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Inspection Summary


Overall summary & rating

Good

Updated 9 February 2017

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

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

When we last inspected this hospital, in July 2015, we rated services as as 'requires improvement'. We rated safe, effective, responsive, and well-led as 'requires improvement'. We rated caring as 'good'.

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

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

We found that the trust had made the required improvements and rated Royal Lancaster Infirmary as good overall, with caring and end of life services rated as outstanding and safe rated as requires improvement.

Our key findings were as follows:

  • There had been significant improvements across most services at this hospital since our last inspection in July 2015.
  • In critical care and end of life care services, there were a number of outstanding examples of compassionate care and emotional support shown by all levels and disciplines of staff who did not hesitate to go the extra mile to make a difference for patients and their loved ones.
  • Leadership of the hospital was good, managers were available, visible, and approachable; staff morale had improved significantly, and they felt supported. Staff spoke positively about the service they provided for patients.
  • There had been significant investment in leadership within end of lfe services.
  • Staff knew the process for reporting and investigating incidents using the trusts reporting system. They received feedback from reported incidents and felt supported by managers when considering lessons learned.
  • 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.
  • The trust reported no incidences of MRSA between September 2015 and May 2016. Eight cases of clostridium difficile were reported in the same period.
  • 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.
  • Nursing and medical staffing numbers had improved since the last inspection. However, there were still several nursing and medical staffing vacancies throughout the hospital, especially in medical care services and the emergency department. There were also nurse staffing concerns in the neonatal unit. The trust had robust systems in place to manage staffing shortfall, as well as escalation processes to maintain safe patient care.
  • The hospital had improved compliance against mandatory training and appraisal targets in most services. Local support and supervision of junior staff had improved, and many areas had developed their own unit-specific competencies for training and development purposes.
  • There had been an improvement in record-keeping standards throughout the hospital, however, we identified some ongoing areas for improvement around legibility and trigger levels for early warning of deterioration, particularly in in medical care services and the emergency department.
  • The trust’s referral to treatment time (RTT) for admitted pathways for surgery services had improved since the last inspection. Information for September 2016 showed an improvement in the trust’s performance, with 75% of this group of patients treated within 18 weeks against the England average of 75%.
  • Access and flow, particularly in the emergency department and medical care services, remained a challenge. The emergency department performance had been deteriorating over the preceding 12 months. The Department of Health’s standard for emergency departments is that 95% of patients should be admitted, transferred, or discharged within four hours of arrival in the A&E. The last month that the trust delivered the 95% ED 4-hour performance standard was in August 2015. Lack of beds in the hospital resulted in patients waiting longer in the emergency department. Delays in obtaining suitable community care placements were causing access and flow difficulties, particularly in medical care services.

We saw several areas of outstanding practice including:

  • The medicine division delivered outstanding Referral to Treatment (RTT) outcomes across all specialisms despite pressures on the service overall.
  • The Listening into Action programme had delivered some clear, effective, and significant quality improvements for the organisation and for patients across the hospital.
  • The service was one of only three trusts which were successful in securing funding to pilot a maternity experience communication project. This was a patient-based, communication-improvement training tool for multi-professional groups in maternity services. The project had the potential to be adopted nationally if learning outcomes and measurable improvements could be made for women who were using maternity services.

  • The bereavement team, Chaplaincy, and specialist palliative care team worked together to promote compassionate care at the end of life. A particular innovation relating to this had been the development of death cafés. A death café provided an opportunity for people to talk more openly about death and dying. The trust had held death cafés for the public as part of 'dying matters week', and also had used them to support staff to talk more openly about death and to promote better communication with patients and relatives at the end of life.
  • There were a number of innovations relating to compassionate care for patients at the end of life. This included the use of canvas property bags with a dragonfly symbol so staff knew that those collecting them had been recently bereaved. In addition, bereavement staff sent out forget-me-not seeds to family members following the death of a loved one. Families were also able to get casts of patient’s hands. Thich was a service provided by an external organisation, with funding for this provided by the trust.
  • The trust had adopted the dragonfly as the dignity in death symbol. This was used as a sign to alert non-clinical staff to the fact that a patient was at the end of life or had died. A card with the symbol could be clipped to the door or curtain where the patient was being cared for. By alerting all staff this meant that patients and family members would not have to face unnecessary interruptions, and non-clinical staff knew to speak with clinical staff before entering the room. An information card had been produced for non-clinical staff explaining the difference between the dragonfly symbol (dignity in death) and the butterfly (dementia care).
  • A remembrance service was held by the Chaplaincy every three months for those bereaved. We were also told that ‘shadow’ funeral services had been delivered within the trust when patients had been too unwell to attend funerals of loved ones.
  • Relatives were sent a condolence letter by the bereavement service a few weeks after the death of a loved one and support was offered at this time.

