All inspections: West Cumberland Hospital

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

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

However:

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

We carried out a follow up inspection between 6 and 9 December 2016 to confirm whether North Cumbria University Hospitals NHS Trust (NCUH) had made improvements to its services since our previous 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 this hospital we rated services overall as ‘requires improvement’. We rated surgery, critical care, services for children and young people, and outpatients and diagnostic imaging as ‘good’. All other services, with the exception of medical care, were rated as ‘requires improvement’. Medical care at this hospital was rated as ‘inadequate’.

There were four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations at this hospital. These were in relation to staffing, safe care and treatment, 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, West Cumberland Hospital (WCH) 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 and surgical services, and children and young people services, 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, particularly in medical care and children and young people services. Medical staffing within these specialities remained reliant upon locum support, and with that, was vulnerable to changes in locum worker preferences or departures.
However, within medical care services medical staffing had improved from the previous inspection with additional workforce assurance plans in place. This included securing long-term locum contracts, developing the composite workforce model, improving links with specialist trainees and securing cross-site support from divisional clinician colleagues at CIC.
Compliance against mandatory training targets was an issue in some services.
Access and flow, across the emergency department, medical care and surgical services, and outpatients remained a significant challenge.
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 it was failing to meet consistently a locally agreed trajectory to see and treat emergency patients within four hours of arrival which had been agreed in conjunction 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 WCH cancelled 292 elective surgeries for non-clinical reasons.
Referral to treatment time (RTT) data varied across specialities, particularly in surgical services.
Patient flow initiatives within the medical division were not fully embedded and required improved coordination, ward staff engagement and more timely discharge plans implemented. Medical outliers accounted for a significant proportion of the in-patients beds at this hospital.
Delays in obtaining suitable community care placements were causing access and flow difficulties, particularly in medical care services.
Within outpatients, there were a number of clinics cancelled within 6 weeks of the clinic across the trust 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.
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 which did not provide evidence of a best interest decision or a 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 was used to monitor quality.
Due to the public consultation taking place at the time of our inspection, it was noted that a preferred option and decision was yet to be taken by Cumbria Clinical Commissioning Group on the future of maternity and children and young people’s services.
However:
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 policy and activity around critical care patient transfer to other hospitals, including children and babies, when required 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:

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.
Honorary Professorship University of Cumbria received by a consultant for work on applying digital technologies in Health Care for elderly population in rural setting, a part of CACHET.
Multinational multicentre prospective study in the use of intramedullary nail in varus malalignment of the knee. The trust had the largest international experience of this technology for this application.
WCH 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 real strength of MDT working and positive patient outcomes in the stroke service;
The ‘expert patient programme’ and ‘shared care initiative’ in the renal business unit exhibited real patient integration, empowerment and care partnerships; and,
There were a variety of data capture measures in use to monitor ‘real-time’ patient experience and collate patient feedback.

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 out of the hospital.

In Medicine

Ensure 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, improve the management of medical outliers by reducing the number of patients receiving care on a non-designated medical ward, improving repatriation processes and minimising service user moves after 10 pm.

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 against 18 week referral to treatment standards for admitted patients for oral surgery, trauma & orthopaedics, urology and ophthalmology.
Improve rate of short notice cancellations for non-clinical reasons specifically for orthopaedic surgery.
Ensure patients whose operations are cancelled are treated within the 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’)
Ensure that systems are in place so that governance arrangements, risk management and quality measures are effective.

In Services for Children and Young People

The trust must ensure children and young people services meet all Royal College of Paediatrics and Child Health (RCPCH) - Facing the Future: Standards for Acute General Paediatric Services (2015 as amended).

In 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.
Ensure that referral to treat indicators (RTTs) 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 target 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
Extend the scope and consistency of staff engagement.

