You are here

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 Westmorland General Hospital in July 2015 we rated services as 'good' overall, although surgical services were rated as 'requires improvement' for being responsive to people’s needs, and outpatients and diagnostic imaging services were rated as 'requires improvement' for safe.

There were two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations. These were in relation to referral to treatment times (RTT) n surgical specialities and suitability of premises within the outpatient department (OPD).

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 WGH as 'goo' overall.

Our key findings were as follows:

  • 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.
  • Patients were treated with compassion, dignity, and respect.
  • Wards, outpatients, and theatre nurse staffing skill mix was variable during shifts, but measures were in place to ensure the safety of patients. Generally, on surgical wards, 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.
  • Medical staffing was provided by consultants and doctors for elective activity between 08:00 and 18:00, Monday to Friday. All surgery was supported by a resident medical officer on a 24 hour basis.
  • 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.
  • There had been no cases of clostridium difficile or Methicillin Resistant Staphylococcus Aureus (MRSA) in the surgical division at WGH between October 2015 and September 2016 .
  • The hospital had infection prevention and control policies in place, which were accessible, understood, and used by staff. Patients received care in a clean and hygienic environment.
  • Allied health professionals (AHPs) worked closely with ward staff to ensure a multi-disciplinary team (MDT) approach to patient care and rehabilitation.
  • 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.
  • 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%.
  • In outpatients, the overall environment had improved. We noted that space was still limited in some areas.
  • In outpatients, there remained a shortage of some staff groups including occupational therapists, radiographers, and radiologists.
  • Leadership across the hospital was reported as good, staff morale had improved, and staff felt supported. All staff spoke positively about the service they provided for patients.

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

The trust should:

In surgery:

  • Continue to sustain improvement in hand hygiene audit result.
  • Continue improving venous thromboembolism (VTE) assessments.
  • Continue improving Referral to Treatment Times (RTT) for patients and continue to implement trust-wide initiatives to improve response.
  • Increase medical/orthogeriatricians 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 with staff recruitment and retention.

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.

In outpatients and diagnostic imaging:

  • 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, ophthalmology, 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 the macular clinic.
  • Ensure that it meets RTT targets in outpatient clinics, and that it addresses backlogs in follow-up appointment waiting times.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Good

Updated 9 February 2017

Effective

Good

Updated 9 February 2017

Caring

Good

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 our previous, in July 2015, we rated maternity and gynaecology services as 'good'. During this inspection, we again rated maternity and gynaecology services as 'good' because:

  • There was a robust incident reporting procedure. Staff knew how and what to report as incidents. There was evidence that learning from incidents was shared with staff.
  • The clinical area was visibly clean, and staff followed trust infection control procedures.
  • Adult and neonatal resuscitation equipment was checked daily so that staff could be assured it was in good working order. There were systems in place to ensure stock items were available and within expiry dates.
  • Medicines and intravenous fluids were stored appropriately.
  • Care and treatment was planned and delivered in line with current evidence-based guidance, standards, best practice, and legislation.
  • The service had an infant feeding policy and was developing an infant feeding strategy.
  • The caseload ratio of Supervisors of Midwives (SoMs) to midwives was 1:15, which was in line with the national recommendation for caseloads. Supervisors had met all of the requirements of the local supervising authority audit.

  • Helme Chase Maternity Unit was available 24 hours a day, seven days a week, for women choosing to give birth there.
  • 100% of staff had received an appraisal.
  • SoMs provided a ‘birth afterthoughts’ service, which provided women with an opportunity to discuss issues surrounding their care during pregnancy and birth.
  • The trust was performing as expected in the CQC maternity survey.
  • WGH scored better than the England average for privacy, dignity, and wellbeing in the PLACE survey in 2015.
  • Women who had been assessed as low risk could choose home birth, birth in the midwifery-led unit at Helme Chase, or birth in one of the two consultant-led obstetric units at the trust.
  • The service employed a range of specialist midwives for patients with complex care needs, or for those in vulnerable circumstances.
  • The service had a robust system for monitoring, processing, and learning from complaints, which ensured that responses were sent in a timely manner, themes and trends were identified, and learning was disseminated to staff.

  • Consultant-led antenatal clinics were held within the unit three times a week, which meant that all women using the service could choose where to receive antenatal care.