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

Importantly, the trust must:

In urgent and emergency care services:

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

In services for children and young people:

  • Ensure there are sufficient nursing staff to ensure compliance with British Association of Perinatal Medicine (BAPM) and Royal College of Nursing (RCN) guidance.

Action the hospital SHOULD take to improve

In urgent and emergency care services:

  • Ensure observations are recorded appropriately to allow the assessment and early recognition of the deteriorating patient
  • Ensure nursing documentation is completed in accordance with trust policy.

In medical care:

  • Ensure all risk assessments (particular reference to venous thromboembolism and multi-factorial falls risk assessments) are completed for all patients where appropriate, and evidence of the same is documented consistently.
  • Ensure medicines documentation records patient allergies, venous thromboembolism risk, and oxygen prescribing.
  • Ensure National Early Warning Score (NEWS) triggers are followed or, in the event of deviation, ensure trigger levels are adjusted, with clinical rationale documented to evidence.
  • Ensure all nursing and medical clinical documentation is completed in full and in accordance with recognised professional standards.
  • Where medicines are stored in fridges, ensure temperature ranges are recorded in accordance with policy to ensure the safety and efficacy of the medicine is not compromised.
  • Ensure all staff complete all elements of their mandatory training requirements, and ensure accurate compliance figures are maintained.
  • Ensure all staff benefit from the appraisal process and these are completed on an annual basis in accordance with local policy.
  • Ensure there is a reasonable and proportionate induction process, or access to relevant induction information, for all locum medical staff attending the hospital on an ad-hoc or short-term basis.
  • Ensure action plans put in place to address shortfalls in local and national patient outcome audits are monitored and reviewed in a timely manner to ensure compliance is measured.
  • Ensure there is a review of patient comments and Patient Led Assessment of the Care Environment (PLACE) findings regarding food quality, and consider measures which may be implemented to improve nutritional care;
  • Ensure staff awareness and knowledge of Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) is underpinned by consideration of procedural competence in making such applications, to avoid potential legislative breaches.
  • Ensure where family attendance is required at care meetings sufficient notice is given;
  • Ensure the patient and family members are given appropriate time and opportunity, in the right arena, to voice opinion on care and treatment plans.

  • Ensure that, where external staff are required to support in 1:1 observation of patients, they are suitably trained to perform the task.

  • Ensure the number of patient bed moves after 10pm is kept to a minimum, to avoid patient and family anxiety and distress;
  • Ensure the effectiveness of the new governance framework is measured and adapted accordingly.
  • Ensure the effectiveness of current staff engagement themes, and consider other formats which will support divisional strategy. 
  • Ensure reasonable measures are put in place to support staff wellbeing, and ensure all staff know what is available to them.

In surgery:

  • The trust must ensure care pathways are reviewed in accordance with the trust policy.
  • The trust should ensure hand hygiene audits take place monthly and that improvements are made.
  • Nursing documentation should include whether a patient has had food or drinks whilst in the emergency department.
  • Continue to improve Referral to Treatment Times (RTT) for patients and continue to implement trust-wide initiatives to improve response.
  • Increase orthogeriatrician’s input on surgical wards.
  • Ensure all transfers between locations are performed in line with best practice guidance and policy. Where practice deviates from the guidance, a clear risk assessment should be in place.
  • Continue to engage staff and encourage team working, to develop and improve the culture within the wards and theatre department.
  • Continue with staff recruitment and retention.
  • Ensure medicines reconciliation is completed in a timely way.
  • Ensure medication fridge temperatures are checked within trust policy timescales.

In critical care:

  • In 2015 we reported that the unit had limited space and during this inspection we noted again that the unit was over twenty years old and would not meet current national standards for new buildings and environment. The trust should continue to monitor environmental standards and challenges in critical care and continue with strategic plans for refurbishment and expansion.
  • Take action to improve physiotherapy staffing and be clear in how it supports rehabilitation for patients in line with GPICS (2015).

