Cumberland Infirmary

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

This means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement.

We looked for evidence that people and communities had the best possible outcomes because their needs were assessed. We checked that people’s care, support and treatment reflected these needs and any protected equality characteristics, ensuring people were at the centre of their care. We also looked for evidence that leaders instilled a culture of improvement, where understanding current outcomes and exploring best practice was part of their everyday work.

We identified that electronic systems did not always work effectively together which required staff had to use several systems to deliver patient care. We also saw that audits were not always acted upon to improve outcomes.

The service was in breach of the legal regulation relating to safe care and treatment, person centred care, and good governance.

We have not awarded this service a score for Effective.

Find out about when we will not publish a key question score and what we look at when we assess Effective.

2. The service did not always make sure people’s care and treatment were effective because they did not always check and discuss people’s health, care, wellbeing and communication needs with them.

Patients did not routinely have individualised care plans in place to support their ongoing needs. Although improvements had been made to patient observations and care following our assessment in February 2026, care plans had not been implemented consistently across the department.

Patients received an initial assessment from a triage nurse on arrival before being directed to either the main emergency department or the Rapid Assessment and Treatment area. Triage records were generally completed appropriately. However, documentation after transfer into the department was not always complete. Gaps were identified in records relating to nutrition and hydration, skin integrity and pain assessment and management.

The department had multiple patient records systems in use, which did not work effectively together. Staff told us they often had to enter information onto more than one system. Staff told us this was a longstanding issue that meant patient records were not always clear and up to date. There were also issues with sharing assessment and risk documentation with partner staff who provided care for patients with mental health needs

The service did not use the NHS Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) process. The ReSPECT process supports personalised emergency care planning through discussions between patients, families and clinicians regarding preferences for treatment and care during future emergencies. Senior leaders were unable to explain why the process had not been adopted within the service.

Staff working within the paediatric emergency department demonstrated an understanding of the specific assessments required when caring for children and young people. This included the application of Fraser guidelines and assessment of Gillick competence to support decision-making and ensure care was delivered appropriately and in accordance with legal and professional requirements.

2. The service did not always plan and deliver people’s care and treatment with them, including what was important and mattered to them.

The service had a range of policies, procedures and clinical pathways in place to support evidence-based care and treatment. However, some key policies were overdue for review. For example, the trust’s Mental Health Policy had been due for review in 2024, had subsequently been extended into 2025, and had still not been updated at the time of our assessment. This reduced assurance that staff had access to the most current guidance when caring for patients with mental health needs. In addition, the patient records we reviewed often did not demonstrate that care met all required standards and guidance.

The trust used recognised national tools to support the identification and management of deteriorating patients, including the National Early Warning Score (NEWS2) and Paediatric Early Warning Score (PEWS). We saw examples of patients presenting with high NEWS score that were not reviewed by staff in line with the tool framework.

Evidence-based clinical pathways were available to support patient care, including pathways such as the stroke pathway, which was aligned to National Institute for Health and Care Excellence (NICE) guidance. Staff described working collaboratively across professional groups to ensure patients were managed in accordance with established pathways and standards of care. However patient records did not include care plans in line with these care pathways.

Staff undertaking triage used the Manchester Triage System to assess clinical priority and determine the urgency of care required. Appropriate training had been provided. Inconsistencies and inaccuracies identified within patient records reduced assurance that the tool was being applied consistently and accurately across the department.

However, systems to monitor compliance with evidence-based practice were not sufficiently robust. Audit processes did not consistently provide assurance that care and treatment were being delivered in line with national guidance, local policy or best practice.

2. The service did not always work well across teams and services to support people. Staff did not always share their assessment of people’s needs when people moved between different services.

Multidisciplinary working within the department was generally positive. Most staff described good working relationships between doctors, consultants, nurses and Advanced Clinical Practitioners (ACPs), with teams working collaboratively to deliver patient care. Staff told us there was a supportive culture with little perceived hierarchy between professional groups, which facilitated communication and joint decision-making.

Information was shared across teams to support continuity of care. Structured handovers took place at shift changes for both medical and nursing staff. Handover processes included discussion of individual patients, current treatment plans, outstanding investigations and any immediate risks or concerns. This supported the transfer of clinical information and helped maintain continuity of care.

The trust held bed capacity meetings three times each day to support patient flow and facilitate the transfer of patients from the emergency department to inpatient wards. However, the environment in which these meetings were conducted was not always appropriate due to background noise. Patient needs and clinical risk were not routinely incorporated into bed-flow discussions despite significant and ongoing pressures at the front door of the hospital. This reduced assurance that clinical risk was being considered alongside operational pressures when decisions about patient movement were made.

Patient flow continued to be affected by a lack of available inpatient beds, resulting in extended stays within the emergency department. Staff described using a "push" model to identify patients suitable for transfer to inpatient wards in order to create capacity within the department. The Same Day Emergency Care (SDEC) service accepted direct referrals from general practitioners, which helped reduce some pressure on emergency department attendances.

