You are here

Cumberland Infirmary Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 29 March 2017

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

Inspection areas

Safe

Requires improvement

Updated 29 March 2017

Effective

Good

Updated 29 March 2017

Caring

Good

Updated 29 March 2017

Responsive

Requires improvement

Updated 29 March 2017

Well-led

Requires improvement

Updated 29 March 2017

Checks on specific services

Maternity and gynaecology

Requires improvement

Updated 29 March 2017

During our previous inspection, in April 2015, the service was rated as ‘requires improvement’ for being safe, effective, and well-led. This was because of a lack of dedicated medical staff cover, no epidural service, mandatory training levels not being met, ineffective medicines management, insufficient governance and audit processes, staff not following guidelines, and a lack of cohesive working across hospital sites.

At this inspection, although some improvements had been made, the service remained as ‘requires improvement’ for being safe and well-led because:

  • Some of the risks identified were still in place and sufficient actions to mitigate the risks had not yet been implemented, particularly the lack of senior paediatric medical cover out-of-hours to manage advanced neonatal resuscitation. Although there was no evidence of adverse outcomes this still presented a risk to patients.
  • There remained no clear vision or formal strategy for the future of maternity services, due to a review of Cumbria-wide provision and managers awaiting the outcome of this consultation.
  • Although there was some improvement in cross site working the cohesiveness of the two hospital sites for maternity services was not fully embedded.
  • There was some improvement in strengthening of governance processes but there were no indicators to ensure performance and understanding of risk or governance roles. There continued to be gaps in how outcomes and actions from audit of clinical practice were used to monitor quality and systems to identify when action should be taken.
  • The checking of equipment and medicines was not consistent across all areas. The quality of record-keeping was variable particularly for ante-natal information.

However:

  • Staff understood their responsibilities to raise concerns and to record safety incidents and near misses.
  • Medical and midwifery staffing levels were similar to the national recommendations for the number of babies delivered on the unit each year.
  • Care outcomes were meeting expectations in most areas, and, where improvements were required, the service had identified action.
  • Women were positive about their treatment by clinical staff and the standard of care they had received. They were treated with dignity and respect.
  • Services were planned, delivered, and co-ordinated to take account of women with complex needs, and there was access to specialist support and expertise. An epidural service was available.
  • Midwifery and medical staff worked together ensuring women received care which met their needs.

Medical care (including older people’s care)

Requires improvement

Updated 29 March 2017

The service was inspected as part of our comprehensive visit in March 2015. Overall, medical care at CIC was rated ‘requires improvement’. A number of areas for improvement were highlighted and the service was told to take action to improve:

  • medical staffing levels;

  • Increase numbers of trained nurses;
  • Improve safety thermometer results;
  • Improve performance for the care of patients with diabetes;
  • Reduce the pressures on the availability of medical beds;
  • Stop moving patients during the night without a medical reason for doing so; and
  • Provide effective leadership for nurse practitioners.

During this inspection, we found the service had made some improvements:

  • While medical staffing was not at full substantive compliment at CIC, there had been recruitment in cardiology, respiratory, and older person’s services. Network support had been strengthened in oncology and haematology services. There was a composite workforce strategy being reviewed, a number of senior interviews were pending, and the division had a clearer recruitment picture;
  • Registered nurse vacancies remained at CIC; however, all wards reported an improved picture since the 2015 inspection. This division had reconfigured wards and there were improved fill rates;
  • There had been a reduction in patient harms aligned to safety thermometer key performance indicators;
  • The division worked with a partner trust to provide diabetes services. A joint diabetologist appointment had been made, and specific programmed activities were in place to develop diabetic foot services;
  • There had been a reduction in the number of medical outliers on the CIC site. The division had developed a number of initiatives to improve access and flow.
  • Moves after 10 pm continued at CIC, however, we were assured staff only effected such a move when clinical demand and patient need necessitated this; and
  • All nurse practitioners were brought into the divisional management structure to provide clinical supervision, and senior nursing support was available to this cohort of staff.