In maternity and gynaecology:

  • Ensure that outcome measures are developed to monitor the effectiveness of the strategic partnership with Central Manchester University Hospitals NHS Foundation Trust and Lancashire Teaching Hospitals NHS Foundation Trust.
  • Ensure that care records, including cadiotocograph (CTGs), are legible, complete, timed, and dated.
  • Continue to monitor the cultural assessment survey for obstetrics and gynaecology, and improve values around organisational culture.

In services for children and young people:

  • Ensure that all children with an acute medical problem are seen by a consultant paediatrician within 14 hours of admission.
  • Ensure the environment of the children’s unit and neonatal unit are fit for purpose.
  • Ensure there is a review of all children and young people’s mortality and morbidity.
  • Ensure that documentation refers to Gillick competency and ensure that staff are properly trained and confident to assess Gillick competency.
  • Continue to ensure that communication takes place with partner agencies about the placement of CAMHS patients.

In outpatients and diagnostic imaging:

  • Continue to build relationships and develop closer team working for medical staff in radiology and breast services across all locations, to develop a one trust culture.
  • Continue to ensure sufficient numbers of suitably qualified, competent, skilled. and experienced persons are deployed in order to meet the needs of the patients. This is particularly in relation to radiology, dermatology, and allied health professionals.
  • Continue work started to ensure that all premises used by the service provider are suitable for the purpose for which they are being used, properly used, properly maintained, and appropriately located for the purpose for which they are being used. This is particularly in relation to services provided from medical unit one.
  • Ensure it meets referral to treat targets in outpatient clinics and address backlogs in follow- up appointment waiting times.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 9 February 2017

Effective

Good

Updated 9 February 2017

Caring

Outstanding

Updated 9 February 2017

Responsive

Good

Updated 9 February 2017

Well-led

Good

Updated 9 February 2017

Checks on specific services

Maternity and gynaecology

Good

Updated 9 February 2017

At the last inspection in July 2015, we rated maternity and gynaecology services as 'requiring improvement' for being safe and well-led, particularly in relation to checking of equipment, medicine management, assessing and responding to risk, embedding governance and risk processes, joint working, and culture. During this inspection, we found good progress had been made in these areas and rated maternity and gynaecology servicse at Royal Lancaster Infirmary as 'good' because:

  • Staff understood their responsibilities to raise concerns and record patient safety incidents. There were processes to ensure reviews or investigations were carried out and action taken.
  • Staff were aware of the procedures for safeguarding vulnerable adults and children, the infant abduction policy had been tested.
  • There were processes for checking equipment and arrangements for managing medicines.
  • Medical, nursing and midwifery staffing levels were similar or better than the national recommendations for the number of babies delivered on the unit each year.
  • Systems were in place for assessing and responding to risk. Staff received training that enabled them to identify and act in the instance of a critically ill woman. There was improvement in the use and completion of the surgical safety checklist compared to the last inspection.
  • Women’s care and treatment was planned and delivered in line with current evidence-based practice, which was audited to ensure consistency of care and treatment pathways.
  • 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, there was access to specialist support and expertise.
  • The leadership team understood the challenges to the service and actions needed to address these. Improvement had been made to ensure staff and teams were working together to promote a culture of learning and continuous improvement. A culture of openness was evident.
  • There were many examples of how people’s views and experience was used and acted on to develop and delivery maternity care.

However:

  • Not all care records were fully completed, dated and signed. This included inconsistent recording on cardiotocographs (CTG) which was not in line with the trust fetal monitoring policy. These areas were audited and recommendations made.

  • Although there was a plan, which set out the principles and governance arrangements for a strategic partnership with Central Manchester University Hospitals NHS Foundation Trust and Lancashire Teaching Hospitals further work was required to effectively capture

Medical care (including older people’s care)

Good

Updated 9 February 2017

The service was inspected as part of our comprehensive visit in July 2015. Overall, medical care at RLI was rated as ‘requires improvement’. During this inspection we found the service had made significant improvements.

