Cumberland Infirmary

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

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 there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of people who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

We identified that the provider did not have effective oversight of risks affecting the safety, experience and outcomes of patients within the department. Some of these concerns had also been identified in our 2023 report and there had been no significant improvement. Concerns identified in February 2026, including waiting room oversight, incident review backlogs, mental health risk assessment, environmental risks and infection prevention and control, were not fully resolved by the March 2026 follow-up visit. This showed that governance systems were not consistently identifying risks, driving timely action or providing assurance that improvements were sustained.

The service was in breach of the legal regulation relating to good governance.

We have not awarded this service a score for Well-led.

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

2. The service did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. Staff did not always understand the challenges and the needs of people and their communities.

The provider had a clinical strategy that was launched in 2025. The purpose was to deliver ‘safe, high quality care, every time’ aiming to be a ‘nationally recognised centre for excellence for integrated rural and coastal medicine and care. However, we did not see that this strategy had supported any meaningful improvement.

Leaders had developed an Urgent and Emergency Unplanned Care Future State document, which set out a number of strategic aims and objectives for the development of urgent and emergency care services. These included the introduction of NHS streaming processes and the development of a co-located workforce model incorporating seven-day GP and nursing provision. These proposals were intended to support more effective patient flow and ensure patients received care in the most appropriate setting.

The senior leadership team demonstrated a strong commitment to addressing the capacity and flow challenges affecting the emergency department. Leaders described a clear ambition to improve operational performance, patient experience and patient flow across the urgent and emergency care pathway. Plans were in place to progress key service developments and improvements. Since the assessment, the interim Chief Executive Officer has been appointed permanently supporting continuity of leadership across the organisation.

Staff reported that the culture within the department had improved. Positive feedback was provided regarding the visibility and engagement of the Chief Executive Officer, with staff describing her as approachable, supportive and receptive to concerns raised by frontline teams. A culture review was underway within the department to better understand staff experiences and identify opportunities for further improvement.

Leaders demonstrated an understanding of the health needs and demographics of the local population and recognised the need for services to evolve in response to changing demand. Strategic plans included the development of patient pathways designed to better meet local needs.

2. Not all leaders understood the context in which the service delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively

Risk was not always recognised or articulated consistently by senior leaders within the department. The provider would not provide assurance that risks specific to emergency care services were always identified, assessed and managed appropriately.

Staff described significant turnover within senior leadership roles over recent years. Feedback indicated that changes in leadership had affected continuity and created challenges in maintaining consistent oversight of the service. Staff expressed concerns that the wider organisation had not always understood the reasons why staff left leadership positions, limiting opportunities to address underlying issues and improve retention.

Staff reported that some newly appointed leaders had limited opportunities for induction and role-specific support due to operational demands.

Staff consistently described receiving good support from their immediate line managers and several staff members reported having access to formal leadership development programmes. However, access to leadership training and development was not consistent across the service. Some leaders reported taking up senior roles with minimal preparation, induction or ongoing support. Information provided by the trust regarding leadership competencies was limited and focused primarily on employment and human resources processes rather than demonstrating how leadership skills, knowledge and capability were assessed, developed and maintained.

Senior nursing leaders advised that operational pressures had limited the time available to complete appraisals for staff. An action plan was in place to improve appraisal compliance. However, findings from the NHS Staff Survey highlighted concerns regarding the quality and effectiveness of appraisals, with staff reporting that appraisals received were not always meaningful or beneficial to their professional development.

Results from the 2025 NHS Staff Survey also indicated that staff within the department perceived leadership to be less compassionate than in other areas of the organisation, this scored 6.2% for medical staff and 6.4% for other staff against the trust comparator of 6.9%.

We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff demonstrated an awareness of how to raise concerns and understood the role of the Freedom to Speak Up Guardian. Most staff reported that they would initially raise concerns with their immediate line manager rather than through formal speaking-up processes. Trust data showed that 88% of staff had completed Freedom to Speak Up training.

Staff described a culture that had previously felt blame-focused; however, many reported that this was beginning to improve. Feedback indicated that relationships between staff and leaders were becoming more open and supportive, contributing to a more positive working environment.