In Medicine

Continue to progress patient harm reduction initiatives;
Ensure IPC compliance improvement and consistency in standards, in particular regarding catheter and cannula care;
Ensure best practice guidelines for medicines related documentation is reinforced to all prescribers;
Ensure oxygen prescribing is recorded and signed for accordingly;
Ensure medicines management training compliance improves in line with trust target;
Ensure all relevant clinical observations are recorded at the required frequent, NEWS scores are accurately calculated and trigger levels are adhered to (or document deviation/individual baseline triggers in the clinical records);
Ensure 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 staff are given time to complete all necessary mandatory training modules;
Ensure all fields within medical and nurse clerking documentation are completed in full, in line with local policy and best practice guidelines;
Ensure all equipment checks are completed in line with local guidance;
Progress JAG accreditation application for new endoscopy suite at WCH;
Continue to proactively recruit nursing and medical staff, considering alternate ways to attract, such as utilising social media;
Ensure measures are put in place to support units where pending staffing departures will temporarily increase vulnerability;
Progress the ‘Composite Workforce Model’ and further embed support from substantive medical colleagues at CIC;
Ensure food satisfaction standards are maintained and where relevant improved;
Work with partnership colleagues to address static diabetes patient outcomes;
Evidence improvements in patient outcomes for respiratory patients around time to senior review and oxygen prescribing;
Support staff development in line with organisational/staff appraisal objectives protecting/negotiating study time where required;
Ensure appraisal rate data recorded at trust level coincides with figures at divisional/ward level;
Ensure patients are given sufficient time to converse with staff regarding care related matters;
Revisit the patient journey, booking and listing procedures at the endoscopy suite at WCH;
Ensure where escalation beds are utilised, they are staffed accordingly with due consideration of existing ward staffing requirements;
Consider local leads for patient flow initiatives and reinforce processes with staff;
Ensure processes seek to repatriate medical outliers at the earliest opportunity to minimise impact into surgical services;
Continue to minimise patient moves after 10 pm;
Ensure the ambulatory care suite is utilised as intended;
Reinforce the dementia strategy across the division to ensure consistency of practice with support initiatives;
Ensure reasonable adjustments available for visually impaired, those with hearing difficulties and those who require translation services are known to all staff;
Consider options available to extend ambulatory care services across seven days;
Ensure senior divisional staff make every reasonable effort to attend divisional governance meetings regularly;
Ensure the risk register is current and reflects actual risks with corresponding accurate risk rating. Ensure all actions and reviews of risk ratings are documented;
Ensure progress continues against QIP, realign completion dates and account for deadline breaches;
Ensure staff feel involved and integrated into engagement activity for their benefit and ensure all staff are aware of existing provisions available to them;
Ensure 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;
Ensure divisional leads and trust leaders promote their visibility when visiting wards and clinical areas; and,
Consider promoting divisional and trust wide success stories to share good news and positive outcomes to improve staff morale.

In Surgery

Ensure 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 all mandatory training is completed by March 2017.
Reduce the management of medical patients on surgical wards.
Ensure bullying allegations in theatres are addressed.

In Critical Care

Senior staff should continue to monitor the staffing shortfall an impact in the unit as a result of increased staff sickness. The action plan produced should be reviewed to ensure achievement of the key points. Staff should be able to provide assurance that the staffing ratios for intensive care are protected as per Intensive Care Society guidance.
CCOR staff should not be moved to cover ward area staff shortage as part of routine escalation plans. This issue needs to be monitored and CCOR staff should be supported to provide the role across the trust as per practice in line with GPICS (2015), NICE CG50 and against the seven core elements of Comprehensive Critical Care Outreach, (C3O 2011).
Take action to improve pharmacy staffing in line with GPICS (2015).
The role of the supernumerary clinical coordinator should be protected as per GPICS (2015) standards. Currently this is not the case in the unit and should be in place to support the team in line with the standards.
The clinical educator should provide a role in the WCH unit in order to meet GPICS (2015) standards for a unit of this size.

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 in place so that record-keeping, medicine management, and checking of equipment are consistent across all areas.
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 a registered children’s nurse (RCN) should support healthcare assistants working in the children’s outpatient department with. Royal College of Nursing staffing standards for children in outpatients states a minimum of one RCN must be available at all times to assist, supervise, support and chaperone children. Healthcare assistances should also be trained and competent in weight management and documentation according to their level of responsibility.

In End of Life Care

Arrange formal contract meetings with members of the Cumbria Healthcare Alliance to monitor that the service being commissioned and provided 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 SPCT within their 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 CDP to demonstrate this.
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.

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. Ensure mandatory training and safeguarding training completion rates and met in line with the trust target.
Ensure there are sufficient staffing levels in place and ensure actual levels match planned levels.
Ensure that equipment, such as refrigerators in diagnostic imaging, are checked as required.
Consider ways of making performance and quality information available for use.

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 RichardsChief Inspector of Hospitals

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

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

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

Surgery key findings:

At the time of inspection the Perioperative Quality Improvement Plan was in the early stages of implementation, impacting upon some areas but not yet fully embedded within the division. Although most staff were aware of the plan, they could not articulate specific outcomes from the plan.
During interviews with staff, they told us that the division had strong leadership and most senior managers were highly visible and ‘hands on’.
Although staff acknowledged that the trust had plans in place to increase staffing levels and develop effective recruitment and retention plans, some staff said they had been working in difficult circumstances during the last eighteen months to cover staff and skill shortages.
The ward cared for high numbers of medical ‘outliers’ with high acuity and different needs to surgical patients. This supported the view expressed by staff that they were working under pressure within the division.