  • There had been a reduction in patient harm related incidents, particularly around pressure ulcers and falls.
  • There had been significant improvements made in the clinical environment to support better care delivery;
  • Although there was still a number of nursing and medical staffing vacancies, the trust had robust systems in place to manage staffing shortfall and had extended their recruitment reach with the appointment of a number of international nurses.
  • The service had improved compliance against mandatory training and appraisal targets which had seen an increased uptake in Safeguarding (incorporating Mental Capacity Act 2005) training. Local support and supervision of junior staff had improved with the implementation of ‘Professional Forums’. The features of this covered facilitated group sessions, reflective practice and a redeveloped preceptorship programme for newly qualified nurses.
  • Overall, medicines management was good.
  • There had been a marked improvement in record keeping standards following a continued programme of training. The division scrutinised audit figures and targeted areas of lower compliance with support from matrons and practice educators.
  • The service had developed an action plan to address and progress areas for improvement highlighted in the 2015 inspection.
  • Staff understood their responsibilities to raise concerns and report incidents. The division had reported a reduction in patient harm related incidents. Senior staff managed nurse staffing shortfalls proactively and there were robust escalation processes in place to deal with nurse staffing concerns.
  • Staff delivered evidence based care and the division were actively involved in local and national audit. There were some positive patient outcomes recorded in a number of national audits and there was good evidence of collaborative and effective multi-disciplinary team working.
  • The division were passionate to deliver quality compassionate patient care and we observed this care being delivered. Patients were complimentary about the care they received and felt informed about treatment and management plans.

  • The division reported excellent referral to treatment time figures across all specialisms. The division was responding to the internal and external demands placed upon it by developing a number of services and care pathways to reduce unnecessary hospital admissions. There was a positive drive to engage with partner organisations to maintain and further services for the benefit of the population in the short, medium and long term. Staff made reasonable adjustments in response to individual patient needs and to accommodate vulnerable patient groups.
  • Managers led the service well. The divisional strategy reinforced with the trust vision and aligned with the on-going work with partner organisations. Staff felt a real and palpable shift in divisional culture referring to a ‘new energy’, an openness and a team approach in dealing with issues faced. Organisational governance structures had been encompassed within the division and there was evidence to show how this supported divisional governance processes.
  • There were many excellent examples of improvement projects and innovative strategies which brought about changes in clinical practice, work efficiencies, improved patient care and delivered organisational benefits.

At this inspection we rated medical care (including older people’s care) as 'good' overall, with safe as 'requires improvement', because:

  • Fall related incidents remained a concern despite reducing numbers of patient related harms. The process of capturing the multi-factorial falls risk assessment was unclear and inconsistently applied. This was compounded by the recent transition of the core safety bundle from paper records to the electronic patient record.
  • Some medicines related record keeping standards required improvement, in particular, around the recording of patient allergies and oxygen prescribing.
  • There remained a significant number of nursing vacancies and there was a reliance on senior locum medical cover across many sub-specialisms at RLI. The division were actively recruiting to vacant posts however many remained unfilled.
  • The division had some static patient outcome measures in stroke services at RLI. These findings were across a number of domains and the division had action plans in place to address areas for improvement.
  • Seven day services were not fully embedded and the division fell below national averages on a number of key metrics in the NHS Services, Seven Days a Week Four Priority Clinical Standards. The division was involved with the trust task group looking at seven day working across the organisation.
  • A combination of factors including extended length of stay, increasing bed occupancy levels and delays in obtaining suitable community care placements were causing access and flow difficulties at RLI. This had led to significant numbers of patient moves after 10pm and a number of medical outliers encroaching into other services. Divisional managers were working with partners looking at all variables affecting patient flow.
  • To achieve the divisional strategic objectives, the service identified staff engagement as one of the key priorities. Clinical leaders recognised there was a risk of staff becoming fatigued and less resilient to deal with the pressures of working demands in the current climate. Staff considered the division managers could do more in terms of recognition and support for their wellbeing.