We rated medical care (including older people’s care) as ‘requires improvement’ overall because:

  • Nurse staffing requirement had not been formally revalidated following recent ward reconfigurations. Registered nurse staffing shortfalls and registered nurse vacancies persisted on all divisional wards. A number of registered nurse shifts remained unfilled despite escalation processes. The ‘floor working’ initiative within medical care should be reviewed in order to support safer nurse staffing. There was a continuing number of patient related harms around pressure ulcers and falls. Some IPC audit outcomes highlighted a variance in compliance with cannula and catheter care key performance measures. Auditors identified some medicines-related documentation that required improvement, and deviation from National Early Warning Score (NEWS) triggers needed further consideration. Mandatory training figures were inconsistent and, overall, were below trust target.
  • Patient outcomes in some national audits were static or worse than the national averages. These were around key performance indicators in diabetes and two domains within myocardial infarction data. Completion of fluid and food charts required improvement and the temperature of some patient meals was not optimal. Staff confirmed that learning opportunities and access to professional development were variable, and appraisal rates provided by the division were inconsistent with those reported at ward level. The division had not fully embedded seven day working across all areas.
  • Staff considered the endoscopy suite at CIC was not fully meeting the needs of the local population due to changes in the booking and list preparation processes. This had led to increased numbers of patients failing to attend. There remained a number of medical outliers being cared for on non-medical wards, and care progression for those patients assessed as medically fit for discharge stalled due to multi-factorial difficulties. Some dementia initiatives to support vulnerable patient cohorts were not fully embedded.
  • The divisional risk register did not correlate with top risks identified by divisional leads. Risk ratings were confusing and details of actions taken against the risks were limited. Divisional progress against the QIP objectives was incomplete and slow. Staff morale was variable and junior doctors resented the perceived shift of onus onto them to take responsibility for covering gaps in the junior doctor medical rota. Staff considered the rate of change to be hurried and difficult. Senior leaders lacked visibility.

However:

  • Staff confidently reported incidents and the division had made considerable efforts to reduce harms to patients from falls and pressure ulcers. Ward environments were clean, and staff used personal protective equipment appropriately to protect themselves and their patients from infection exposure. Overall, medicines management was good and clinical documentation, in particular risk assessments and safety bundles, were completed thoroughly. Medical staffing establishment had improved and the division considered alternative initiatives to bolster medical staffing.
  • The division was actively involved in local and national audit, which provided a strong evidence-base for care and treatment. Patient outcomes in a number of national audits were good and there had been some reported improvements in others. Patients reported pain management to be good and considered their nutritional needs to be met. MDT working across the divisional wards was integrated, inclusive, and progressive. Staff had an understanding and awareness of consent issues and Mental Capacity Act and Deprivation of Liberty Safeguards, and capacity assessments were completed.
  • 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. Staff proactively involved family and considered all aspects of holistic wellbeing.
  • The division supported the trust in service-planning to meet the needs of the local population, acknowledging the internal and external demands upon it. The division had developed new services, extended the remit of existing services, appointed specialist practitioners, and collaborated with neighbouring trusts in service development. There were good 18 week standards reported. Access and flow was monitored, and the division worked to minimise obstacles. The division provided additional services to redirect flow and avoid unnecessary admissions. The management of medical outliers had improved. The division had made reasonable adjustments to reduce environmental conflict for vulnerable patient groups, and complaint numbers were low on divisional wards at CIC.
  • The division had a clearly defined strategy and vision, which was aligned to organisational aims and wider healthcare economy goals. Divisional leads had an understanding of the pressures and risks the service faced. Governance processes across the division were clinician-driven, and quality measures were monitored. There were defined leadership structures, and staff confirmed there was a strong clinical leadership presence across the division. Cultural improvements had been made in the preceding 18 months, evident by greater openness. Public engagement was good and utilised a variety of mechanisms to capture opinion. The staff engagement agenda had increased, in particular around health and well-being. The division was involved in a number of improvement projects.

Urgent and emergency services (A&E)

Good

Updated 29 March 2017

  

At our previous inspection in April 2015, we rated this service as ‘requires improvement’. In December 2016 we rated the service as ‘good’ because:

  • Risks to the delivery of care and treatment for patients were mitigated and a risk register for accident and emergency reflected key risks. Safeguarding procedures were in place.

