remained no clear vision nor any formal strategy for the future of maternity or of services for children and young people.

However:

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 policy and activity around the transfer of critical care patients, including children and babies, to other hospitals were good.
The hospital 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.
There were no cases of Methicillin Resistant Staphylococcus Aureus infection (MRSA) reported between November 2015 and October 2016. Trusts have a target of preventing all MRSA infections, so the hospital met this target within this period. The trust reported nine MSSA infections and 23 C. Difficile infections over the same period.
Safeguarding processes were embedded throughout the hospital.
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.
Patients were positive about the care they received. Staff were committed to delivering high quality care. Staff interactions with patients were compassionate, kind, and thoughtful. Patient privacy and dignity was maintained at all times.
Patient feedback was routinely collected using a variety of measures, including real time patient experience.

We saw several areas of outstanding practice including:

The trust was a National Patient Safety Awards finalist for ‘Better Outcomes in Orthopaedics’.
The trust had the only surgeon between Leeds and Glasgow doing a meniscal augment in the knee.
A University of Cumbria Honorary Professorship had been received by a consultant for work on applying digital technologies in health care for an elderly population in a rural setting; a part of CACHET.
The trust had set up a multinational, multicentre prospective study in the use of intramedullary nail in varus malalignment of the knee. It had the largest international experience of this technology for this application.
CIC was one of only 18 Hospitals in England and Wales referred to in the first NELA audit for contributing examples of best practice in care of patients undergoing emergency laparotomy.
There was evidence of real strength in multidisciplinary team (MDT) working across stroke, neurorehabilitation, and older person’s services;
An ‘expert patient programme’ and a ‘shared care initiative’ had been set up to promote patient empowerment and involvement in care;
A variety of data capture measures were used to monitor ‘real-time’ patient experience and collate patient feedback;
The trust operated innovative and progressive Frailty Unit projects;
There had been growth, expansion, and development of the MPU service; and
The trust had implemented dance-related activities for vulnerable patient groups, to stimulate social interaction, patient involvement, family partnerships, and exercise.

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

Importantly, the trust must:

In urgent and emergency services

Meet the target to see and treat 95% of emergency patients within four hours of arrival linked to meeting the locally agreed trajectory to see and treat emergency patients within the standard agreed with regulators and commissioners.
Ensure medical and nursing staff use the computer system fully as intended so that patient real time events are recorded accurately and this is demonstrated through audit.
Take further steps to resolve the flow of patients into and out of the hospital.

In Medicine

Ensure that systems and processes are established and operated effectively to assess, monitor, and improve the quality and safety of the services provided, and evaluate and improve practice to meet this requirement. Specifically, review the escalation process involving ‘floor working’ to ensure the quality and safety of services are maintained; and
Ensure that sufficient numbers of suitably qualified, competent, skilled, and experienced persons are deployed across all divisional wards. Specifically, ensure safe staffing levels of registered nurses are maintained, especially in areas of increased patient acuity, such as NIV care and thrombolysis.

In Surgery

Must ensure the peri-operative improvement plan is thoroughly embedded and that all debrief sessions are undertaken as part of the WHO checklist to reduce the risk of Never Events.
Improve compliance with 18 week referral to treatment (RTT) standards for admitted patients for oral surgery, trauma and orthopaedics, urology, and ophthalmology;
Improve the rate of short notice cancellations of operations for non-clinical reasons, specifically for ENT, orthopaedic, and general surgery; and
Ensure that patients whose operations are cancelled are treated within the following 28 days.

In Maternity and Gynaecology

Review staffing levels, out of hours consultant paediatric cover, and surgical cover to ensure they meet the Royal College of Obstetricians and Gynaecologists (RCOG) guidelines (including ‘safe childbirth: minimum standards for the organisation and delivery of care in labour’); and
Ensure that systems are in place so that governance arrangements, risk management, and quality measures are effective.

In Services for Children and Young People

Ensure that children and young people’s services meet all Royal College of Paediatrics and Child Health (RCPCH) - Facing the Future: Standards for Acute General Paediatric Services (2015 as amended); and
Ensure that nurse staffing levels on SCBU adhere to establishment and meet recognised national standards.

In End of Life Care

Ensure that DNACPR forms are fully completed in terms of best interest assessments, in line with the Mental Capacity Act.

In Outpatients and Diagnostic Imaging

Address the number of cancelled clinics in outpatient services; and
Ensure that referral to treat (RTT) indicators are met across outpatient services.