Urgent and emergency services (A&E)

Requires improvement

Updated 9 February 2017

We rated the emergency and urgent care service as 'requires improvement' because:

  • The emergency department performance had deteriorated over the last 12 months. The last month that the Trust delivered the 95% ED 4-hour performance standard was in August 2015. Whilst there are multiple factors that impact upon patient flow it was recognised the most important factor was bed occupancy. Lack of beds in the hospital resulted to patients waiting longer in the emergency department.
  • Guidance issued by the Royal College of Emergency Medicine (RCEM) states a face to face assessment should be carried out by a clinician within 15 minutes of arrival or registration. The median time from arrival to initial assessment was worse than the overall England median in all months over the 12 month period.
  • Staffing levels and skill mix was below the actual planned levels at times despite the use of bank, agency and locums
  • The department was not meeting the trust’s target for staff completing mandatory training. The target for appraisal rates was not being met. Following our previous CQC inspection in July 2015 an action that the hospital must take to improve was to ensure that staff receive appropriate support, training, supervision and appraisal. Appraisal rates and mandatory training remains below the trust target for completion.
  • The outcomes of people’s care was not always monitored regularly or robustly, using the national early warning score which could prevent early recognition of a deteriorating patient
  • Nursing assessments were not always completed.
  • Patient group directives were overdue a review in January 2016. Prescription pads were not stored securely.
  • Care pathways were not regularly reviewed.
  • Emergency equipment was not always checked daily.
  • Hand hygiene audit results were poor.
  • The trust’s unplanned re-attendance rate to the emergency department within seven days was generally worse than the national standard of 5% and generally better than the England average.
  • Between September 2015 and August 2016 there was an upward trend in the monthly percentage of ambulance journeys with turnaround times over 30 minutes. A ‘black breach’ occurs when a patient waits over an hour from ambulance arrival at the emergency department until they are handed over to the emergency department staff. Between August 2015 and July 2016 the trust reported 1210 black breaches. The trust reported 157 black breaches in July 2016. There was an upward trend in the monthly number of black breaches reports over the period.
  • In the previous CQC inspection in July 2015, an action that the hospital should take was to improve the ambulance turnaround times. The department was continuing to fail to meet the standard.
  • Between August 2015 and September 2016 the trust’s monthly percentage of patients waiting between four and 12 hours from the decision to admit until being admitted for this trust was worse than the England average.
  • Between August 2015 and July 2016, the trust’s monthly median total time in A&E for admitted patients was consistently similar to the England average. 

Surgery

Good

Updated 9 February 2017

The overall surgery rating from the 2015 inspection was 'requires improvement'. During the 2016 inspection we found that action had been taken to address the issues identified. There were systems in place to identify themes from incidents and near miss events. We saw improved audits for the 5 steps to safer surgery and had discussions with staff about the process and procedure for raising safeguarding referrals. There were risk assessments and escalations plans in place for situations where practice deviated from guidance.

We rated surgical services as 'good' because:

  • Staff knew the process for reporting and investigating incidents using the trusts reporting system. They received feedback from reported incidents and felt supported by managers when considering lessons learned. All wards used the national early warning scoring (NEWS) system for recording patient observations and systems for recognition and management of deteriorating patients. Infection prevention and control was managed effectively.
  • Wards and theatre skill mix was variable during shifts, but measures were in place to ensure the safety of patients. Generally, nursing staff to patient ratio was one to eight. We reviewed the nurse staffing levels on all wards and theatres and found that numbers and skill mix appropriate at the time of inspection.
  • The hospital had an escalation policy and procedure to deal with busy times and staff attended bed meetings in order to monitor bed availability on a daily basis. Staff treated patients in line with national guidance and used Enhanced Recovery (fast track) pathways.
  • Local policies were written in line with national guidelines. Staff told us appraisals were undertaken annually and records for Royal Lancaster Infirmary showed that 82% of staff across surgical wards, and theatres had received an appraisal against the trust target of 95%. Appraisals were on going to the year end.
  • Allied health professionals (AHP’s) worked closely with ward staff to ensure a multi-disciplinary team approach to patient care and rehabilitation.
  • Evidence based care and treatment national audits identified mixed outcomes for all audits. The National Bowel Cancer Audit Report (2015) showed better than the England average for four measures.
  • The National Emergency Laparotomy Audit (NELA) report (2015) showed Royal Lancaster Infirmary achieved a rating over 70% for five measures and had a good rating for nine out of 10 elements of the audit. The element which was worse than required related to orthogeriatricians input for patients over 70 years old.
  • The Patient Reported Outcomes Measures (PROMS) for groin hernia metrics and knee replacement metrics were about the same as the England average whilst hip replacement metrics had mixed performance. We saw that orthogeriatricians had contributed to the development of the care pathway of elderly patients.
  • Staff received Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) training as part of staff induction. All the staff we spoke with received training in and knew about safeguarding policies and procedures
  • The trust’s referral to treatment time (RTT) for admitted pathways for Surgery has been worse than the England overall performance between October 2015 and August 2016. However, the latest figures for September 2016 showed an improvement in the trust’s performance, with 75% of this group of patients treated within 18 weeks against the England average of 75%.
  • We saw staff treating patients with compassion, dignity, and respect throughout our inspection.
  • Ward managers and matrons were available on the wards so that relatives and patients could speak with them
  • Complaints were dealt with informally at ward level in the first instance and where necessary escalated to ward managers and matrons in line with trust policy. Complaints were discussed at monthly staff meetings where training needs and lessons learning were discussed. The directorate risk register was updated at governance meetings with action plans monitored across the division.