Children and young people key findings:

The wards planned staffing in accordance with recognised standards and were compliant with BAPM and RCN recommendations. There were escalation plans to address shortfalls or changing acuity.
Medical staffing was heavily supported by locum appointments in senior positions however many of these posts were filled by unit known clinicians on extended contracts. Unit managers recognised the vulnerability of the situation and were taking steps to recruit to vacancies to reduce temporary engagements and stabilise turnover. The unit did not meet all Royal College of Paediatric and Child Health (RCPCH) - Facing the Future: Standards for Acute General Paediatric Services (2015 as amended). The standards covered areas such as consultant presence, time to consultant review and consultant led handovers.
There was a clear strategy for the remodelling of the services provided by the Child Health Clinical Business Unit. Unit management had worked up a number of proposals which were now encompassed within the wider Success Regime looking at the improvement and sustainability of various provisions across the region. Staff confirmed their awareness of the proposals however were concerned about the implications for the service at WCH. Managers needed to ensure staff were kept up-to-date with Success Regime progression.
The unit had maintained a comprehensive governance and assurance structure to monitor and mitigate risk. The unit leadership team was visible and there was a real strength and ‘team’ culture with staff at ward level. Staff were proud to work for the trust and were passionate about delivering good care. Staff were supported locally and felt engaged with unit leaders.

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

Importantly, the trust must:

Ensure that children and young people services meet all Royal College of Paediatrics and Child Health (RCPCH) – Facing the Future: Standards for Acute General Paediatric Services (2015 as amended).

In addition the trust should:

In surgical services:

Ensure there are no inconsistencies with adhering to trust policy in signing for controlled drugs.
Ensure robust recruitment and retention policies are adopted to cover staff and skill shortages identified on the divisional risk register.
Identify appropriate mechanisms for supporting the wellbeing of staff during periods of additional pressures.

In children and young people services:

Ensure staff provide an initial assessment and classification of harm for all submitted incidents in accordance with policy and national standards.
Continue to monitor on-going medical staffing requirements to ensure safety and sustainability of service.
Ensure all staff are kept up-to-date with Success Regime progression to reduce anxiety and uncertainty.
Consider the designation of a clinical lead to reinforce the quality of the unit audit activity.

Professor Sir Mike Richards

Chief Inspector of Hospitals

At the previous inspection in April 2014 we found that since our last inspection and the Keogh review, there had been a significant improvement in mortality rates, which were now within expected limits. Infection rates had also improved and were within expected limits. There were numerous consultant vacancies that were adversely affecting timely treatment for patients and effective support for junior doctors in a number of core services. Nurse staffing levels, although improved, remained of concern and there was a heavy reliance on staff covering extra shifts, and bank and agency staff to maintain adequate staffing levels. Adequate staffing levels were not consistently achieved in all core services.

There had been changes to the functions regarding the management of trauma, high risk general surgery and colorectal cancer patients, which began in June 2013. This care had transferred to the Cumberland Infirmary in Carlisle. This has led to routine elective work being regularly cancelled at the Cumberland Infirmary, but the transfer of routine work to West Cumberland has not been as systematic as anticipated, as patients preferred to wait to have their procedure at Carlisle. The distance between the two sites appeared to be a major factor in patients’ decisions regarding where to have their surgery rather than the quality of care delivered. This had exacerbated the trust’s inability to meet referral to treatment time (RTT) targets for admitted patients, particularly in orthopaedics. Communication from the executive team with front line staff had improved. However, we were concerned about the culture within the trust as we received a high number of anonymous whistleblowing concerns before, during and after the inspection. This demonstrated a lack of openness and that staff felt unable to share their concerns with the trust directly.

At this inspection our key findings were as follows:

Medical Staffing

Medical staffing in the emergency department consisted of three consultants with vacancies for another three consultants. Two of the posts were covered by locums.
In medicine, in February 2015, five out of seven consultants in on call positions were filled by locums and all resident doctors were locums. At the time of our inspection there were consultant vacancies in specialist posts such as gastroenterology, respiratory, care of the elderly and general cardiology. A medical workforce review produced by the trust, which is dated February 2015, described the nature of medical cover at the hospital as “fragile and unsustainable”.
In surgery during February 2015, there were nine whole time equivalent consultants employed by the hospital, which met the consultant establishment requirement. Additional cover was also provided by one locum consultant during the month. The wards and theatres we inspected had a sufficient number of medical staff with appropriate skills to ensure that patients were safe and received appropriate care. We found there was sufficient on-call consultant cover over the 24-hour period and there was sufficient medical cover outside of normal working hours and at weekends.
There were five vacancies for consultant anaesthetists at the hospital during February 2015. The hospital used a locum consultant anaesthetist to provide additional cover during the month. The clinical business unit director told us they had appointed four anaesthetists during March 2015 to address the shortfall across both hospitals. The consultants had not yet commenced their employment at the time of our inspection.
At our last inspection there were concerns raised that there was no dedicated anaesthetist for the maternity services and one consultant anaesthetist during the night who was available for both maternity services, general surgery and intensive care. The position remained the same at this inspection. We raised this with the trust who took immediate action to improve anesthetic cover in these areas. In gynaecology the number of consultants had increased since the last inspection and there were now no vacant posts. Those recruited had a variety of interests including gynaecology, oncology, foetal medicine and minimal access gynaecology. This had led to an increase in the services offered, such as laparoscopic surgery. There should be seven middle grade doctors employed by the trust however there were five locum middle grades working at the time of the inspection.
In children and young peoples services there was still a shortage of medical staff that meant consultants were filling in gaps in the rota and there was a reliance on locum staff at both junior and middle grades.
Within the radiology department the service was challenged in recruiting senior radiologists in particular a senior MRI radiologist for the new hospital.

Nurse Staffing

In urgent care the trust was reviewing the draft NICE guidance at the time of the inspection and confirmed professional judgement was currently applied in relation to safe staffing levels and additional nurses had been approved by the board in March 2014 based on this judgement.
We observed the numbers of nursing staff in A&E to be below requirements especially when the number of patients increased.
There was no provision for a specific paediatric trained nurse in the A&E department. At the time of the inspection, a nurse had been transferred from the children’s ward and was working in a supernumerary capacity within the department to support the paediatric element of A&E care. The trust had recruited 2.8 whole time equivalent (WTE) Emergency Nurse Practitioners (ENP) to work in the new hospital; one ENP was in post and a further two were due to start their employment in the following weeks.There were a total of 12 advanced nurse practitioner (ANP) posts which the trust were recruiting into at the time of the visit.
Although nurse staffing levels had improved since our last inspection, there were still high nurse vacancy rates on some medical wards. Of particular concern were the trained nurse staffing levels on Pillar/ Patterdale ward where there were six whole time equivalent vacancies, increasing to eight within two weeks of our inspection.
The surgical wards and theatres we inspected had sufficient numbers of trained nursing and support staff with appropriate skills to ensure that patients received appropriate care.
The surgical wards were supported by a team of Advanced Nurse Practitioners (ANP’S) with at least two ANP’s on shift over a 24-hour period. This included at least one nurse trained as a nurse prescriber. However some were still undergoing training and were not yet able to carry out all aspects of this role.
Nurse staffing levels were appropriate to meet the needs of Children and young people.
The midwife to birth ratio was 1 to 24. This was better than the England average which was 1 to 28.
In maternity there were now surgical assistants, which were qualified nurses who had completed additional training so they could assist in operating theatres should there be a need for an emergency caesarean section out of hours or when a team of theatre personnel were not available.
A rolling recruitment programme to fill vacant nursing posts was on-going. Several new initiatives had been implemented, including an increase in the student nurse intake to two per year, with a view to retaining them once qualified and partnership working with other trusts. The trust was in the process of recruiting 50 nurses from the Philippines.

Patient outcomes

Performance reported outcomes measures (PROMs) data between April 2013 and March 2014 showed that the percentage of patients with improved outcomes following groin hernia, hip replacement, knee replacement and varicose vein procedures was either similar to or better than the England average.
The average length of stay for elective and non-elective patients across all specialties was better the England average.
The rate of normal births was in line with the England average and maternal readmission rates were in line with the England average.
.A local audit of End of Life Care had taken place as a base line for the pilot of the new End of Life Care plans. This showed that patients had access to anticipatory medications for pain and distress at the end of life. There were no robust systems in place to monitor that all patients received good end of life care.
Outcomes for stroke patients between April to September 2014 had improved with the Sentinel Stroke National Audit Programme (SSNAP) showing the trust’s stroke services moved from an 'E' rating to a ‘D’ on a scale of A to E, with A being the best.
The latest National Diabetes Inpatient Audit (NADIA) 2013 showed that the hospital was performing below the England average in 10 of the 21 indicators and was unchanged from the previous inspection.
Submission of data to the Intensive Care National Audit and Research Centre (ICNARC) was now consistent. The data showed that patient outcomes and mortality were within the expected ranges when compared with similar units nationally.
Myocardial Ischaemia National Audit Project (MINAP) showed that West Cumberland Hospital achieved a similar or better performance than England averages.
National Diabetes Inpatient Audit 2013 showed that the hospital was performing below the England average in 11 of the 21 indicators.
The national joint registry data up to July 2014 showed that hip and knee mortality rates were in line with the national average.
The lung cancer audit 2014 showed the trust performed better than the England and Wales average for the number of cases discussed at multidisciplinary meetings and the percentage of patients having a CT scan before bronchoscopy. The trust performed worse than the England and Wales average for the percentage of patients receiving surgery in all cases (9.8% compared with the average of 15.1%).
The national bowel cancer audit of 2014 showed that the trust was performing better than the England average for the number of patients that had a CT scan, the number of patients for whom laparoscopic surgery was attempted and length of stay above five days.
The Trust had not participated in the Care of the Dying National Audit. However, we were given assurances that the Trust would participate in 2015.
High risk clinical pathways within the trust had been reviewed, including the stroke pathway. A business case was in the final stages of development.