In addition the trust should:

Ensure that levels of staff training continue to improve in the hospital, so that the hospital meets the trust’s targets by 31st March 2017;

In urgent and emergency services

Increase the complement of medical consultant staff as identified in the accident and emergency service review
Achieve quantified improvements in response to the trauma audit and research network (TARN) audit and the NICE clinical guideline self-harm audit (CG16), and demonstrate progress achieved through audit.
Take steps to ensure patient confidentiality can be maintained in the accident and emergency reception area.
Extend the scope and consistency of staff engagement

In Medicine

Continue to progress patient harm reduction initiatives;
Revisit the ‘floor working’ initiative, particularly across Elm wards;
Revisit thrombolysis cubicle bed utilisation to reduce potential unnecessary, inappropriate, or inconvenient bed moves;
Ensure infection prevention and control (IPC) compliance improvement and consistency in standards, in particular regarding catheter and cannula care;
Ensure that best practice guidelines for medicines-related documentation is reinforced to all prescribers;
Ensure that care and treatment of service users is appropriate, meets their needs, and reflects their preferences. Specifically, ensure the endoscopy pathway design meets service user preferences and care or treatment needs;
Ensure that oxygen prescribing is recorded and signed for accordingly;
Ensure that medicines management training compliance improves in line with trust target;
Ensure that NEWS trigger levels are adhered to (or document deviation/individual baseline triggers in the clinical records);
Ensure that fluid and food chart documentation is accurate, to reflect nutritional and hydration status;
Ensure that staff are given time to complete all necessary mandatory training modules and an accurate record is kept;
Ensure that all equipment checks are completed in line with local guidance;
Continue to proactively recruit nursing and medical staff, considering alternate ways to attract, such as utilising social media;
Ensure that measures are put in place to support units where pending staffing departures will temporarily increase vulnerability;
Ensure that food satisfaction standards are maintained and, where relevant, improved;
Develop an action plan to detail objectives to improve and progress diabetes care across the division;
Evidence improvements in patient outcomes for respiratory patients around time to senior review and oxygen prescribing;
Ensure that all staff can access development opportunities in line with organisational/staff appraisal objectives, protecting/negotiating study time where required;
Ensure that appraisal rate data recorded at trust level coincides with figures at divisional/ward level;
Revisit the patient journey, booking, and listing procedures at the endoscopy suite at CIC;
Continue to minimise patient moves after 10 pm;
Continue to work with community colleagues to develop strategies to minimise delayed transfer of care (DTOC) and unnecessarily lengthy hospital stays for patients medically fit for discharge;
Reinforce the benefits of dementia initiatives to ensure consistency of practice;
Ensure that the risk register is current and reflects actual risks with corresponding, accurate risk rating;
Ensure that all actions and reviews of risk ratings are documented;
Ensure that progress continues against its Quality Improvement Plan (QIP), and realign completion dates and account for deadline breaches;
Revisit medical rota management processes for junior doctors;
Revisit modes of communications with staff to ensure efficiency whilst avoiding duplication;
Ensure that staff involved in change management projects are fully informed of the aims and objectives of the proposal, and these are implemented and concluded in appropriate timeframes; and
Ensure that divisional leads and trust leaders promote their visibility when visiting wards and clinical areas.

In Surgery

Ensure that robust recruitment and retention policies continue, to improve staff and skill shortages;
Continue to embed the perioperative quality improvement plan;
Improve debrief in theatres post-surgery;
Improve the proportion of patients having hip fracture surgery on the day or day after admission;
Improve the rate of patients receiving a (VTE) re-assessment within 24 hours of admission;
Improve cancellation rates;
Ensure that all mandatory training is completed by 31st March 2017;
Reduce the management of medical patients on surgical wards; and
Ensure that bullying allegations in theatres are addressed.

In Critical Care

The trust should take action to improve pharmacy staffing in line with GPICS (2015);
The clinical educator should provide a full time role in the CIC unit in order to meet GPICS (2015) standards for a unit of this size;
The role of the clinical coordinator should be protected as per GPICS (2015) standards. and
Staff should not be moved to cover ward shortages if this compromises safe nurse to patient ratios of care in the critical care unit. Senior staff at trust and unit level should offer continued support and monitor this issue closely, to reduce the need for the frequency of unplanned staff movement to reduce risk of compromising patient safety and to improve morale amongst nursing staff in the unit.

In Maternity and Gynaecology

Ensure that processes are in place for midwives to receive safeguarding supervision in line with national recommendations;
Continue to improve mandatory training rates to ensure that trust targets are met by the end of March 2017;
Ensure that there are processes so that record-keeping, medicine management, and checking of equipment is consistent across all areas; and
Review the culture in obstetrics to ensure there is cohesive working across hospital sites and improved clinical engagement.

In Services for Children and Young People

Ensure that staff adhere to and update the cleaning schedule and cleaning log in the children’s outpatient department as appropriate;
Ensure that medical staff sign all signature sheets, and print their names and designations against all entries on all patient notes;
Ensure that all staff have completed the required mandatory training, and the trust should ensure that its systems accurately reflect this data;
Ensure that all staff are trained in the use of the flagging system on the patient database system in A&E for children and young people who have multiple attendances at A&E, children who are looked after, and children subject to a child protection plan’; and
Ensure that the new paediatric anaesthetist lead (when appointed) receives an appropriate amount of professional leave time to develop a specialist skill base for this highly specialised role. This should include robust training and support, including time spent at specialist centres for paediatric surgery.