Intensive/critical care

Good

Updated 9 February 2017

Following our last inspection in July 2015, we found that overall the critical care service provided at the Royal Lancaster Infirmary required improvement.

During this inspection we rated this service as 'good' overall, with 'good' ratings in safe, effective, responsive and well-led, and a rating of 'outstanding' for caring because:

  • Patients were at the centre of decisions about care and treatment. The weight of positive comments gave evidence of a caring and compassionate team. Staff were positive and motivated and without exception delivered care that was kind and promoted peoples dignity, and focused on the individual needs of people.
  • During our inspection we found that nurse staffing was good with sufficient staffing levels for provision of critical care. Recruitment was underway to provide 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. This was an improvement to findings in 2015 where we found that although nurse staffing levels had improved from the 2014 inspection findings, there was no supernumerary coordinator or funded practice educators in post.
  • Medical staff we spoke with discussed the historical shortfalls in anaesthetic staffing levels for out of hours cover. We had noted in 2015 that the intensive care services, obstetrics, anaesthetics and emergency surgical services across the trust did not have enough anaesthetic staff to meet the required national recommendations and standards. However, this was well understood by the executive team and clinical staff. An additional five consultants at RLI and three consultants at FGH have been funded to ensure safe staffing levels and mitigate risks. A recruitment strategy was in place.
  • Pharmacy cover was good at RLI and met the standards outlined in GPICS (2015) with a critical care pharmacist and senior technician support. We had reported in 2015 that medicines were not stored securely in the unit; however this had improved with provision of new storage cabinets and performance of a regular safe storage of medicines audit.
  • The emergency resuscitation equipment and patient transfer bags were checked daily with a good system in place as per trust policy. There was good provision of equipment in critical care with robust systems for medical device training. The risks associated to loss of service if equipment was broken and needed replacement were on the risk register.
  • The unit was visibly clean; standards of infection prevention and control were in line with trust policy. 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 and the small proportion of patients that may need specialist ventilated isolation facilities would be transferred if required. Patients with infections were isolated as per policy, however the two isolation rooms were not designed in line with Health Building Note (HBN 04-02) and did not have ensuite shower rooms or ventilated lobby areas.
  • There was on-going progress towards a harm free culture. Incident reporting was good with low incidence of harm and infection. There was a proactive approach to the assessment and management of patient-centred risks and staff took responsibility for driving improvement to reduce risk of patient harm or acute deterioration. The programme for care of patients with tracheostomy across wards was comprehensive.
  • In 2015 we reported there was no Critical Care Outreach Team across both units at UHMB. The trust did not have a dedicated CCOR team and this continued to be on the risk register, however during our inspection we noted good provision of principles in line with GPICS (2015), NICE CG50 and against the seven core elements of Comprehensive Critical Care Outreach,(C3O 2011). Staff we spoke with told us that there was an ‘educational model’ of outreach embedded across the trust. We observed three occasions of a rapid response to acute emergencies by the team.
  • The team in critical care services were well-led. A genuine culture of listening, learning and improvement was evident amongst all staff we spoke with. Staff we spoke with across the team were passionate about their roles and proud of the trust. The investment in leadership programmes was good and it was clear the learning was shared, staff had a shared purpose and made an impact in practice. Governance arrangements were embedded in the directorate.
  • We found that ICNARC data showed that patient outcomes were comparable or better than expected when compared with other units nationally, this included unit mortality.
  • Follow up clinics were in place at the RLI for critical care patients, as recommended by NICE CG83 and GPICS (2015), who had experienced a stay in critical care of longer than 4 days. Emotional support was given as part of the follow up appointment, post critical care admission and additional psychological support was assessed on an individual basis. The use of patient diaries had been embedded in practice since our last inspection.
  • Patients received timely access to critical care treatment and consultant led care was delivered 24/7. A low number of critical care elective admissions were cancelled and there was a low number of readmissions to the unit. Patients were not transferred out of the unit for non-clinical reasons. Staff worked hard to not discharge patients to wards during the night with low number of out of hours discharges, comparable with other similar units.
  • Over half of all discharges to ward areas were delayed beyond 4 hours due to the pressures on hospital beds, however this did not prevent the patient from receiving the care and treatment they needed and staff paid attention to patient dignity when single sex accommodation breaches occurred. ICNARC data did indicate that the unit position was comparable nationally with other units against the 8 hour reported target in the CMP.
  • Staff we spoke with in critical care and theatres did not express concern about risk to patients when ‘outlier’ admissions took place and staff had not reported any incidents of harm as a consequence. This was an improved arrangement since our last inspection, with a 50% reduction in annual admissions, (from 46 to 24). Critical care training had been increased for staff in theatres. Nurse skill mix in the critical care unit was not compromised to cover the theatre recovery activity, as had been previously reported.

