Cumberland Infirmary

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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

This means we looked for evidence that the service met people’s needs.

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 were always at the centre of how care was planned and delivered. We checked that the health and care needs of people and communities were understood, and they were actively involved in planning care that met these needs. We also looked for evidence that people could access care in ways that met their personal circumstances and protected equality characteristics.

We identified that care was not always planned or delivered around people’s individual needs. Mental health risk assessments were not completed consistently, care plans were not routinely in place for people who spent long periods in the department, and pressures in the department affected access, privacy and timely support. These concerns were also reflected in the safe and caring sections but are included here because they show how the service did not always respond to people’s individual circumstances and needs. The service was in breach of the legal regulation relating to person centered care and good governance. This was because people’s individual needs were not always assessed, documented or reviewed in a way that supported safe, coordinated and personalised care.

We have not awarded this service a score for Responsive.

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

2. The service did not always make sure people were at the centre of their care and treatment choices and they did not always work in partnership with people, to decide how to respond to any relevant changes in people’s needs.

We observed differences in the care, assessment and treatment completed in different parts of the urgent and emergency care centre.

Risks and needs for patients with mental health needs were not always assessed or documented. However, in the Rapid Assessment and Treatment (RAT) area, risk assessments had generally been completed. All 12 patient records reviewed on 17 February 2026 contained documented risk assessments. We did not see care plans in patients’ records, particularly for patients who spent long periods in the RAT or other areas.

We raised these concerns with the trust during the assessment. Leaders advised that mental health risk assessments would form part of future audit activity to improve oversight and compliance. However, at our follow-up visit in March 2026, no evidence was available to demonstrate that this audit activity had commenced.

Care plans were not consistently developed or documented across the department. None of the patient records we reviewed contained an individualised care plan. This reduced assurance that patients' ongoing physical, psychological and personal care needs were being assessed, monitored and managed appropriately during prolonged stays within the emergency department. The absence of care planning increased the risk of unmet needs and made it more difficult to demonstrate that care was being delivered in a coordinated, personalised and evidence-based manner.

3. We scored the service as 3. The evidence showed a good standard. The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

Leaders demonstrated an understanding of the health needs of the local population and the challenges presented by the geographical location served by the hospital. Due to limited access to alternative healthcare services within the area, many people attended the emergency department for urgent and unscheduled care. To help ensure patients accessed the most appropriate service, the trust had developed plans for an Urgent Treatment Centre (UTC) that would support the streaming of patients according to clinical need and reduce pressure on the emergency department. However, the UTC was not operational at the time of the assessment because recruitment to key staffing roles remained ongoing.

The service was also aware of the increasing proportion of older people within the local population and had recognised the need to adapt services to meet changing demographic demands. Plans were underway to establish a frailty assessment unit to provide more tailored assessment and care for older patients with complex needs. This demonstrated an intention to develop services that better reflected the needs of the population served and supported more appropriate pathways of care for older people.

Strategic planning reflected consideration of future healthcare demand within the local community. The service had developed objectives, priorities and improvement plans designed to respond to anticipated changes in population need and service demand. These plans were aligned to the organisation's longer-term ambitions and demonstrated a commitment to developing services that meet the current and future needs of local people.

2. The service did not always supply appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Information for patients was not routinely available in a range of languages within the department. Patient leaflets and information about local services were primarily available in English. The trust indicated that translated materials could be obtained through the Patient Advice and Liaison Service (PALS) when required.

Information was not consistently available in formats designed to meet the needs of people with communication or accessibility requirements, such as easy-read versions or braille. Although these formats could be requested, they were not routinely available within the department. This reduced assurance that all patients could easily access information in a format that supported their understanding and participation in decisions about their care.

We saw good practice within the Paediatric Emergency Department (PED). A play specialist had developed information booklets specifically for children and young people attending the department. Paediatric nursing staff had also developed communication flashcards to support interactions with children and other patients who may require additional communication support. These resources helped staff communicate more effectively and supported the delivery of more inclusive, person-centred care.

3. The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. Staff involved people in decisions about their care and told them what had changed as a result.

Information was displayed throughout the department encouraging patients and relatives to provide feedback about their experiences. Staff information boards within the Emergency Department (ED) and Same Day Emergency Care (SDEC) areas, titled “Quality of Care the CIC Way”, were used to share compliments received from patients and families, as well as themes arising from complaints and areas identified for improvement.

Learning from patient feedback was used to inform service development and improve the patient experience. Examples of changes implemented following complaints and feedback included the introduction of additional visual aids within waiting areas, the development of family liaison roles and changes to cannulation processes.

Information on how to provide feedback, raise concerns or make a complaint was available on the trust’s website. Patients we spoke with during the assessment were aware of how to provide feedback about their care and felt able to do so if required.

The department reviewed feedback received through the Friends and Family Test (FFT), the national patient feedback programme. Recent feedback was generally positive, with patients commenting favourably on the care and support they received from staff. Over the month of February 2026 77% of patients reported a positive experience and 15% reported a negative experience.

At 23 February 2026, there were 17 complaints relating to the emergency department that remained under investigation. Of these, initial acknowledgement to complaints was prompt, however 5 had exceeded the provider’s expected timescales for response and remained overdue. The main theme was clinical treatment including delays and staff attitude. This created a risk that learning from complaints and concerns may not always be identified and acted upon in a timely manner.

2. The service did not always make sure that people could access the care, support and treatment they needed when they needed it.

In January 2026, 155 patients with mental health needs attended the department. Ten patients were in the department for over 24 hours. These waits were mainly caused by problems in the wider healthcare system, as mental health care was provided by another trust. However, this meant patients did not always receive timely care that met their needs.

The psychiatric liaison team usually responded quickly to requests from the ED. The clinical manager told us that around 85% of patients were seen within one hour. At night, only one member of the psychiatric liaison team was on duty, which could sometimes cause delays.

Staff told us that children and young people with mental health needs often waited a long time to be seen by the Child and Adolescent Mental Health Service (CAMHS) crisis team. Staff told us that the CAMHS team provided support, but waiting times were often long.

Outside normal working hours, CAMHS support was provided by the adult psychiatric liaison team. This risk had been identified by the trust and is included on the department's risk register.

The service monitored waiting times and triage performance. Performance had worsened in the months before the assessment. November data showed performance was much lower than regional and national averages and did not meet expected standards.

Performance against the four-hour A&E target had also worsened. It fell from 62% in October to 56% in November. This was below the trust's target of 75%, the integrated care system (ICS) average of 77%, and the national average of 74%.

A key reason for poorer performance was delays in patients receiving their first assessment by a senior clinician. The target was for patients to be assessed within 60 minutes. In November, only 32% of patients were seen within this time. The average wait for assessment was 135 minutes.

Staff told us that delays in moving patients to hospital beds affected patient flow through the department. As a result, 38% of patients who were admitted to the hospital spent more than 12 hours in the emergency department

3. Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

The trust policies which we reviewed had undergone equality impact assessments to ensure that protected groups and people with different needs were not disadvantaged by service policies or procedures. Trust data showed that 92% of staff had completed equality, diversity and human rights training, supporting awareness of inclusive practice and equitable care delivery.

The department had also developed initiatives to improve care for specific patient groups. Staff delivered targeted training to increase knowledge and confidence when caring for patients with particular needs. For example, staff used the HEADSSS assessment tool, a structured psychosocial screening framework designed to support holistic assessment of adolescents and identify factors affecting their wellbeing.

Additional tools had been developed locally to support staff in meeting the needs of individual patient groups. These included triage guidance documents designed to promote consistent assessment, improve communication and support equitable access to care for patients with differing needs and vulnerabilities.

2. People were not always supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

End of life care was not always provided in a quiet environment due to capacity in the department and the wider organisation, however we observed an end-of-life nurse providing care and advice to the family and staff in the department. Staff recognised the ED was not the appropriate environment to provide dignified end of life care, staff reported these deaths as incidents to reflect this.

Staff were aware of the Do Not Attempt Resuscitation document and when we reviewed notes, we saw that these were in place, however we could not always see from the notes that these had always been discussed with the patient or relative.

90% of staff had completed End of Life training.