Staff spoke positively about the Chief Executive Officer and described her as visible, approachable and engaged. Staff reported feeling listened to and believed that she understood the operational pressures and challenges faced by the department.

Staff consistently described immediate line managers as supportive when concerns were raised. However, staff perceived that concerns were not always followed by visible action or sustained improvement. As a result, staff were not always confident that issues raised through local reporting and escalation processes would result in meaningful change.

3. The service valued diversity in their workforce. Staff work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Leaders monitored staff experience through the NHS national staff survey and the NHS Workforce Race Equality Standard. This was completed at trust level and was published on the trust website with actions for improvement.

There was a workforce Disability Equality Standard (WDES) published in 2025 available on the trust website. The outcomes are clearly stated, and compliance with the standards and where improvements have been made or where they are ranked in the country. This report was trust wide and not specific to the emergency department.

The trust had a specialist advisor for inclusion.

The trust’s 2025 national staff survey scores were significantly lower than in 2024 for the whole trust. The urgent and emergency care department scored below the trust average for the People Promise theme “we are safe and healthy”. This included staff reporting that they were at risk of burnout, which corroborated what staff told us during our assessment. The department scored higher than the wider trust for personal development, which reflected feedback from staff during our assessment. There was no specific action plan in place for the urgent and emergency care department from the previous year.

1. The service did not have clear responsibilities, roles, systems of accountability and good governance. Staff did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The department maintained a risk register; however, risks we identified during the assessment were not always reflected within it. Significant operational and clinical risks, including the lack of clinical oversight within the emergency department waiting area and concerns regarding safe staffing levels, had not been recorded.

The room designated for the care of patients presenting with mental health needs was not recorded as a risk on the departmental risk register and had been assessed locally as compliant with Psychiatric Liaison Accreditation Network (PLAN) standards, despite not meeting those requirements. Following feedback, the trust acknowledged this issue and advised that work was underway to improve compliance and reduce environmental risks.

Governance structures were in place to review incidents and complaints. However, meeting discussions and documentation lacked sufficient detail to evidence oversight, shared learning and improvement actions. Similarly, mortality and morbidity reviews did not consistently identify learning, actions or responsibilities. Governance meetings provided opportunities to discuss emerging risks and incidents. During a weekly governance meeting, recent risks and incidents were discussed; however, a significant number of incidents awaiting review were not included within these discussions.

We raised concerns regarding the backlog of incident investigations with the trust following our February 2026 assessment. By the follow-up visit in March 2026, limited progress had been made, although an additional member of staff had been allocated to support incident review activity. This meant learning from incidents may still not have been identified or shared quickly enough to reduce the risk of recurrence.

The lack of clinical oversight within the emergency department waiting area was not included on the risk register despite presenting an ongoing risk to patient safety. During the follow-up visit in March 2026, no significant changes had been implemented and there remained no dedicated clinical oversight of patients waiting to be assessed or treated. This meant leaders did not have adequate assurance that patients who deteriorated while waiting would be identified and escalated promptly.

Information governance arrangements also presented risks. Five separate information technology (IT) systems were operating across the department and did not work effectively together. This had been identified on the departmental risk register but was overdue for review in 2025. Staff described locally developed processes to collate information from multiple systems; however, there was limited assurance that these arrangements had been formally approved through the trust’s governance structures.

Patient records were not always stored securely. In addition, computer screens throughout the department were not always locked when staff left their desk.

Governance arrangements relating to the care of patients with mental health needs were not sufficiently robust. Mental health risk assessments and care plans were not completed consistently, increasing the risk that patients would not receive care and support appropriate to their needs and level of risk. These concerns were escalated to the trust following the February 2026 assessment. At the follow-up assessment in March 2026, insufficient progress had been made to demonstrate sustained improvement. Although an action plan had been developed to improve compliance with mental health risk assessment processes, implementation remained at an early stage and the trust could not yet demonstrate that risks to patients has been reduced.

Incident reporting data had identified recurring themes involving patients with mental health needs. Reported incidents included episodes of self-harm where mental health risk assessments had not been completed consistently.

Following the February assessment, the trust advised that duty consultants would review mental health documentation during patient handovers to provide additional assurance that risk assessments had been completed. By the March follow-up visit, staff reported that these reviews were taking place; however, there was no documented evidence to demonstrate that they had been undertaken consistently.