However:

  • In 2015 we reported that the unit had limited space and during this inspection we noted again that the unit would not meet current national standards for new buildings and environment. There was an estates strategy which outlined the plans for unit upgrade and expansion. Issues around estates and environment were on the directorate risk register and had been identified as a ‘not met’ against National D16 commissioning service specifications for critical care services, during an assessment by the LSCCCN.
  • We observed good compliance with hand hygiene by all nursing staff, with regular 100% audit results of compliance. However there was poor access to sinks in the unit, which did not comply with health building note HBN 00-09, (infection control in the built environment; hand hygiene facilities, clinical wash-hand basin provision).
  • Patients discharged from critical care should receive a ward follow up visit by critical care nurses within 36 hours of discharge, it was reported that this could not be provided consistently by staff in the unit and was affected by activity and staffing resources. Staff we spoke with were planning improvement as part of the appointment of a supernumerary coordinator.
  • We observed that physiotherapy cover in the unit did not provide enough opportunity to be involved in unit activity, deliver care to eight patients that was in line with GPICS (2015) and reduced opportunity to develop standards of patient rehabilitation in critical care.

Services for children & young people

Good

Updated 9 February 2017

Following our previous inspection in 2015, children and young people’s services were rated as 'requires improvement'. Issues were identified with the reviewing of incidents, medical staffing levels, the design and layout of the neonatal unit, insufficient resuscitation trolleys on the children’s unit and the abduction policy had not been tested.

At this inspection we found that the majority of these issues had been resolved with the exception of the design and layout of the neonatal unit. Incidents were reviewed appropriately, medical staffing levels had improved, although we found that not every child was seen within 14 hours of admission, there were sufficient resuscitation trolleys and the abduction policy had been tested.

Overall, we rated the services for children and young people at RLI as 'good'. Effective, caring, responsive and wellled were rated as 'good'. We rated safe as 'requires improvement'.

  • Staff were aware of their responsibility to report incidents and appropriate systems were in place. Staff received feedback about incidents and learning was shared.
  • Staff were clear about their responsibilities if there were concerns about a child’s safety. Safeguarding procedures were understood and followed. Staff had completed the appropriate level of training in safeguarding and received safeguarding supervision.
  • A paediatric early warning system was used for early detection of any deterioration in a child’s condition and appropriate transfer arrangements were in place for those children requiring more specialised care.
  • Staff had access to evidence based policies which were compliant with national guidance.
  • There was a programme in place for local and national audit.
  • Feedback from children, young people and their parents was positive.
  • Services were planned to meet people’s needs. Facilities were provided for parents.
  • There were governance systems in place to ensure that quality, performance and risks were managed and information could be cascaded between senior management and clinical staff.

However:

  • Not all children were seen within 14 hours of admission in line with Royal College of Paediatric and Child Health (RCPCH) standards.
  • Staffing was not always compliant with British Association of Perinatal Medicine (BAPM) and Royal College of Nursing (RCN) guidance.
  • The layout of the children’s unit meant that staff could be isolated when working in the assessment unit.
  • The Neo Natal Unit (NNU) had insufficient space and there was not always a member of staff present in the special care room.