Access and flow

The trust had done extensive work to investigate why the 4 hour waiting target was sometimes exceeded. Factors contributing to poor performance included bed occupancy within the hospital, which had been above the England average of 85% between April 2013 and September 2014 for general and acute beds.
The A&E department met the target between April 2014 and September 2014 with a range of 95.9% to 97.9% compliance with the four hour target. However, over the second half of the year, West Cumberland Hospital only achieved the target in November 2014 (95.1%) with the lowest achievement in February 2015 (86.3%). All individual breaches of the four hour target were investigated. At the time of our inspection we found that a number of four hour target breaches had occurred. We found patients who had been in the department for over seven hours and others that had been in the department for five hours. One patient had stayed overnight in the monitoring bays. Overall a total of 12 patients waited for more than 12 hours from the decision to admit to being admitted in the last quarter.
Bed occupancy in the trust overall exceeded the England average throughout 2014, with bed occupancy levels for medical patients frequently in excess of 100%.
The excessive number of medical patients meant they were being cared for on all of the surgical wards. This was having a negative effect on the numbers of operations that were cancelled. Trust data for all operations cancelled across the trust (including prior to admission and on day of surgery) showed that there had been a total of 695 operations cancelled for non-clinical reasons between January and March 2015, and 419 (62%) of these cancellations were due to ward beds unavailable and bed shortages. Medical review of medical patients being cared for on surgical wards varied. Some consultants would visit the ward regularly to review patients, while others did not. We reviewed eight sets of records of medical patients who were receiving care and treatment on surgical wards and found that none of them received a daily review during the week, with four receiving a review only twice weekly. We spoke with three of these patients who told us they were unhappy about the frequency of medical reviews.
Beds were frequently occupied by patients, otherwise fit for discharge, who were awaiting transfer to Carlisle Infirmary for diagnostic tests such as angiograms. We reviewed the records of two patients who had been waiting seven and eight days for this procedure. Staff confirmed that these waits were unusually long, but that a wait of three or four days was normal.
Bed management meetings were held throughout the day. We found these to be disorganised and lacking basic essential information, such as exact patient numbers. The meetings were too focused on the specifics around the care and treatment of individual patients rather than the flow of patients throughout the hospital.
Referral to treatment times were close to meeting national targets but up to December 2014 the percentage of patients waiting longer than 6 weeks for diagnostic tests was almost 12% against a target of less than 1% and in dermatology and rheumatology where no patients had been seen within 18 weeks. There had been a deteriorating trend in the referral to treatment times across the medical specialities throughout the last year.
NHS England data showed national targets for 18 week referral to treatment (RTT) standards for admitted patients were not achieved between April 2013 and November 2014. There was an on-going action plan to improve performance against RTT standards for each specialty. This included key actions such as improved planning to reduce the back log of patients, improving theatre capacity and use of private sector healthcare organisations to treat patients awaiting surgery.

Importantly, the trust must:

Urgent and Emergency care

Ensure equipment is stored correctly, decontaminated effectively and all single use items are within expiry date.
Provide safe and secure storage for medication with access limited to qualified staff only.

Surgery

Improve compliance against 18 week referral to treatment standards for admitted patients.
Improve number of patients whose operations were cancelled and were not treated within the 28 days.

Medicine

Improve medical staffing levels.
Increase numbers of trained nurses.
Improve the way in which medicines are stored.
Provide sufficient infusion pumps so that there are pumps always available for patient use.
Ensure the requirements of the Mental Capacity Act 2005 are followed with regard to the application of Deprivation of Liberty Safeguards.
Improve the routine review of medical patients receiving care and treatment on wards outside their speciality.