In End of Life Care

Arrange formal contract meetings with members of the Cumbria Healthcare Alliance to monitor the service being commissioned and provided, and ensure it is of an appropriate standard in terms of quality and meeting patient need;
Ensure that it is aware of the number of referrals to the Specialist Palliative Care Team (SPCT) within its hospitals;
Ensure that it is aware of how many patients are supported to die in their preferred location, and there is regular audit of the Care of the Dying Plan to demonstrate this; and
Produce an action plan to address areas in national audits where performance was lower than the England average, with key responsibilities and timelines for completion.

It is apparent that the trust is on a journey of improvement and progress is being made clinically, in the trust’s governance structures and in the implementation of a credible clinical strategy. I am therefore happy to recommend that North Cumbria University Hospitals NHS Trust is now taken out of special measures.

Professor Sir Mike Richards

Chief Inspector of Hospitals

North Cumbria University Hospitals NHS Trust provides acute hospital services in North Cumbria and services are based at the Cumberland Infirmary in Carlisle (CIC) and the West Cumberland Hospital (WCH) in Whitehaven and a birthing centre at Penrith Community Hospital. During this inspection we visited Cumberland Infirmary and West Cumberland Hospital.

This was a focussed unannounced inspection to review the safe and well-led domains within surgery and children and young people services across the trust. In surgery we carried out this inspection as a consequence of a series of ‘never events’ between June 2015 and February 2016. These had raised concerns about the lack of compliance in surgery with the completion of safety checks and procedures within theatres, particularly non-compliance with the ‘Five Steps to Patient Safety’, World Health Organisation Surgical Safety Checklist. We also reviewed progress in the implementation of the division’s Perioperative Quality Improvement Plan which had been developed in response to these never events.

Within children and young people services (CYP), a shortage in medical staffing, particularly at consultant level, was highlighted at our previous inspection in 2015. During this inspection we reviewed medical and nursing staffing in line with the trust’s workforce strategy as well as escalation and contingency plans in these areas. The service was under review with a number of models being considered and evaluated in order to better meet the needs of the CYP population at the time of this inspection. This formed part of the Success Regime agenda within North Cumbria (a national initiative designed to support local improvement programmes by bringing together wider healthcare economy partners).

Surgery key findings:

There were no never events reported within surgery in the six months before inspection (March to August 2016). Previous never events had been fully investigated and changes to practice made where appropriate.
At the time of inspection the Perioperative Quality Improvement Plan was in the early stages of implementation, impacting upon some areas but not yet fully embedded within the division. Although most staff were aware of the plan, they could not articulate specific outcomes from the plan.

Senior nursing staff had daily responsibility for safe and effective nurse staffing levels. Staffing guidelines with clear escalation procedures were in place. Site cover was provided out of hours 24 hours per day, seven days per week by a team of senior nurses with access to an on-call manager. Numbers of staff on duty was displayed clearly at ward entrances.

We reviewed staff rotas for the month before inspection and saw large numbers of shifts not staffed to establishment across most surgical wards at Cumberland Infirmary.

Although staff acknowledged that the trust had plans in place to increase staffing levels and develop effective recruitment and retention plans, they expressed they had been working in difficult circumstances during the last eighteen months to cover staff and skill shortages.

The numbers of shifts not staffed to establishment across most surgical wards and areas, caring for medical ‘outliers’ and the high acuity and needs of patients supported the view expressed by staff that they were working under pressure within the division.

Staff said this had led to some staff working under extreme pressures for an extended period to cover shifts, resulting in exhaustion and increased the potential for harm to patients.

Although staff were enthusiastic about their work and the service they provided and generally the organisation they worked for, staff morale was variable and not always high on wards and in theatres.

CYP Key Findings:

The unit had a full complement of consultants in post at CIC (7 WTE, inclusive of a recent appointment). The majority of the consultant’s job plans provided for 10-11 programmed activities a week however in reality most were working in excess of this, in the region of 11-12.5. The unit did not meet all Royal College of Paediatric and Child Health (RCPCH) – Facing the Future: Standards for Acute General Paediatric Services (2015 as amended). The standards covered areas such as consultant presence, time to consultant review and consultant led handovers.
The unit had maintained good safeguarding procedures and nurse staffing levels on the paediatric ward. The wards planned staffing in accordance with recognised standards however we found a deteriorating compliance against British Association of Perinatal Medicine (BAPM) standards on SCBU. There were escalation plans to address shortfalls or changing acuity. Managers were taking steps to recruit to vacancies to ensure patient safety was maintained however such plans needed to cover all eventualities in the event of recruitment difficulties.
The unit managers were considering a variety of options to bolster nurse staffing numbers and train staff. This included further recruitment adverts, internal promotion with backfill of more junior posts, training staff up to become advanced nurse practitioners (ANPs) and accessing medical support to ensure short-term sustainability. Unit managers considered workforce assurance and succession planning as an on-going concern and this formed part of the Success Regime agenda (a national initiative designed to support local improvement programmes by bringing together wider healthcare economy partners).
Staff were confident and comfortable in reporting incidents of harm or concern however the importance of reporting all incidents irrespective of previous submission needed addressing. A number of reported incidents lacked a classification of harm. Procedures for sharing learning from such incidents were variable and required consistency.

