West Cumberland Hospital

Urgent and emergency care at the North Cumbria Integrated Care NHS Trust operates from two district general hospital sites: West Cumberland Hospital (WCH) in Whitehaven; and Cumberland Infirmary in Carlisle (CIC).

Both hospitals operate a 24/7 consultant-led emergency department (ED). However, the WCH ED accepts trauma cases for stabilisation only, before transferring these to either CIC or a tertiary centre.

At WCH there are also a selected number of conditions that follow a high-risk transfer pathway from WCH to CIC. These include:

• Gastro-intestinal bleed

• Respiratory patients assessed as high risk (i.e. those with an initial diagnosis of pneumothorax or potential empyema, cardiac NSTEMI/ACS/endocarditis, or bradycardia requiring urgent cardiac pacing).

• Emergency surgical pathways including; General surgery, orthopaedics, ear nose and throat, ophthalmology, Urology and vascular. ​

Both sites operate emergency assessment units; there is a 29-bedded unit at WCH for medicine and surgical admissions. The unit is supported by acute care physicians (ACPs).

Each site also operates an emergency ambulatory care unit Monday to Friday, supported by the acute medical and surgical consultants and nurse practitioners. The WCH unit operates five chairs, one bed and two examination couches from 8am to 8pm.

The emergency assessment unit and ambulatory care unit were inspected under our Medical Care Core Service Framework. This part of our report focuses on the emergency department (ED). The ED has a large waiting-room, with a reception station behind transparent screens, a triage room, a ‘majors’ area comprising six cubicles, a ‘minors’ area comprising eight cubicles, including one room designed to accommodate patients who present with mental health needs and another designed for ear, nose and throat (ENT) patients, a separate paediatrics area, comprising a waiting room and three cubicles (one of which can be used flexibly as an adult or paediatric room), a spacious resuscitation area containing three bays (one of which is also equipped for paediatric patients), a viewing room, and a relatives’ room.

During the inspection, we visited the emergency department only. We spoke with 12 members of staff including registered nurses, health care assistants, reception staff, medical staff, and senior managers. We spoke with five patients and one relative. During our inspection, we reviewed 22 sets of patient records. These included records of mental health patients and children and young people who had attended the department as well as medical and nursing records.

We carried out an unannounced inspection of the emergency department at the West Cumberland hospital on the 25 February 2020 due to concerns of crowding and patient care.

Services we rate

During this inspection we used our focussed inspection methodology. We did not cover all key lines of enquiry, we looked at the safe domain and aspects of both the responsive and well led domains.

We rated it as Requires improvement overall.

• Staff did not always have the training on how to recognise and report abuse. This meant the service did not always protect patient from harm or abuse.

• The design, maintenance and use of facilities, premises and equipment kept people safe. Staff were trained to use them. Staff managed clinical waste well.

• Staff did not complete risk assessments for each patient. They did not remove or minimise risks or update the assessments. Staff did not identify or quickly act upon patients at risk of deterioration.

• The service did not have enough nursing staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm or to provide the right care and treatment.

• The service did not have enough medical staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment.

• Staff did not always recognise and report incidents and near misses.Although when incidents were reported managers investigated incidents and shared lessons learned with the whole team. When things went wrong, staff apologised and gave patients honest information and suitable support.

• People could not access the service when they needed it to receive the right care promptly. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were not in line with national standards.

• Local leaders were visible and approachable. However, their ability to effectively manage the department was limited by staff shortages and poor access and flow of patients. Leaders at senior levels did not comprehend the challenges faced within the department and had not identified suitable action plans to mitigate the risks such as challenged medical and nurse staffing.

• Staff satisfaction was poor, and staff did not always feel actively engaged or empowered.

• Systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected were not effectively planned or implemented.

Following this inspection, wrote a letter of intent to the trust to gain assurance regarding the concerns we found in particular safe staffing, timely triage and assessment for both adults and children; In addition we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve. We also issued the provider with three requirement notice(s) that affected Urgent and Emergency. Details are at the end of the report.

Ann Ford

Deputy Chief Inspector of Hospitals (North)