Maternity

Ensure out of hours surgical cover to protect the safety of patients in a surgical emergency.
Ensure a dedicated obstetric anaesthetist is available at all times.
Ensure that resuscitation equipment is appropriately checked in order to that it is suitable for use at all times.
Ensure the safe management and storage of medicines in the maternity unit.
Ensure medical and midwifery staff are up to date with the training necessary for their role.
Improve the governance arrangements to include investigation of the higher than target rate of unexpected admissions to the neonatal unit; the potential wait for patients requiring a termination of pregnancy from referral to procedure, especially when medical staff were absent from work; the necessary measures to adequately manage patients with a high body mass index, multi-disciplinary clinics which should be routinely available for patients with complex needs or multiple health needs; possible extension of the early pregnancy service to a seven day service, the standardisation of the post natal listening service across the trust and introduction of mechanism for monitoring the number of cancelled inductions of labour.

Services for Children

Review the consultant paediatric cover provided out of hours. This was a concern as the service still offered a 24 hour emergency service for children and young people.
Recruit a ward manager and ensure oversight from a matron.

Outpatients and diagnostics

Recruitment of senior radiologists in particular a senior MRI radiologist and ultrasound radiologist.

End of Life

Improve the accurate completion of DNACPR forms.

In addition the trust should:

Urgent and Emergency care

Improve the four hour wait target results.
Improve the mandatory training completion rate.

Medicine

Ensure that medical staff document information in patient records appropriately.
Work towards JAG accreditation in endoscopy.
Improve access to psychiatric review.
Improve access to information systems for newly appointed doctors and locums.
Continue with plans to improve outcomes for stroke patients.
Implement the Butterfly scheme on all medical wards
Review and improve bed management.

Surgery

Improve bed capacity on the surgical wards.

Maternity

Systems to protect the privacy and dignity of gynaecology patients accommodated on a mixed sex ward should be in place.
Improve incident reporting, monitoring and mechanisms for sharing learning across the whole staff team on both sites.
Complete the actions identified on the mortality action plan within the agreed timescales.
Improve the level of staff with up to date with training in the prevention and control of infection.
Medical staff should be up to date with practical obstetric multi-professional training.
Staff should have information and advice regarding the management of patients who may have received female genital mutilation surgery.
Make sure the emergency pager system works in all parts of the hospital for all staff.
Audits of clinical practice should included recommendations and actions where a shortfall in provision is assessed.

Services for Children

Progress work regarding the longer term strategy for children’s services.

Professor Sir Mike Richards

Chief Inspector of Hospitals

North Cumbria University Hospitals NHS Trust serves a population of 340,000 people living in north and West Cumbria. In total, the trust employs 4,272 staff and has 629 inpatient beds across the Cumberland Infirmary, Carlisle, West Cumberland Hospital in Whitehaven and the Penrith Birthing Centre.

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

We undertook an announced inspection of the trust between 30 April and 2 May 2014, and an unannounced inspection visit between 8.30am and 4pm on 12 May 2014.

Our key findings were as follows:

Mortality rates

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

Infection control

The hospital was clean throughout. Staff generally adhered to good practice guidance in the prevention and control of infection.
Infection rates were within expected limits.

Food and hydration

Patients had a choice of nutritious food and an ample supply of drinks during their stay in hospital. Patients with specialist needs were supported by dieticians and the Speech and Language Therapy Team (SALT).
There was a period over mealtimes when all activities on the wards stopped, if it was safe for them to do so. This meant that staff were available to help serve food and assist those patients who needed help. We also saw that a red tray system was in place to highlight which patients needed assistance with eating and drinking.

Medicines management

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

Medical and nurse staffing

Care and treatment was delivered by committed and caring staff who worked hard to provide patients with good services. However:
There were numerous consultant vacancies that were adversely affecting timely treatment for patients and effective support for junior doctors in a number of core services.
Nurse staffing levels, although improved, remained of concern and there was a heavy reliance on staff covering extra shifts, and bank and agency staff to maintain adequate staffing levels. Adequate staffing levels were not consistently achieved in all core services.

Service changes

There had been changes to the functions within both accident and emergency and surgical services regarding the management of trauma, high risk general surgery and colorectal cancer patients, which began in June 2013. This care has now transferred to the Cumberland Infirmary in Carlisle. This has led to routine elective work being regularly cancelled at the Cumberland Infirmary, but the transfer of routine work to West Cumberland has not been as systematic as anticipated, as patients prefer to wait to have their procedure at Carlisle. The distance between the two sites appears to be a major factor in patients’ decisions regarding where to have their surgery rather than the care delivered.
This had exacerbated the trust’s inability to meet referral to treatment time (RTT) targets for admitted patients, particularly in orthopaedics. The distance between the two sites was a major factor in patients’ decision making.

Staff concerns and whistleblowing

Communication from the executive team to the staff on the wards and departments had improved. Staff were positive about the executive team for the direction they have communicated regarding the future of services. However, we were concerned about the lack of openness of the culture within the trust as we received a high number of anonymous whistleblowing concerns about this hospital before, during and after the inspection. This indicated that staff felt unable to share concerns with the trust despite the concerns being about patient safety and the quality of services provided.

We saw some areas poor practice where the trust needs to make improvements.

Care and treatment was not always provided in accordance with best practice guidance.
Care and treatment was not always delivered in accordance with national expectations.
Poor patient flow meant patients were placed in areas not best suited to their needs.
The provision of case notes and records was inconsistent across the hospital. Storage and retrieval of patient records was poor, which meant some patients did not have a consultation at their appointments because the records could not be traced. This was particularly important because of the use of agency staff.
Nurse record-keeping was poor in the paediatric ward.
We did not see a formal plan in place for a replacement for the Liverpool Care Pathway for patients at the end of life, although the trust has since informed us that it has a formal plan in place.
Audit data was incomplete in some areas and the application of learning from incidents and complaints lacked consistency.

Importantly, the trust must:

Ensure that there are sufficient numbers of suitably qualified, skilled and experienced nurses to meet the needs of patients at all times.
Ensure medical staffing is sufficient to provide appropriate and timely treatment to patients at all times.
Ensure that all departments within the hospital have the required skills to meet the needs of patients at all times.
Improve the support given to junior medical staff.
Take action to ensure that the planning and delivery of patient care and treatment is consistently carried out in accordance with published research and guidance issued by professional and expert bodies.
Take action to protect the health and welfare of children and young people with mental health needs by ensuring that timely health and social care support is provided in collaboration with other providers.
Take action to improve the patient flow through the hospital to cope with the routine workload and reduce patient waiting times.
Work towards achieving the target of no more than 18 weeks wait from referral to treatment.
Improve the standard of nursing records in the paediatric service.
Develop clear action plans to assess and manage the impact of the lack of a dedicated second theatre and no provision for urgent obstetric/gynaecology surgery at the hospital.
Take action to ensure that patient records are fully complete and up to date and made available in a timely way for all outpatient clinic appointments.
Develop a formal End of Life Care standard framework to assure safe, effective care at the end of life. Plans need to be in place to formally replace the Liverpool Care Pathway by July 2014.
Ensure the safety and security of all patients, staff and visitors who attend the A&E department by training all the staff on the procedures to follow in the event of a security or safety incident.

In addition the trust should:

Improve the management of people with diabetes, stroke and people with a diagnosis of dementia in line with national guidance.
Ensure that staff have the opportunity to regularly discuss their personal development and any issues or concerns they may have.
Ensure the security roles and responsibilities of the portering staff when dealing with violence and aggression are within the acceptable parameters of legal restraint.
Improve access to CT/MRI scanning to ensure patients receive a scan quickly.
Improve reporting times for radiology and CT scans so that patients receive timely results to improve the quality of treatment outcomes.
Ensure the maternity service has the ability to undertake grade 3 caesarean sections.
Ensure the trust’s information regarding ‘How to make a complaint’ is accurate.
Ensure the infrastructure is in place before establishing additional outpatient clinics.
Ensure there is a clear vision and strategy for end of life care and provide clear leadership for end of life care, both at director and non-executive director levels.
Provide training for staff to enable care bundles to be implemented.
Review the lack of standardisation across trust locations, such as the availably of evening clinics for early pregnancy advice and access to termination of pregnancy clinics.
Continue to develop robust audit processes to verify that staff are adhering to the ‘five steps to safer surgery’ checklist.
Review the lack of standardisation across trust’s locations, such as the availably of evening clinics for early pregnancy advice and access to termination of pregnancy clinics.

Professor Sir Mike Richards

Chief Inspector of Hospitals

We initially inspected the West Cumberland Hospital in May 2013. We found that they were non-compliant in three areas: Care and welfare, staffing and records. The areas of concern we saw were around the poor management of patient flow with patients being moved from ward to ward on several occasions and patients waiting for substantial periods in the accident and emergency department awaiting admission. We also found that there were inadequate staffing levels, particularly medical staff, in most areas of the hospital. Patient's told us that they often had to wait for basic tests or medical assessments. Staff told us that they were under immense pressure and in some instances were working long hours to make sure they could care for patients adequately. Staff were not keeping accurate records that reflected the care that they had given to patients.

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

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

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

We spoke with over 80 people and visited nine wards. We spoke with patients all of whom told us that their basic care needs were being met. They told us:

"The care here is unbelievable, The Consultant was excellent, everything was fully explained to me. I have never been as well looked after and would be happy to come back to West Cumberland Hospital if I needed an operation."