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

Importantly, the trust must:

Ensure ward rotas within surgery services are staffed to establishment in line with the needs of patients.
Ensure nurse staffing levels within children and young people services adhere to establishment and meet recognised national standards.
Ensure children and young people services meet all Royal College of Paediatrics and Child Health (RCPCH) - Facing the Future: Standards for Acute General Paediatric Services (2015 as amended).

In addition the trust should:

In surgical services:

Ensure appropriate changes in practice are identified, communicated and implemented following learning from previous never events.
Ensure robust recruitment and retention policies are adopted to cover staff and skill shortages identified on the divisional risk register.
Identify appropriate mechanisms for supporting the wellbeing of staff during periods of additional pressures.
Determine processes for the management of medical patients on surgical wards.

In children and young people services:

Ensure staff are informed of the importance of reporting all incidents irrespective of previous submission. Incidents should have harm levels classified in accordance with policy and national standards.
Ensure staffing escalation plans are robust to respond to changing acuity and dependency of vulnerable babies.
Ensure all staff are informed of the unit strategy and kept up-to-date with Success Regime proposals.
Consider the designation of a clinical lead to reinforce the quality of the unit audit activity.
Ensure procedures to support learning from incidents are consistently applied. Ensure learning from incidents is cascaded to all staff to embed the learning cycle.
Proactively address the concerns and morale issues on SCBU.

Professor Sir Mike RichardsChief Inspector of Hospitals

The Cumberland Infirmary, Carlisle provides a 24-hour A&E service with Trauma Unit status, a consultant-led maternity service and special care baby unit, a wide range of clinical services, including delivering complex vascular and general specialist services, and outpatient clinics. The hospital has 412 inpatient beds and serves the local people around Carlisle and throughout North Cumbria. The North Cumbria University Hospitals NHS Trust serves a population of 340,000 who live in a largely rural area of Cumbria. We carried out this inspection to follow up on the improvements identified as part of our last inspection of the hospital in May 2014.

Our key findings were as follows: The senior team was visible approachable and demonstrated a deep commitment to improving the quality of the services provided in the hospital. There had been a lot of work undertaken to engage and include staff in the change agenda. There was evidence that a number of significant improvements had been made and the hospital team had sustained its performance in a number of key areas. Four core services, surgery, critical care, outpatients and children and young people services had improved and were now providing good services. However, urgent and emergency care services, medical services, maternity services and end of life care still required improvement. Overall we rated the hospital as requiring improvement in the safe, effective, responsive and well led domains and good in the caring domain. The hospitals mortality rates had remained within expected limits and the processes and systems for reviewing mortality and morbidity were increasingly robust. Patients received care and treatment in a visibly clean and well maintained environment. Staff in the main, adhered to good practice guidance in the prevention and control of infection. Infection rates remained within expected limits. Care and treatment was delivered by committed and caring staff who worked well together for the benefit of patients. However managers were still faced with some substantial challenges with particular reference to the recruitment and retention of medical, nursing and some allied health professional staff. Staff shortages were having a negative impact of patients accessing and receiving treatment in a timely way.

Access and flow

The Department of Health target for emergency departments to admit, transfer or discharge patients within four hours of arrival was not being met consistently. In 2014/15, Cumberland Infirmary only met the target once in July 2014 with a range over the year between 69.1% to 96.6%. Over the year, 12 patients waited for more than 12 hours from the decision to admit to being admitted. Individual breaches of the four hour target were investigated and the majority were due to patients waiting for a bed in the ward areas. Other reasons for delays included patients waiting for a specialist opinion and waiting for a mental health assessment. A norovirus outbreak in the ward areas during January to March 2015 had impacted negatively on the emergency department as it had caused additional bed shortages and longer waiting times.
There was insufficient bed capacity in the surgical wards due to beds being occupied by medical patients. This meant that operations were frequently cancelled due to the lack of available beds. The number of patients whose operations were cancelled and were not treated within the 28 days was worse than the England average between July 2013 and September 2014.
Waiting times for outpatient physiotherapy were commonly longer than four months for a routine referral and over three weeks for urgent referral against a target of one week. On 12 December 2014 49 people were waiting over six weeks for a routine physiotherapy outpatient appointment and 42 people were waiting over one week for an urgent referral. The physiotherapy outpatient service was struggling to meet the referral rates due to low staffing numbers. These delays were having a negative effect on rehabilitation times for patients.

Nurse Staffing

There continued to be shortages of trained nursing staff on some wards. This was a particular issue in medical services .Nursing staffing levels had been reviewed and assessed using a validated acuity tool with minimum numbers set. Although nurse staffing levels had improved since our last inspection, there were still on average 3 trained nurse vacancies per ward when measured against their agreed establishment.
In intensive care when bed numbers and/or patient acuity increased it was not always possible to maintain the Intensive Care Societies minimum nursing staffing levels and as no supernumerary clinical hours for senior nurses were built into the staffing rota should patient numbers and acuity demanded the nurse in charge would need to care for a patient compromising their management and clinical supervisory role.
A rolling recruitment programme to fill nursing posts was on going. Several new initiatives had been implemented. However the outcome of these initiatives was not evident at the time of our inspection.