  • Patient care and treatment followed evidence based guidance and recognised best practice standards. Sepsis screening and management and other clinical guidelines were used effectively.
  • Staff provided considerate and compassionate care for patients and treated them with dignity and respect. Staff interacted with patients empathetically and responses to their needs were prompt. Care and treatment was explained to patients in a way they understood. Patients were consulted and involved in decisions about their care and treatment and received emotional support.
  • Patients with a learning disability, patients with dementia, and bariatric patients accessed emergency services appropriately and their needs were supported. Patients with mental health needs could access services in a joined up way.
  • Patient's consent to care and treatment was documented and the requirements of the Mental Capacity Act were followed. Patients’ nutrition and hydration needs were provided for and pain was managed effectively.
  • Incident reporting had increased and serious incidents had reduced. Learning from the investigation of incidents was shared and duty of candour requirements were followed. Emergency preparedness arrangements were in place to respond to major incidents.
  • Public engagement included consultation events about changes to services and although few complaints were received they were investigated and learning was shared with staff.
  • Staffing had improved and staff were deployed in the department effectively so that staffing levels were sufficient to meet patients’ needs. Mandatory training had been completed by most staff. The learning and development of medical and nursing staff was supported and staff received an annual appraisal. Multidisciplinary teams operated effectively. An improved, positive culture was apparent in the emergency department and staff worked well together.
  • The hospital was taking steps to address performance as part of its improvement plan for emergency care and the accident and emergency service undertook a strategic service review during 2016. A frailty assessment unit and an ambulatory care unit recently opened. Seven day working was operated 24 hours a day throughout the year including key support services, for example radiology.
  • Cleanliness, infection control and hygiene procedures were followed and standards were monitored. Equipment and medicines stocks were managed effectively.
  • The department participated in relevant national audits and undertook regular local audits which supported consistent improvements in care and treatment for patients.
  • Local clinical leadership was visible and approachable; governance of the emergency department was more embedded and the vision and strategy for emergency care was understood. The department implemented innovation to benefit patients.

  However:

  • For an extended period, the hospital has 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.
  • Emergency department waiting time data was incorrect. Staff were not fully utilising the computer system as intended so that the times recorded were not accurate.
  • Material issues remained with patient flow into the hospital. The accident and emergency service review had identified a shortfall of two whole time equivalent consultant staff due to increasing patient demand. This was only partially filled by locum consultant staff.
  • Paediatric nursing resource was limited, although the department was taking steps to address this shortfall.
  • Changes in the operational nursing structure for the emergency department needed to become embedded.
  • Although the service had made improvements in its responses to the trauma audit and research network (TARN) audit and the NICE clinical guideline self-harm audit (CG16), work to achieve further improvements remained in progress.
  • Patient confidentiality was not always maintained in the reception area.
  • Staff engagement needed to be extended.

Surgery

Requires improvement

Updated 29 March 2017

The overall surgery rating from the 2015 inspection was ‘good’. During the December 2016 inspection we rated surgical services as ‘requires improvement’ because:

  • The trust had reported its staffing numbers as at August 2016. These numbers showed that the majority of surgical wards were below nursing establishment levels. The data showed that Beech B required 14.4 whole time equivalent (WTE) members of staff, but had only 11.72 WTE in post. Similarly, Beech D was 2.24 short and Maple D was 6.49 WTE short.

  • As of September 2016 the trust reported a vacancy rate of 8.9% in surgical staff at Cumberland Infirmary with a turnover rate of 23.6% between April 2015 and March 2016.
  • There had been seven Never Events for Surgery between June 2015 and February 2016.
  • We saw that, in November 2016, 26% of patients were re-assessed for VTE within 24 hours of admission. This was a decrease from October 2016, when 72% of patients were re-assessed with 24 hours of admission. September 2016 figures were 37%. The target is 95%.
  • Surgical debrief, as part of ‘five steps to safer surgery’, was undertaken 14% of the time. A trust audit recommended further work on encouraging the team debrief through business unit governance meetings and dissemination of learning by governance leads.
  • We found that training rates, in areas such as fire safety (58%), hygiene for clinical staff (67%), trust doctors’ patient safety programme (31%), and duty of candour (45%) were below the trust target of 95%.
  • The proportion of patients having hip fracture surgery on the day or day after admission was 68.3%, which does not meet the national standard of 85%. The 2015 figure was 75.1%.
  • Between March 2015 and April 2016 patients at the trust had a higher than expected risk of readmission for both elective and non-elective admissions. Relative risk of readmission for general surgery and trauma and orthopaedics were both similar to the trust level.
  • For the period Q2 2014/15 to Q1 2016/17 the trust cancelled 1,438 operations on the day of surgery. Of these, 12% were not rescheduled and treated within 28 days. The overall trend for this was that the trust’s percentage was much higher than the England average. Performance improved from Q1 2015/16 to Q3 2015/16; however, performance deteriorated again from Q4 2015/16 and was showing signs of deteriorating further.
  • Cancelled operations as a percentage of elective admissions includes all cancellations rather than just short notice cancellations. Cancelled operations as a percentage of elective admissions for the period Q2 2014/15 to Q1 2016/17 at the trust were consistently greater than the England average. The trust trend had followed a similar pattern to the England average, although the peaks and troughs were far more pronounced, particularly the increase in Q3 2015/16, although it should be noted that junior doctor strikes were planned during this period and may have contributed to the sharp rise.
  • For the period November 2015 to November 2016 CIC cancelled 573 surgeries for non-clinical reasons.
  • Four surgical specialties were below the England average for admitted RTT (percentage within 18 weeks).
  • An action in the QIP stated that the division aimed to achieve compliance with 18 week RTT for the incomplete pathway standard by September 2016. The status of this action remained ‘in progress’ as of December 2016.
  • At trust level general surgery had a longer average length of stay than the England average for both elective and non-elective admissions.
  • At the time of inspection the perioperative improvement plan was in the early stages of implementation, thus impacting upon some areas but not yet fully embedded within the division.
  • Staff morale was variable on the wards, in theatres, and in recovery areas. Morale was affected by working in difficult circumstances during the preceding 18 months to cover staff and skill shortages.
  • We were advised that there were ongoing bullying allegations within the theatre departments.