"I came in just for tests and was admitted straight away, staff are excellent and the Consultant was very proactive."

"Staff are marvellous but there is not enough of them day or night."

"Excellent care, very obliging staff."

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

"It's going well, lots to do, lots to change."

"They [the Trust] have been recruiting but it's going to be October before we see any new staff."

"There's light at the end of the tunnel."

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

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

The majority of people using the service (patients) told us that they were satisfied with the care and treatment they received at the West Cumberland Hospital:

"The nurses are brilliant, they are run off their feet but are very helpful."

"I am very comfortable, I have no complaints."

'I've watched very carefully as you see a lot on the news about poor care in hospitals but everyone gets care here and is looked after.'

Staff we spoke with said there was some concerns about staffing levels, particularly the amount of doctors available:

'During the day the cover is reasonable, it's not good at night.'

'There are not enough junior doctors.'

'We are concerned about how we are going to cope, two consultants are retiring in August.'

We found there were not enough qualified, skilled and experienced staff to meet patient's needs and patients were not protected from the risks of unsafe or inappropriate care and treatment because accurate records were not maintained. However we spoke with senior managers at the site and they were able to demonstrate that plans were in place to rectify many of the issues around staffing and record keeping at the hospital. The Trust may wish to note that paperwork relating to discharges was not always completed properly and that care plans were not always written in a person centred way.

This unnanounced inspection focused on the provision of care within the surgical division of West Cumberland Hospital. We spoke with 21 patients on the day of our visit. They said:

"The nurses are brilliant...they explain what they are doing and are very reassuring".

"The nurses are busy at times...can be run off their feet...but they manage to look after me all right ...and they are fine in the main".

"They clean the ward really well...under beds and the bed itself...sheets are changed frequently".

"The treatment and care has been wonderful...from the staff who make the tea right up to the consultant...they work as a team and tell me how I am progressing...couldn't be better".

"I was given the chance to make up my mind...told the options and the outcomes in a very open way. I felt I was in control of my treatment".

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

We did not seek the views of people using this service as part of this inspection.

Patients we spoke to were positive about their experience of care and treatment. They said they had their care needs met and had been treated respectfully. Comment received included:

'There has been no waiting for care, treatment generally has been very good and staff are very caring.'

'Staff are very polite, kind and considerate'

Patients we spoke with felt informed on their diagnosis, treatment and prognosis. All patients interviewed said staff were good at explaining treatments and let them know what they were about to do prior to carrying it out.

Overall patients are satisfied with the meals, the menu choice and the standard of the food on offer. They felt they were given the right amount of help and that staff were supportive and considerate.

Patients were complimentary about their experience of mealtimes stating:

'The food is very good and there is always plenty of choice'

'My special diet is catered for, food is hot and good, and choice is also very good.'

'Staff check I have had enough to eat'

Patients we spoke to were mostly very positive about their experience of care and treatment. Most patients said they had their care needs met and had been treated respectfully. A typical comment received was 'There has been no waiting for care, treatment generally has been very good and staff are very caring.'

A relative said 'We have been very happy with care in this hospital, we have experienced two hospitals out of the area and this is by far the best for care, and staff treating you right'.

The trust undertakes a patient satisfaction survey and between October 2010 and March 2011 this demonstrated a high level of patient satisfaction with regards to dignity and privacy. The data also shows that there has been an improvement in results compared with 2010 for all wards in the hospital.

Patients we spoke to felt well informed on their diagnosis, treatment and prognosis. All patients interviewed said staff were good at explaining treatments and let them know what they were about to do prior to carrying it out.

Overall patients are satisfied with the meals, the menu choice and the standard of the food on offer. They felt they were given the right amount of help and that staff were supportive and considerate.

Patients and relatives were mostly very complimentary about their experience of mealtimes stating:

'The food is good and improved since my last stay.'

'My special diet is catered for, food is hot and good, and choice is also very good. Amount eaten always recorded.'

'Staff check I have enough to eat and drink. I've never missed a meal and there's always plenty of choice.'

These findings are supported by the trust's inpatient Catering satisfaction survey for the hospital which had a 81% overall satisfaction rating, (Oct 10-Jan 11), This had been an improvement on the previous year.

All Inspections

Professor Sir Mike Richards

Medical Staffing

Nurse Staffing

Patient outcomes

Access and flow

Urgent and Emergency care

Surgery

Medicine

Maternity

Services for Children

Outpatients and diagnostics

End of Life

Urgent and Emergency care

Medicine

Surgery

Maternity

Services for Children

Professor Sir Mike Richards

Mortality rates

Infection control

Food and hydration

Medicines management

Medical and nurse staffing

Service changes

Staff concerns and whistleblowing