Medical Staffing

The levels of substantive medical cover on the medical wards remained insufficient to provide a safe and effective service and in February 2015, four out of ten consultants in on call positions were filled by locums. Three long term locums contributed to the out of hours on-call rota. There were no short term consultant locums on-call out of hours at the time of the visit.
Fifteen out of 36 resident medical doctors were locums. Registrar, core trainee (CT) and foundation doctor rotas for the front and back of house within Medicine were all populated from substantive staff but occasional gaps had been covered by substantive clinical fellows.
There were 7.6 whole time equivalent surgical consultant vacancies. Staff rotas were maintained through the use of locum and agency consultants. Where locum doctors were used, they were subject to recruitment checks and induction training to ensure they understood the hospital’s policies and procedures. The clinical business unit director for surgery and anaesthetics confirmed that the majority of locum and agency doctors had worked at the hospital on extended contracts so they were very familiar with the hospital’s policies and procedures and applied them appropriately.
The intensive care service had access to a consultant and middle grade anaesthetist at all times although out of hours the middle grade anaesthetist had on call responsibilities for other specialties such as theatres and maternity. This meant that potentially a patient could find themselves waiting in an emergency for appropriate medical attention. This was discussed with the medical director at the time of the inspection who took remedial action to increase anaesthetist cover and mitigate this risk.

Meeting Patients Needs

As a result of targeted work by managers the availability of case notes being available for a patient’s consultation in outpatient clinics had significantly improved from 75% to 95%.
Referral to treatment times for diagnostic tests had improved and were close to meeting national targets but up to December 2014 the percentage of patients waiting longer than 6 weeks for diagnostic tests was almost 12% against a target of less than 1%.
The waiting time for outpatient physiotherapy was commonly longer than four months for a routine referral and over three weeks for urgent referral against a desired target of one week. The physiotherapy outpatient service was struggling to manage referrals in a timely way due to low staffing numbers. These delays were having a negative effect on rehabilitation times for patients.
The surgical services had failed to meet 18 week referral to treatment standards across all specialties between July 2013 and September 2014.
In 2014/15, Cumberland Infirmary only met the Department of Health target for emergency departments to admit, transfer or discharge patients within four hours of arrival, once in July 2014 with a range over the year between 69.1% to 96.6%. Over the year, 12 patients waited for more than 12 hours from the decision to admit to being admitted. Individual breaches of the four hour target were investigated and the majority were as a result of patients waiting for a bed in the ward areas.
There had been only one further ‘never event’ reported relating to radiology services at the hospital in April 2014.

Effective Care

Outcomes for stroke patients between April to September 2014 had improved with the Sentinel Stroke National Audit Programme (SSNAP) showing the trust’s stroke services moved from an 'E' rating to a ‘D’ on a scale of A to E, with A being the best.
The latest National Diabetes Inpatient Audit (NADIA) 2013 showed that the hospital was performing below the England average in 10 of the 21 indicators and was unchanged from the previous inspection.
Submission of data to the Intensive Care National Audit and Research Centre (ICNARC) was now consistent.

Competent staff

Staff carried out skills training in the management of maternity emergencies. Not all midwives or doctors were up to date with this training which meant they not be able to respond as necessary in an emergency. The last practice drill for evacuating a patient from the birthing pool could not be given. A new safety net for this purpose had been purchased but staff had not practised using this equipment in an emergency.
Concerns raised at the last inspection relating to the mortuary had been addressed and porters had received training in the transfer and care of deceased patients. Equipment in the mortuary had been replaced, a manual to explain about last offices had been developed by the Bereavement and End of Life Group and the mortuary now adhered to infection control procedures and a risk assessment was undertaken on all patients who had died from blood borne diseases.
We saw 12 “do not attempt cardio-pulmonary resuscitation” (DNACPR) forms some of which were inconsistently completed. This was supported by the Trusts annual audit figures for DNACPR which showed 170 forms out of 542 forms were not fully completed. This could result in inappropriate resuscitation taking place and the hospital was addressing this through training and further audit.

We saw areas of outstanding practice including:

The medical Oncology / Chemotherapy / Radiotherapy unit where we saw a cohesive team delivering best practice to this vulnerable group of patients. There were no delays in access to treatment. National guidelines were readily available and utilised. Patients spoke very highly of the standard of care they received.
The midwife to birth ratio was 1 to 25. This was better than the England average which was 1 to 28. All patients had one to one care during labour. The midwifery staffing numbers were above the National recommendations.

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

Urgent and Emergency care

Improve performance against the DH target for emergency departments to admit, transfer or discharge patients within four hours of arrival
Improve the rates for consultant led trauma teams being ready for patients with an injury severity score greater than 15 on arrival (currently 41%).
In relation to NICE clinical guideline CG16 (Self-harm: The short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care) increase the number of patients who receive a clear risk assessment (currently 22%).

Medical Care

Improve the number of substantive medical posts.
Improve nurse staffing levels
Improve safety thermometer results particularly on Elm B ward.
Improve performance in relation to the care and treatment of patients with diabetes.
Reduce the pressures on the availability of medical beds which resulted in patients regularly being cared for on wards outside of their speciality.
Stop moving patients during the night without a medical reason for doing so.
Provide effective leadership for the newly created team of nurse practitioners.