However:

  • 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 NHS Foundation Trust, further work was required to effectively capture and monitor outcomes.

Surgery

Good

Updated 9 February 2017

We rated surgical services as 'good' because:

  • 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. 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. 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.
  • 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 were 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 that appraisals were undertaken annually and records for WGH showed that 82% of staff across surgical wards and theatres had received an appraisal, against the trust target of 95%. Appraisals were ongoing to the year end.
  • Allied health professionals (AHPs) worked closely with ward staff to ensure a multi-disciplinary team (MDT) approach to patient care and rehabilitation.

  • Between March 2015 and February 2016, patients at WGH had a lower than expected risk of readmission for non-elective admissions, and a lower than expected risk for elective admissions.
  • 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 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 showed mixed performance.

  • The divisional management team had taken action to address the low referral to treatment targets (RTTs). This included a local amnesty with CCGs allowing the treatment of patients in order, treating the longest waiters on the RTT pathway, changes to the RTT standard, and provision of additional capacity (sub-contracting to the independent sector, additional activity sessions, and operating department efficiencies).
  • For the period Q1 2015/2016 to the date of inspection, the trust had cancelled 561 operation on the day of surgery. Of the 561 cancellations, all were rescheduled and treated within 28 days. This was better than the England average. The trust’s cancelled operations as a percentage of their elective admissions was worse than the England average.
  • 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 their induction. All the staff we spoke with received training in and knew about safeguarding policies and procedures.
  • 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 also discussed. The directorate risk register was updated at governance meetings with action plans, which were monitored across the division.
  • Leadership of the service was reported as good, staff morale had improved, and staff felt supported at ward level. All staff spoke positively about the service they provided for patients, and emphasised quality and patient experience.

However:

  • The National Oesophago-Gastric Cancer Audit (2015) data showed patients diagnosed after an emergency admission was 0.0% placing the trust within the lowest 25% of all trusts for this measure.
  • An audit sample of 116 surgical patients completed in April 2016 showed 110 patients had venous thromboembolism (VTE) risk and bleeding risk recorded within 24 hours of admission (95%), and 34 patients had VTE risk and bleeding risk reassessed 24 hours after admission (29%). Following poor audit results, the trust had established a VTE Lead, a VTE Policy (rewritten to comply with NICE guidance), and a steering group, and had developed standalone bridging guidelines. A VTE training package had been made available on the training management system, and there was a new VTE algorithm in the clerking documentation.

Outpatients

Good

Updated 9 February 2017

We rated outpatients and diagnostic imaging services as 'good' because:

  • During our last inspection we had identified concerns about 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 that there had been significant improvements in the availability of case notes. Staff were positive about the improvements in efficiency and effectiveness for outpatient services, such as the availability of test results and timely access to information.

  • We found that there had been some improvements in diagnostic imaging staffing numbers since the previous inspection. When we inspected this time the department continued to work with vacancies, but a new rota system enabled it to make improvements.

  • During our last inspection we had noted that there was no information available in the department for patients who had a learning disability, nor any written information in formats suitable for patients who had a visual impairment. At this inspection we saw hat 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.
  • We noted that space was still limited in some areas and the service provision was physically constrained by the existing environment. However, the overall environment had improved, with changes in flooring materials. We found that overall access to appointments had improved, but performance was variable.
  • 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.
  • Staff were competent and supported to provide a good quality service to patients. Competency assessments were in place for staff working in the radiology department, along with preceptorships for all new staff to the department.
  • We found that access to new appointments throughout the department had improved.
  • Overall, staff felt engaged with the trust and felt that there had been some improvements in service delivery since our previous inspection. There were systems in place for reporting and managing risks. Staff were encouraged to participate in changes within the department, and there was departmental monitoring at management and board level in relation to patient safety. The service held monthly core clinical governance and assurance meetings, with standard agenda items, such as incident reporting, complaints, training, and lessons learned.

However:

  • There remained a shortage of some staff groups, including occupational therapists, radiographers, and radiologists. Some staff raised concerns about the sustainability of the team under prolonged staffing pressures.
  • Some referral to treatment targets were missed, and follow-up appointments continued to suffer backlogs and delays.