End of life care

Outstanding

Updated 9 February 2017

In the last inspection of Royal Lancaster Infirmary, in July 2015, we rated end of life care services as 'good'. During this inspection we rated the end of life care service as 'outstanding' because:

  • The trust had clear leadership for end of life care services that was supported at a senior level within the organisation. There was active involvement strategically from the deputy chief nurse and executive leadership at board level.
  • End of life care services were very well led. There was a clear vision and strategy that focused on all people are treated with dignity, respect and compassion at the end of their lives.
  • We saw evidence of proactive executive involvement in terms of the development of the end of life care strategy.
  • There was very good public and staff engagement
  • There was a commitment by the trust and this was underpinned by staff that patients were cared for in a dignified, timely and appropriate manner
  • There were examples of innovation across the service. Leading Dying Matters week, the trust had introduced death cafés with an aim to raise the profile end of life care. This included the development of the bereavement service.
  • Patients were cared for holistically and there was strong evidence of spiritual and emotional support being recognised for its importance within the trust. This was apparent through the development of ‘death cafés’ where issues relating to death and dying were talked about openly.
  • The staff throughout the hospital knew how to make referrals and people were appropriately referred to and assessed by the specialist palliative care team in a timely manner, therefore individual needs were met.
  • Staff had access to specialist advice and support 24 hours a day from a consultant on-call team for end of life care.
  • The chaplaincy and bereavement service supported families’ emotional needs when people were at the end of life, and continued to provide support afterwards.
  • The mortuary was clean and well maintained, infection control risks were managed with clear reporting procedures in place.
  • The bereavement palliative care service had been nominated for a compassionate care award in 2015.
  • The survey of bereaved relatives results were positive in relation to dignity and respect afforded to patients.
  • The trust had recently introduced a Hospital Home Care Team service, where patients could be transferred to their own homes and supported by trust staff where care packages were difficult to access in the community.

  • An ‘ease of access to hospital’ group had been developed by the trust which included representation from the bereavement and chaplaincy service where initiatives were in place to improve access to the mortuary.
  • DNACPR (do not attempt cardio-pulmonary resuscitation) records were generally completed well and the trust was making use of audits and learning from incidents to drive improvements.
  • Mandatory training was in place and attendance by the specialist palliative care nurses exceeded the trust target.
  • The care of the dying patient (CDP) document in use throughout the trust.
  • The trust had introduced EPaCCS (electronic palliative care co-ordination system). This enables recording and sharing of people’s care preferences and details about their care at the end of life.

Outpatients

Good

Updated 9 February 2017

We rated this service as 'good' because:

  • During our last inspection we noted that space was limited and working areas were cramped in breast and physiotherapy services. We noted this time that space remained limited in some areas and the service provision was physically constrained by the existing environment. The trust had made plans for structural and estate changes.

  • During our last inspection we identified concerns with the timely availability of case notes and test results in the outpatients department. At this inspection staff and managers confirmed that the trust had reduced the use of paper records and implemented an electronic records system for most outpatient areas. This was still being rolled out across all departments but we found there had been significant improvements in the availability of case notes.
  • Since the last inspection we found that there had been some improvements in staffing. CT scanning staff had previously raised concerns about shortage of staff and their access to knowledge and skills competencies. When we inspected this time the department continued to work with vacancies but a new rota system enabled the department to make improvements.
  • During our last inspection we noted that there was no information available in the departments for patients who had a learning disability or written information in formats suitable for patients who had a visual impairment. We saw this time that there was a range of information available in different formats and staff had involved the public and groups including vulnerable people in producing information for use by patients.
  • The service had previously experienced issues with effective team working and had challenges in building team resilience and communication. We found examples of strong local and senior leadership and staff from all departments commented on management improvements. Staff were proud of opportunities they had been involved in to drive forward service improvements and innovation.
  • Outpatient and diagnostic services were delivered by caring, committed and compassionate staff.
  • Patients were overwhelmingly positive about the way staff looked after them. 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. Care and treatment was evidence based and followed national guidance. We found that access to new appointments throughout the departments had improved.
  • The Breast Screening Service at this hospital had been the subject of an external review by an independent body.  During this inspection we observed that recommendations from the review had been implemented and maintained