Surgery

Improve the recruitment of medical and nursing staff.
Improve compliance against 18 week referral to treatment standards for admitted patients.
Improve number of patients whose operations were cancelled and were not treated within the 28 days.
Develop a strategic plan specifically for surgical services.

Critical care

Ensure there is access to a consultant and middle grade anaesthetist out of hours who do not have on call responsibilities for other specialities such as theatres and maternity.

Maternity and Gynaecology

Ensure the epidural service is available though plans in place to introduce this in September 2015.
Ensure staff are trained in the management of maternity emergencies.

Services for Children

Improve the staffing position regarding the continued shortage of junior medical staff and the provision of 24-hour paediatric consultant presence on the hospital site which remained a concern as the service still offered a 24 hour emergency service for Children and young people.
Conclude the children’s and young people’s service review in order to better meet the needs of children and young people living in the area and to maximise the effective use of resources.

End of Life care

The Trust needs to liaise with CPFT to ensure that the substantive consultant post for Specialist Palliative Care is recruited to.
Address the Trusts annual audit figures for DNACPR which showed 170 forms out of 542 forms were not fully completed.

Outpatients and diagnostic imaging

Improve the percentage of patients waiting longer than 6 weeks for diagnostic tests which is currently almost 12% against a target of less than 1%.
Improve waiting times for outpatient physiotherapy which are commonly longer than four months for a routine referral and over three weeks for urgent referral against a target of one week.

In addition the trust should:

Medical

Continue to improve the quality of care and treatment provided to patients who have suffered a stroke.

Critical Care

Review the nurse staffing ratios at times of high acuity of patients.

Maternity and Gynaecology

Mitigate against the security and privacy issues in the maternity ward due to the layout of the environment.

End of Life care

Provide a bereavement office on site.

Outpatients and diagnostic imaging

Continue to improve referral to treatment times.

Professor Sir Mike Richards

Chief Inspector of Hospitals

We carried out this comprehensive inspection because North Cumbria University Hospitals NHS Trust had been identified as a high risk trust on the Care Quality Commission’s (CQC) Intelligent Monitoring system. The trust was also one of 11 trusts placed into special measures in July 2013 following Sir Bruce Keogh’s review into hospitals with higher than average mortality (death) rates. At that time, there were concerns regarding inadequate governance, the pace and focus of change to improve overall safety, and patient experience, as well as slow and inadequate responses to serious incidents and a culture that did not support openness, transparency and learning. In addition, there were concerns regarding staffing shortfalls in a number of staff groups that may have been compromising patient safety, a lack of support for staff, a lack of effective, honest communication from middle and senior managers, failures in governance to ensure adequate maintenance of the estate and equipment and significant weaknesses in infection control practices.

We looked at how the trust had responded to the review as part of this inspection.

The announced inspection of the Cumberland Infirmary, Carlisle took place on 1 and 2 May 2014, and unannounced inspection visits took place between 8.30am and 4pm on 12 May 2014.

Overall, this hospital was found to require improvement, although we rated it good in terms of having caring staff.

Our key findings were as follows:

Mortality rates

Since our last inspection in October 2013 and the Keogh review in June 2013 there had been a significant improvement in mortality rates, which are now within expected limits.
Patients whose condition might deteriorate were identified and escalated appropriately.

Infection control

The hospital was clean throughout and staff generally adhered to good practice guidance in the prevention and control of infection. However, we noticed a build-up of refuse in dirty utility rooms at busy times, and that good practice guidance for infection control was not always adhered to in the special care baby unit in relation to the management of clean and dirty laundry.
Infection rates were within expected limits.
Deceased patients with infectious diseases were not always transferred to the mortuary with appropriate preventative measures in place.

Food and hydration

Patients had a choice of nutritious food and an ample supply of drinks during their stay in hospital. Patients with specialist needs were supported by dieticians and the Speech and Language Therapy Team (SALT).
The ‘red tray’ system was used to support patients who needed help to eat and drink.

Medicines management

Medicines were provided, stored and administered in a safe and timely way.

Medical and nurse staffing

Care and treatment was delivered by committed and caring staff who worked hard to provide patients with good services. However,
There were numerous vacant consultant posts. This had an adverse effect on the timeliness of treatment for patients and meant support for junior doctors was ineffective in a number of core services.
Nurse staffing levels, although improved, remained a concern and the hospital relied heavily on existing staff to cover extra shifts and on bank and agency staff to maintain adequate staffing levels. Adequate staffing levels were not consistently achieved in all core services.