Emergency department staff described delays in specialty assessments and a lack of ownership of patient care once referrals had been made. Staff reported that communication between teams was not always effective, resulting in patients waiting extended periods without updates regarding their care or treatment plan. Reception staff described instances where patients became distressed due to a lack of communication and explanation regarding delays. Following the assessment, trust leaders advised that work was underway to develop an interdepartmental standard aimed at improving specialty response times and reducing delays to patient care.

Despite the pressures within the department, staff demonstrated a strong commitment to teamwork. Staff were often working in challenging conditions with high patient numbers and increased demands associated with patients requiring enhanced supervision. A positive culture of mutual support was evident, with staff helping each other to manage workload pressures and maintain patient care. Staff stated that these pressures had become a regular feature of the service and reflected increasing attendance levels.

Examples of effective multidisciplinary working were evident throughout the department. Physiotherapists worked proactively with clinical teams to facilitate same-day discharges and support timely patient flow. This also contributed to safeguarding arrangements by ensuring patients received appropriate assessment and support before discharge. Effective collaboration was also observed between triage nurses and Rapid Assessment and Treatment (RAT) nurses, supporting timely assessment and prioritisation of patients. Staff also demonstrated consideration for colleagues' wellbeing, supporting one another when operational pressures prevented staff from taking breaks.

Support from local managers was not always consistent which meant some staff and leaders felt they were not always well prepared for senior roles.

2. The service did not always support people to manage their health and wellbeing, so people could not always maximise their independence, choice and control. The service did not always support people to live healthier lives, or where possible, reduce their future needs for care and support.

We saw limited evidence of health promotion information within the department

The service was working in partnership with the Alcohol Care Team to collect information and promote people understanding of the impact of alcohol on health.

The trust website had health information leaflets in place from a recognised evidence-based care provider. For example, there were leaflets on managing diabetes and coping with alcohol cravings. These could be translated into other languages or requested in other formats from the communication team.

1. The service did not routinely monitor people’s care and treatment to continuously improve it. Staff did not ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

The service undertook a limited number of audits as part of its quality assurance and governance arrangements. Of the 33 audits recorded from July 2025 to December 2025, 13, (40%) were overdue. The monitoring and audit activity was not effective for monitoring or improving patient outcomes.

Staff and leaders described operational pressures as a significant barrier to completing audit activity. The audits we reviewed included small sample sizes over three-month periods, which did not reflect the volume of patients attending the service and did not provide an accurate picture of clinical practice or patient outcomes across the department.

Audit processes were not always completed consistently and there was limited evidence that findings were being used effectively to drive improvement. Staff were not always aware of recent audit outcomes, recommendations or actions arising from audit activity.

Leaders were unable to describe findings from recent audits or explain how identified issues had been monitored through to completion. This limited the department's ability to evaluate practice, identify trends and implement sustainable improvements to patient care and experience.

The provider acknowledged challenges in maintaining effective audit and assurance processes during periods of sustained operational pressure.

Assurance processes relating to pain management were not consistently effective. Audit activity had not resulted in sufficient assurance that pain was being assessed and managed consistently for adults and children attending the department. Leaders advised that a recent quality improvement project undertaken by a resident doctor had identified several recommendations for improvement. These actions had been incorporated into the emergency department improvement plan, with further audit cycles planned to monitor progress and support sustained improvement.

The organisation had considered the Royal College of Paediatrics and Child Health (RCPCH) Facing the Future: Standards for Children and Young People in Emergency Care, published in October 2025. A self-assessment against these standards was planned for April 2026. Leaders advised that the paediatric team had already undertaken preparatory work to understand their current level of compliance and identify areas requiring further development. This work was intended to strengthen governance arrangements and support compliance with nationally recognised standards for children and young people's emergency care.

Leaders recognised that existing audit arrangements were not sufficiently robust to support quality improvement where standards fell below expected levels. The provider advised that immediate action was being taken to strengthen governance processes, including the introduction of audit training, increased audit frequency and a review of current audit methodologies to ensure they were effective and consistently applied. Leaders also advised that all audits would be supported by formal action plans, with clearer oversight and monitoring arrangements to support improvement and provide greater assurance regarding compliance with evidence-based care and treatment standards.

2. The service did not always tell people about their rights around consent and did not always respect their rights when delivering care and treatment.

All staff within the service received consent training. We reviewed the latest mandatory training compliance figures submitted by the trust and saw it was 87%, which was above the trusts own target of 85%. However, we saw that staff did not always complete appropriate risk assessments for patients presenting with mental health needs. Our review of records did not demonstrate how staff clearly assessed all patients’ capacity to consent to treatment.

Staff completed deprivation of Liberty Safeguard training (DoLS) and Mental Capacity Training (MCA). We saw compliance figures for the combined DoLS and MCA training was again 87% at the time of assessment.

Paediatric staff were aware of Gillick competency and were able to describe the processes for undertaking and recording consent for children and young adults.

We observed people having their care explained to them and giving implied consent.