However:

  • The division held regular emergency surgery and elective care business unit meetings, at which serious incidents were discussed, investigations analysed, and changes to practice identified.
  • 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 were displayed clearly at ward entrances.
  • A ‘red flag’ and safer staffing system had been introduced to identify when lower than optimal staff numbers may impact upon patient care and so to initiate mitigation. Escalation processes were in place through the matron, service manager, and chief matron. Capacity bed meetings were held twice daily to monitor bed availability, review planned discharges, and assess bed availability throughout the trust.
  • All wards participated in the NHS safety thermometer approach, displaying consistent data to assure people using the service that the ward was improving practice based on experience and information. This tool was used to measure, monitor, and analyse patient ‘harm free’ care.
  • We looked at medical records across wards and saw that they were appropriately completed, legible, and organised consistently. All documentation checked was signed and dated, clearly stating details of the named nurse and clinician.
  • Patients were treated in accordance with national guidance, and enhanced recovery (fast track) pathways were used. Local policies were written in line with national guidelines. A range of standardised, documented pathways and agreed care plans was in place across surgery.
  • During 2015/16 the surgical business unit participated in 12 out of 14 national clinical audits covering a range of specialties and completed 122 local audits. Outcomes from each audit were reported to the Business Unit Governance Board (BUG Board).
  • The perioperative surgical assessment rate was 92.4%, which does not meet the national standard of 100%. However, the 2015 figure had been 62.4%, so the 2016 figure did show considerable improvement.
  • 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.
  • Patients admitted with a fractured neck of femur had their pain assessed immediately upon presentation at hospital and within 30 minutes of administering initial analgesia, then hourly until settled on the ward and regularly as part of routine nursing observations throughout admission.
  • A dedicated pain team was accessible to support with analgesia as required. The pain team visited patients when baseline pain relief was ineffective. Anaesthetists provided support with pain relief out-of-hours.
  • The Friends and Family Test (FFT) response rate for surgery at the trust was 38%, which was better than the England average of 29%, between November 2015 and October 2016. Ward level recommendation rates were variable, although recommendation rates were generally high, being between 70 and 100% for the overall period across all participating wards.
  • We observed the treatment of patients to be compassionate, dignified, and respectful throughout our inspection. Ward managers and matrons were available on the wards so that relatives and patients could speak with them if necessary.
  • The trust was actively working with commissioners to provide an appropriate level of service based on demand, complexity, and commissioning requirements.
  • The division had an escalation policy and procedure to deal with busy times, and matrons and ward managers held capacity bed meetings to monitor bed availability.
  • Complaints were handled in line with the trust’s policy and discussed at all monthly staff meetings. Patients or relatives making an informal complaint were able to speak to individual members of staff or the ward manager. Wherever possible the patient Advice Liaison Service (PALS) would look to resolve complaints at a local level.
  • We met with senior trust and divisional managers, who had a clear vision and strategy for the division and identified actions for addressing issues within the division. The divisional leadership team detailed its understanding of the challenges associated with providing good quality care, and it identified actions needed.
  • The trust had developed a quality improvement plan (QIP) and had identified specific objectives to improve the management of the deteriorating patient, the recognition of, and initiation of treatment for, patients with sepsis, and ongoing development of the Mortality and Morbidity Framework.
  • The division had also developed a Perioperative Improvement Plan in response to then recent issues identified within surgery. This aimed to enhance governance through learning from events and incidents, to develop the workforce through a positive learning environment, and to initiate external assessment and compliance.
  • There was a systematic programme of clinical and internal audit, which was used to monitor quality and systems to identify when action should be taken. Monthly audits were undertaken and audit outcomes were published quarterly.
  • The division’s risk register was updated following Safety and Quality meetings, with risks discussed, controls identified, progress against mitigation, risk grading, assurance sources, and gaps in control documented.