Importantly, the hospital MUST:

Ensure that there are sufficient numbers of suitably qualified, skilled and experienced nurses to meet the needs of patients at all times.
Ensure medical staffing is sufficient to provide appropriate and timely treatment to patients at all times.
Ensure that all staff within departments in the hospital have the required skills to meet the needs of patients at all times.
Take action to ensure that the planning and delivery of patient care and treatment is consistently carried out in accordance with published research and guidance issued by professional and expert bodies.
Ensure that all equipment is stored safely.
Ensure emergency equipment is complete and fit for purpose.
Ensure that children are consistently risk assessed at the time of arrival into the paediatric department to meet national standards.
Ensure triage services in A&E are always effectively staffed by appropriate personnel.
Improve patient flow throughout the hospital to reduce waiting times in the A&E department.
Develop a standard governance system across all surgical specialities to ensure surgical dashboard information is discussed, recorded and disseminated to all staff.
Ensure that any children who are treated on the adult intensive care unit receive care that is appropriate for their age.
Ensure that the maternity service reviews its identified risks and implements sufficient actions to mitigate them.
Ensure that risk management processes in the maternity service are embedded to implement a robust quality assurance checking mechanism across the service to ensure an effective service.
Ensure that the risk register for the hospital’s children’s ward accurately reflects the risks identified in the completed audits and reviews.
Take action to protect the health and welfare of children and young people with mental health needs by ensuring that appropriate health and social care support is provided in collaboration with other providers.
Ensure that good practice guidance in infection control is followed in the special care baby unit, particularly in relation to the management of clean and dirty laundry.
Take action to prevent the build-up of refuse in dirty utility rooms at busy times.
Develop a formal End of Life Care standard framework to assure safe, effective care at the end of life. Plans need to be in place to formally replace the Liverpool Care Pathway by July 2014.
Address the problem caused by the downdraft air ventilation system in the mortuary, which was posing an infection risk.
Improve how patient records are made available for outpatient appointments and clinics.
Ensure that information about ‘How to make a complaint’ is accurate. We found that some complaint leaflets were available, but information for both the role and contact details for the Care Quality Commission was out of date and inaccurate and did not clearly direct people to the Public Health Service Ombudsman.

In addition the hospital should:

Ensure effective patient flow through the A&E department to cope with its routine workload and reduce patient waiting times.
Take action to prevent patients being moved between wards during the night.
Ensure that a major incident plan for the surgical directorate is available and regularly tested.
Ensure adequate services for patients who are accommodated in A&E overnight while waiting for a bed in the hospital.
Make improvements to the major haemorrhage protocol to bring it into line with national standards.
Ensure staff are aware of, and have access to, a robust policy for transferring sick children to tertiary children’s hospitals.
Continue to develop robust audit processes to verify staff adherence to the ‘five steps to safer surgery’ and World Health Organisation (WHO) procedures.
Ensure that the surgical service uses patient-reported outcome measures (PROMS) data effectively.
Make sure that staff on the children’s wards document whether children are able to be involved in making decisions about their care and treatment.
Improve access to equipment and provide more suitable storage for larger pieces of equipment.
Improve staff training with regard to all care bundles.
Improve support given to junior medical staff.
Improve the management of people with diabetes and stroke in line with national guidance.
Improve the management of people living with dementia.
Clarify a leadership role with a clear remit to promote ‘normality’ in child birth as supported by the Royal College of Midwives Campaign for Normal Birth and the National Childbirth Trust Birth Policy.
Improve the use of information technology to improve the effectiveness of data flows. We were told that approval had just been given to introduce the IT data.
Take the necessary action to ensure that staff have the opportunity to regularly discuss their personal development and any issues or concerns.
Show how it has responded to information from patients, relatives and staff, and used this information to develop the service.

Professor Sir Mike Richards

Chief Inspector of Hospitals

We initially inspected the Cumberland Infirmary in March 2013. We found that they were non-compliant in three areas: Care and welfare, staffing and records. The areas of concern we saw were around the poor management of patient flow with patients being moved from ward to ward on several occasions and patients waiting for substantial periods in the accident and emergency department awaiting admission. We also found that there were inadequate staffing levels in most areas of the hospital which meant that some patients did not receive basic levels of care such as personal hygiene. Patient's told us that staff were often too busy to help them. Staff told us that they were under immense pressure and in some instances were working long hours to make sure they could care for patients adequately. Staff were not keeping accurate records that reflected the care that they had given to patients.

Due to the complex nature of the problems highlighted in our initial report the Trust put together a detailed and robust action plan which included all the areas of concern. They set timescales and demonstrated what they were going to do to achieve compliance with the essential standards of quality and safety. The plan showed that the Trust would aim to be compliant in the three areas of concern by the end of March 2014.

In May 2013 the Trust was part of the Sir Bruce Keogh Review into hospital mortality rates. The Keogh review highlighted similar issues at the Cumberland Infirmary.

Because of the substantial amounts of improvement needed following our inspection in March we returned to the Cumberland Infirmary in early September 2013 to monitor the progress of the Trust. We wanted to assess whether the targets outlined in the Trust's action plan were being implemented and what impact that had on improving the patient experience and the care being given.

We spoke with over 100 people and visited 16 wards. We spoke with patients all of whom told us that their basic care needs were being met. They told us:

"The staff work very hard."

"They have been good with me."

"This is a clean, friendly and loving ward."

"I was in a year ago, it's like a completely different hospital, in a good way!"