The service routinely monitored triage performance and waiting times. Performance across urgent and emergency care services had deteriorated in the months preceding the assessment and remained significantly below expected standards. November 2025 performance data showed outcomes that were below constitutional standards as well as regional and national averages.

Performance against the four-hour emergency care standard declined from 62% in October 2025 to 56% in November 2025. This was substantially below the trust's operational target of 75% and below both the Integrated Care System average of 77% and the national average of 74%.

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

Audit processes did not consistently provide assurance that care and treatment were being delivered in line with national guidance, local policy or best practice.

3. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. Staff share information and learning with partners and collaborate for improvement.

The emergency department worked collaboratively with external partners to support the delivery of care and improve patient outcomes. Regular meetings were held between emergency department staff and the psychiatric liaison team to discuss operational issues, patient pathways and opportunities to improve care for patients presenting with mental health needs. Police representatives also attended emergency department operational meetings, supporting a multi-agency approach to managing shared risks and complex presentations.

Leaders described ongoing work with healthcare partners, commissioners and community services to develop sustainable models of care that reflected the needs of the local population. This demonstrated a commitment to partnership working and service development across organisational boundaries.

Feedback was sought from partner organisations as part of the assessment process, however, feedback was limited.

The service worked closely with the local ambulance service to support compliance with the national ambulance handover standard of 45 minutes and feedback received was this was being met.

Staff described how the rural nature of the population that accessed the hospital required services to develop alternative approaches to meet the needs of the local population. Leaders and staff had responded to workforce and service challenges by significantly expanding the Advanced Clinical Practitioner (ACP) workforce and developing alternative patient pathways. Staff reported that service models had evolved over the previous two years through collaboration with a range of internal and external stakeholders, with the aim of improving access to care and ensuring patients were treated in the most appropriate setting

2. The evidence showed some shortfalls. The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

Audit programmes and senior leadership meetings were in place to monitor performance, quality and improvement activity. There was limited evidence that audit findings and improvement initiatives had led to significant or sustained improvements in practice. Progress against some improvement actions had been slow and there was little evidence of substantial improvement since the previous assessment.

Quality improvement activity was being undertaken within the department. For example, a resident doctor had completed a quality improvement project focused on pain management following concerns regarding the timely assessment and treatment of pain in the emergency department. An action plan had been developed to address identified issues. However, audit data continued to demonstrate that only 50% of patients received pain relief within expected timeframes, indicating that improvements had not yet translated into consistently better outcomes for patients.

Sustained operational pressures presented challenges to implementing and embedding innovation within the service. Despite these constraints, staff were able to describe several initiatives aimed at improving patient care, patient flow and service delivery.

The trust had a number of improvement initiatives in progress to improve patient flow. A new Urgent Treatment Centre (UTC) had been constructed adjacent to the emergency department but was not yet operational due to workforce recruitment challenges. Leaders described plans to improve patient experience and flow through the service, including investment in additional staffing to support compliance with Royal College of Emergency Medicine (RCEM) workforce standards. Recruitment activity for consultant posts was ongoing. A business case had also been developed to establish a frailty-focused Same Day Emergency Care (SDEC) service, with the intention of enabling appropriate patients to bypass the emergency department and access more suitable assessment pathways.

The service recognised the need to develop alternative admission and assessment pathways to improve patient experience and reduce pressures within the emergency department. This included plans to develop dedicated frailty pathways and services that would enable older patients to access more appropriate assessments and support, while improving patient flow through the hospital.

Positive examples of local innovation were evident within the Paediatric Emergency Department. Paediatric nurses had developed prompt cards and flashcards to support nursing staff when caring for children and young people. These tools were designed to improve consistency of care and ensure key aspects of assessment and treatment were not overlooked.

Staff had developed a triage guide to support discussions and assessment of adolescents presenting with mental health needs. This provided a structured approach to assessment and helped staff consider the wider emotional and psychological needs of young people attending the department.

A multidisciplinary group had been established to improve the management and coordination of care for patients who attended the emergency department on a frequent basis. The aim was to support personalised care planning with other care providers closer to home.