Intensive/critical care

Good

Updated 29 March 2017

During our previous inspection of CIC, in July 2015, we rated critical care services as ‘good’ overall, with safe as ‘requires improvement’, due to concerns about nurse and medical staffing levels. Effective, caring, responsive and well-led were rated as ‘good’. We rated the service as ‘good’ overall, after our comprehensive announced and unannounced inspection visit in December 2016, with evidence of ongoing improvement in the unit:

  • There was ongoing progress towards a harm free culture. Incident reporting was understood by the staff we spoke with and improvements in reporting culture had been noted by the critical care team. There was a proactive approach to the assessment and management of patient-centred risks and staff had a good understanding of the trust position related to learning from incidents, serious incidents, and Never Events.
  • There had been no Never Events in critical care and no reportable serious incidents at the CIC site. There had been ten NRLS reported incidents, and themes were monitored closely by grade and seriousness of harm.
  • A 24/7 Critical Care Outreach Team (CCOR) was well established. We observed good practice for recognition and treatment of the deteriorating patient. One hundred percent of patients received follow-up care once discharged from the unit. Practice was in line with GPICS (2015), NICE CG50 and against the seven core elements of Comprehensive Critical Care Outreach, (C3O 2011) ‘PREPARE’; 1. Patients track and trigger, 2. Rapid response, 3. Education and Training, 4. Patient safety and governance, 5. Audit and evaluation (monitoring patient outcome), 6. Rehabilitation after critical illness and 7. Enhancing service delivery.
  • Nurse staffing was good with sufficient staffing levels for provision of critical care. There was provision of a supernumerary coordinator and practice educator in line with Guidelines for the Provision of Intensive Care Services (GPICS) (2015).
  • Supernumerary induction for new nursing staff was good with an organised approach to nurse appraisal and nursing achievement of competence in critical care skills.
  • Medical staff we spoke with described good anaesthetic staffing levels and continuity for rotas and out-of-hours cover, however, this was achieved with 35% use of locum consultant staff at CIC, as sickness and vacancy rates for anaesthetic cover were greater than average for 2015/16.
  • The policy and activity around critical care patient transfer to other hospitals when required were good. The arrangements for the small numbers (17 in 2015/16) of paediatric admissions for stabilisation for hours prior to transfer were also good, this included levels of staff training and competence and storage and checking of essential equipment. The unit was part of the ‘North East Children’s Transport and Retrieval’ (NECTAR) new transport service.
  • The emergency resuscitation equipment and patient transfer bags for both adults and children were checked daily with a good system in place as per trust policy. There was good provision of equipment in critical care, good storage, and robust systems for medical device training.
  • The unit was visibly clean; standards of IPC were in line with trust policy. One isolation room was available with a ventilated lobby area, in line with Health Building Note HBN 04-02. Staff we spoke with told us that isolation of patients was risk assessed and documented. Liaison with the infection control team supported assurance that patients with infections received best practice.
  • The team in the unit had invested in and implemented an electronic patient record and prescription system specific to intensive care, which we observed to be comprehensive and well understood by staff. All records checked in the system were complete, and the risk assessment and patient review process was good.
  • Patients were at the centre of decisions about care and treatment. We reviewed consistent positive survey feedback and comments, which gave evidence of a caring and compassionate team. The team had established a memorial service for relatives of patients who had died in the unit, and this was well attended in the local community. There was evidence of well-attended support groups for patients in the local community. Staff whom we observed and spoke with were positive and motivated and delivered care that was kind and promoted dignity, and that focused on the individual needs of people. The improvements made towards the rehabilitation of patients after critical illness since our last inspection were comprehensive.
  • The team members in critical care services spoke highly of their local leadership and felt supported by matrons, consultants, and senior matrons. A culture of listening, learning, and improvement was evident amongst staff we spoke with in the unit. Staff we spoke with across the team were positive about their roles and clear about governance arrangements, despite frequent changes in the senior team over the preceding five years. Staff expressed desire for a period of stability in the senior and executive team.

  • We found that Intensive Care National Audit and Research Centre (ICNARC) data showed that patient outcomes were comparable or better than expected when compared with other units nationally, this included unit mortality. ICNARC data had been collected and submitted consistently at CIC for around three years, since the appointment of a dedicated member of the team. The data was available to the team and, during our inspection, we were able to review consistent annual reports. However, we reported to the critical care team that, although its data was published on the ICNARC website, this was only for one unit. Staff we spoke with were not aware of this and could not explain why data for the other unit was not published.

  • Plans were in place to provide multidisciplinary follow-up clinics across both units for rehabilitation of patients after critical illness, as recommended by NICE CG83 and GPICS (2015). These were for those patients who had experienced a stay in critical care of longer than four days. A small, dedicated team was being recruited to deliver this standard, and progress was good. Support groups had been well attended in the local community, with staff organising a range of supportive and educational opportunities. The use of patient diaries had been embedded in practice.
  • Patients received timely access to critical care treatment and consultant-led care was delivered 24/7. Readmissions to the unit were monitored closely by the consultant and CCOR team and were below national average. Patients were not transferred out of the unit for non-clinical reasons. We found that patients were not cared for outside of the critical care unit when Level 2 or 3 care was required, and we did not see examples of critical care outliers in theatre recovery or ward areas.
  • Patients in the critical care unit were discharged to the wards within eight hours once a decision to discharge was made, as per GPICS (2015). ICNARC data indicated a position that was much better than national performance against this target. Almost all patients were discharged within four hours of being ready for discharge. There were no single sex breaches and low numbers of out-of-hours discharges (0.8%).

However:

  • Although substantive and establishment nurse staffing were good in critical care, with low vacancies and sickness rates, staff (including members of the CCOR team) were moved frequently to support shortfalls in staffing in other wards and departments. We spoke with staff who felt that this affected the morale of nursing staff in the unit. Nonetheless, patient safety was not compromised, and we did not see evidence that patient-to-nurse ratios were compromised, as we had found that they had been during previous inspections. We also noted that it was not possible to protect the supernumerary coordinator role when staff were moved.
  • The role of the supernumerary clinical educator was embedded and valued. However, this role was provided in a 0.8 WTE post, and the post-holder had commitments to deliver nasogastric (NG) education across the trust in response to trust-wide serious incidents. Although this training was valuable it meant that the clinical educator was only able to provide a part time service in the CIC unit and was unable to provide a service across the trust.
  • The number of pressure sores recorded in the incident reporting system had not shown improvement since our previous inspection, and staff reporting of pressure ulcer grading and level of harm was inconsistent.
  • The critical care pharmacist provision was well below GPICS (2015) standards. We spoke with staff in the unit who did not report any issues with management of medicines and pharmacy support. However, pharmacists were not able to fulfil the critical care role, join ward rounds, or deliver improvements in practice, with only 0.2 WTE dedicated hours.
  • In 2015 we reported that the unit had limits in storage and patient bed space, and, during this inspection, we noted again that, although the unit was modern in design, it would not meet current national standards for new buildings and environment. (HBN 04-02). The senior team had submitted proposals which outlined plans for unit upgrade and expansion. 

Services for children & young people

Good

Updated 29 March 2017

  • The leadership, governance, and culture promoted the delivery of high quality person-centred care. Staff were competent and had the skills they needed to carry out their roles effectively and in line with best practice. Managers were visible, and there was a real strength, passion, and resilience across medical and nursing teams to deliver high quality care to children, young people, and their families.
  • Staff told us that they were proud to work for the trust and promoted a patient-centred culture. Children, young people, and parents felt that medical staff communicated with them effectively, kept them involved and informed about care and treatment, promoted the values of dignity and respect, and were kind and compassionate.
  • Staff protected children and young people from harm and abuse. Medical and nursing staff understood and fulfilled their responsibilities to raise concerns and report incidents, and managers took appropriate action to investigate and share learning.
  • Medical and nursing staff followed appropriate processes and procedures to safeguard children and young people. The trust was represented at local safeguarding children board meetings and other sub-groups. Clinicians shared learning from serious case reviews, and care records showed staff provided very good standards of care.
  • Children and young people received effective care and treatment, planned and delivered in line with current evidence-based practice and legislation. Children’s services participated in national and local audits and other monitoring activities, including service reviews and accreditation schemes. Managers shared outcomes from audits, and actions plans were developed to address areas of concern.
  • Children’s services were organised to meet the needs of children and young people. Managers and healthcare professionals from the team worked collaboratively with partner organisations and other agencies to ensure services provided choice, flexibility, and continuity of care.

However:

  • 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) within contracted hours. Despite ongoing recruitment campaigns, the trust had struggled to recruit appropriate clinicians. The current paediatric consultant team members voluntarily worked in excess of their programmed activities to ensure that children and young people were safe. However staffing constraints meant that this was done in their own time. In a letter to CQC the trust formally acknowledged our concerns and outlined actions taken to address the current shortfall, which included robust handovers and ward rounds, and on-site consultant presence, plus out-of-hours support.
  • Due to staff shortages in the special care baby unit (SCBU), the trust could not provide a qualified in specialty (QIS) senior nurse on every shift. Paediatric consultants supported the nurse-led unit, which mitigated the risk to babies, however, this also contributed to their own increasing workload. The trust formally acknowledged our concerns in the aforementioned letter, highlighting the mitigating actions taken to ensure babies received safe care. In addition to senior QIS nurses working extra shifts, the trust planned to support less experienced neonate nurses to complete advanced neonatal nurse practitioner courses, and to ensure that all senior staff completed neonatal life support training.

End of life care

Good

Updated 29 March 2017

During our previous inspection of End of Life Care Services at Cumberland Infirmary, in April 2015, we rated the service as ‘requires improvement’ overall. During this inspection there was evidence of ongoing improvement. We have rated the service as ‘good’ overall, with effective as ‘requires improvement’ because:

  • Staff delivering end of life and specialist palliative care understood their responsibilities with regard to reporting incidents. Staff we spoke with told us that when an incident occurred it would be recorded on an electronic system for reporting incidents.
  • We viewed mortuary protocols and spoke with mortuary and porter staff about the transfer of the deceased. Staff told us that the equipment available for the transfer of the deceased was adequate, and we saw that this included bariatric equipment.
  • The trust had developed a care of the dying patient (CDP) care plan that provided prompts and guidance for ward-based staff when caring for someone at the end of life. We observed the use of these and saw that information was recorded and shared appropriately and that the plans were completed.
  • We saw that specialist palliative care nurses worked closely with medical staff on the wards to support the prescription of anticipatory medicines. The guidance that the specialist nurses provided was in line with end of life care guidelines and was delivered in a way that focused on developing practice and confidence in junior doctors around prescribing anticipatory medicines.
  • The palliative care end of life communication training (Sage and Thyme) was part of the mandatory training for all staff at CIC.
  • We observed the use of McKinley syringe drivers on the wards and saw that regular administration safety checks were being recorded. Ward staff told us that syringe drivers were available when they needed them.
  • The trust had also introduced a “Care after Death” document. The document provided a standard operating procedure for healthcare staff to understand that end of life care extends beyond death, to provide care for the deceased person and support to their family and carers.
  • An early warning scoring system was in use throughout the trust to alert staff to deteriorations in a patient’s condition. Patients recognised as being at the end of life had their care plan transferred to the CDP framework when they were expected to die within a few days.
  • The Trust had an organ donation policy which adhered to national guidelines. The framework process made reference to specialist nurses, clinicians, and nursing staff supporting the family throughout the process.
  • Staffs were able to demonstrate compassion, respect, and an understanding of preserving the dignity and privacy of patients following death. Mortuary staff told us there was always a member of staff on call out-of-hours. This service was available for families who wanted to visit during an evening or a weekend.
  • Porters had face-to-face mortuary training that included the transfer of the deceased, promoting dignity and respect, and an understanding of bereavement.
  • The chaplaincy service provided spiritual support for patients and their families, together with the Bereavement Nurse Specialist
  • The trust ensured that there was timely identification of patients requiring end of life care on admission. Systems were in place so that when a patient who was known to the palliative care team was admitted that team would be alerted.
  • We observed staff caring for patients in a way that respected their individual choices and beliefs, and we saw that records included sections to record patient choices and beliefs so that these were widely communicated between the teams.
  • An Integrated End of Life and Bereavement group was in operation. This was headed by the Deputy Director of Nursing, and the members of the group included the SPCT, the chaplaincy, the bereavement lead, education and training staff, and consultant medical staff.
  • The trust had developed “Welcome to Hospice at Home – West Cumbria” initiative. This service included the provision of daytime and night nursing care, respite care during the day, evening, or night, and volunteer support in the home The service could also refer patients to other services within the organisation, including complementary therapies for patients, carers, and those bereaved, one-to-one or group support, bereavement support, and Lymphedema support. All services provided were free of charge
  • The SPCT had developed a care pathway tool for patients in all areas of the hospital. This was to ensure that patients who required end of life care were identified at the earliest opportunity, and to facilitate the most appropriate care in the most appropriate place for each patient.
  • A clear vision had been established, providing that ‘All people who die in Cumbria are treated with dignity, respect and compassion at the end of their lives, and that, regardless of age, gender, disease, or care setting they will have access to integrated, person-centred, needs-based services to minimise pain and suffering and optimise quality of life’.
  • The vision’s aim was to provide a framework for the delivery of services allowing all adults in Cumbria who were approaching the end of their lives, “to live as well as possible until they die,” in accordance with their own wishes and preferences.
  • The lead bereavement nurse and the chaplain had leadership roles in terms of end of life care and raising awareness of aspects of their service across the trust. This involved attending meetings and working collaboratively across services and departments to raise awareness of end of life care issues.
  • There was a commitment at all levels within the trust to raise the profile of death, dying, and end of life care. This included improving ways in which conversations about dying were held and engaging with patients and their families to ensure their choices and wishes were achieved.
  • Discharge coordinators were available to support the process of rapid discharge at the end of life, and the trust had recently implemented a community service where patients could be supported by trust staff in their own homes should care packages be difficult to access in the community.

However:

  • For patients who did not have mental capacity, DNACPR forms we viewed at this inspection were inconsistently completed. We saw DNACPR forms that did not provide evidence of a best interest decision or a mental capacity assessment being undertaken and recorded. In a letter to CQC the trust formally acknowledged our concerns and outlined actions to be taken to address this issue.

  • The trust had not achieved two clinical indicators and three organisational indicators in the End of Life Care Audit: Dying in Hospital in 2016.
  • The trust had not produced an action plan with key responsibilities and timelines for achievement to address areas where performance was lower than the England average at the time of our inspection.
  • The trust could not provide us with the number of referrals to the SPCT.
  • Both the SPCT and staff on general wards supported patients in their endeavours to die in their preferred location. However, the trust did not collate or hold the data that would demonstrate the percentage of patients who had done so. This information was held by the Clinical Commissioning Group and could not be provided by the trust.
  • There was no regular audit of the CDP.
  • Specialist palliative care was not provided across a seven day service.
  • The trust did not have formal contract meetings with members of the Cumbria Healthcare Alliance to monitor the service being commissioned and provided, and so could not demonstrate that the service was of an appropriate standard in terms of quality and meeting patient need. 

Outpatients

Good

Updated 29 March 2017

We rated this service as ‘good’ because:

  • An electronic incident reporting system was in place. Staff we spoke with could describe how they would report incidents.
  • The environment was suitable, clean, and tidy. Hand gel dispensers were available for use in all areas visited, and staff adhered to the ‘bare below the elbow’ policy in services that we visited.
  • We found that equipment had been checked appropriately, and medicines that we checked were found to be in date and securely stored. Medical records availability had been identified as an issue at previous inspections, and we found improvements had generally been maintained.
  • Staffing levels and skill mix were ascertained by the department managers. Actual staffing levels were mostly in line with the planned staffing levels in most areas.
  • Staff used evidence-based guidance and followed national guidance. We found that a number of staff members had undertaken additional courses and training to enhance their competency. Staff had access to the systems and information they required for their role.
  • Care was planned and delivered in a way that took account of patients’ needs and wishes. Patients attending the outpatient and diagnostic imaging departments received effective care and treatment.
  • Staff provided compassionate care and ensured patient privacy and dignity was respected whilst using the services. Patient feedback was positive about the services. Diagnostic services were delivered by caring, committed, and compassionate staff.
  • The service offered clinics throughout the week and on weekends to ensure that patients were seen and to meet demand. Additional clinics were added to manage demand for the services. Interpreter services were accessible and available if required.
  • Management could describe the risks to the service and the ways in which they were mitigating these risks. However, we found that not all risks identified were on the risk register.
  • Staff were mostly positive about their roles, local leadership, and team work. Daily huddles in the outpatient department had increased information sharing between staff and were found to be useful.

However:

  • Mandatory training completions had not achieved the trust target of 95%.
  • There were staff shortages in the orthopaedic practitioner staff group and oncology outpatients.
  • There was no formal clinical supervision in main outpatients or ophthalmology outpatients.
  • There was no current strategy for outpatients. However, staff told us that they were developing one.
  • Performance measurement information was limited.
  • The trust did not measure how many patients waited over 30 minutes to see a clinician in outpatient departments.
  • Turnaround times for inpatient plain film radiology reporting did not meet Keogh standards, which require inpatient images to be reported on the same day.