Many of the staff we spoke with said that though they remained concerned about staffing levels the level of concern was not as high as it had been previously and they could see signs of improvement. Communication between the Trust Chief Executive Officer (CEO) and senior staff had improved and staff working on the wards and departments were more aware of how the Trust was trying to rectify problems. We saw some wards/departments where staffing levels had improved and where new staff had been recruited and were waiting to start work. Staff told us:

"We are using agency, bank and overtime to cover [the ward] things are improving but there is still pressure."

"There are lots of newly qualified nurses coming, it's do-able"

"We remain under pressure."

We found that there had been improvements across the three areas of non compliance. This meant that the Trust was meeting the objectives outlined in its action plan and the levels of concern had reduced. The Trust did remain non compliant in all three areas but because of the improvements seen our judgement of the impact on the health and safety of patients had reduced. We noted that the Trust continued to work with the Cumbria Clinical Commissioning Group (CCG) and the national Trust Development Authority (nTDA) as part of improving care for patients.

We will be re-inspecting the Trust in due course to see if compliance has been fully achieved in line with the Trust's action plan.

People using the service (patients) told us that they thought the staff at the Cumberland Infirmary were professional and hard working. However they told us that they did not always receive support with their personal care:

"They are very short staffed, I have to wait for help."

"The staff are lovely, very helpful and kind."

"Nothing is too much trouble for the staff, they are very caring. My care has been excellent, I have nothing but praise."

"They are run off their feet."

Staff we spoke with said that they were concerned about staffing levels. Some staff felt hopeful about the future and believed that the senior management were working hard to rectify problems, others felt things were not progressing as swiftly as they might. One staff member said:

"I can't give proper care as I have no time."

"Staffing levels have been horrendous due to vacancies."

We found that patients had not received care, treatment or support that met their needs in a timely manner. There were not enough qualified, skilled and experienced staff to meet people's needs. People were not protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were not maintained. However we spoke with senior managers at the site and they were able to demonstrate that plans were in place to rectify many of the issues around staffing within the hospital.

We returned to the A&E department to review compliance actions around cleanliness and infection control, safety and availability of equipment, supporting of workers and quality monitoring. The compliance actions were set following our inspection in June 2012.

We spoke with people who used the service. They told us that they were satisfied with the service they received one person said "They've explained everything that is happening." and added "We have nothing to complain about." Another person said "They're doing the best for me but I would welcome a cup of tea." We spoke with staff who told us that "Things have improved in some areas." Staff also commented that senior managers "Seemed to listen." but would welcome closer engagement with senior members of staff.

We found that there had been improvements made since our previous inspection. People were cared for in a clean, hygienic environment and protected from unsafe or unsuitable equipment. Staff were supported to deliver care and treatment safely and to an appropriate standard. The trust had an effective system to regularly assess and monitor the quality of service that people received.

This unannounced inspection focused on the provision of emergency care within the Accident and Emergency (A&E) department. We spoke with ten patients and a number of carers who had used the A&E department both on the day of our visit and the day before. People said:

"Staff were helpful and polite".

"I am very happy with the care I received".

"I was seen very quickly".

"Spot on".

"I have no complaints".

"Straight in, straight through".

All the people we spoke with were positive about their experience and the way they were treated whilst in the A&E department.

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

We have not asked for the views of people within this review

Patients who were interviewed on the day expressed that they were satisfied with care and treatment given to them during their stay at the Cumberland Infirmary.

They told us that staff respected their views and that they were always helpful, polite and explain everything to them. Patients also told us that they felt that their care needs were being met and that staff responded quickly to their needs.

Patients told us that they were generally satisfied with the care given in meeting their nutritional needs. They also told us that the food choices, availability, presentation and special diets were of a good quality. All patients spoken to felt the choice of menu was good, and most of the meals they received were appetising and hot.

The hospital's own patient satisfaction survey shows within their dignity and privacy data all wards included in the survey between January and March 2011 scored a 100% satisfaction score with a large proportion of inpatients expressing satisfaction with care, treatment, privacy, dignity, information and treatment with respect.

There were two complaints received by the trust in relation to outcome 1 between April 2010 ' March 2011 but there were no complaints received regarding outcome 5 for the same period. Two positive comments were reported through NHS Choices between June and December 2010 about the care received.

The hospital provided several reports which demonstrate they seek and monitor patient satisfaction on a regular basis, this work is across all inpatient areas. The patient satisfaction surveys demonstrate a high level of satisfaction with care, treatment, privacy, dignity, information and treatment with respect in the months of January and March 2011. The results also support high levels of satisfaction with menus, meal choice and dietary requirements.

All Inspections

Access and flow

Nurse Staffing

Medical Staffing

Meeting Patients Needs

Effective Care

Competent staff

Urgent and Emergency care

Medical Care

Surgery

Critical care

Maternity and Gynaecology

Services for Children

End of Life care

Outpatients and diagnostic imaging

Medical

Critical Care

Maternity and Gynaecology

End of Life care

Outpatients and diagnostic imaging

Professor Sir Mike Richards

Mortality rates

Infection control

Food and hydration

Medicines management

Medical and nurse staffing

Importantly, the hospital MUST:

In addition the hospital should: