All inspections: Royal Lancaster Infirmary

The Royal Lancaster Infirmary is a part of the University Hospitals of Morecambe Bay NHS Foundation Trust (UHMBT). It provides acute hospital services including urgent and emergency care, medical care, surgery, maternity, critical care, paediatrics, and out-patients for people in the North Lancashire and South Cumbria areas.

We carried out an unannounced inspection of the maternity and medical care core services at Royal Lancaster Infirmary following the trust making applications to have conditions from their registration removed.

Following our previous inspection in April 2021, under Section 31 of the Health and Social Care Act 2008, we imposed urgent conditions on the registration of the provider in respect to the regulated activities of diagnostics and screening and treatment of disorder, disease and injury in relation to the trusts stroke pathway.

The trust was inspected to assess whether the required improvements, had been made and sustained.

Our rating of this location stayed the same. We rated it as requires improvement because:

Maternity

Our rating of this service stayed the same. We rated it as requires improvement because:

Staff did not all have training in key skills.
Senior leadership still needed to address some important areas.

However:

The service had enough staff to care for women and keep them safe. Staff understood how to protect women from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to women, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them.
Staff provided good care and treatment, gave women enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of women, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
Staff treated women with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to women, families and carers.
The service planned care to meet the needs of local people, took account of women’s individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of women receiving care. Staff were clear about their roles and accountabilities. The service engaged well with women and the community to plan and manage services and all staff were committed to improving services continually.

Medical Care

Our rating of this service improved. We rated it as good because:

The service had enough staff to care for patients and keep them safe. Staff understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them.
Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families, and carers.
The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported, and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However:

The service provided mandatory training but not all staff completed it on time.

A summary of CQC findings on urgent and emergency care services in Lancashire and South Cumbria.

Urgent and emergency care services across England have been and continue to be under sustained pressure. In response, CQC is undertaking a series of coordinated inspections, monitoring calls and analysis of data to identify how services in a local area work together to ensure patients receive safe, effective and timely care. We have summarised our findings for Lancashire and South Cumbria below:

Lancashire and South Cumbria.

Provision of urgent and emergency care in Lancashire and South Cumbria was supported by services, stakeholders, commissioners and the local authority.
We spoke with staff in services across primary care, integrated urgent care, acute, mental health, ambulance services and adult social care. Staff felt tired and continued to work under sustained pressure across health and social care.
We found demand on urgent care services had increased. Whilst feedback on these services was mostly positive, we found patients were accessing these services instead of seeing their GP. Local stakeholders were aware that people were opting to attend urgent care services and were engaging with local communities to explore the reasons for this.

The NHS 111 service which covered the all of the North West area, including Lancashire and South Cumbria, were experiencing significant staffing challenges across the whole area. During the COVID-19 pandemic, the service had recruited people from the travel industry. As these staff members returned to their previous roles, turnover was high and recruitment was particularly challenging. Service leaders worked well with system partners to ensure the local Directory of Services was up to date and working effectively to signpost people to appropriate services.

However, due to a combination of high demand and staffing issues people experienced significant delays in accessing the 111 service. Following initial assessment, and if further information or clinical advice was required, people would receive a call back by a clinician at the NHS 111 service or from the clinical assessment service, delivered by out-of-hours providers. The NHS 111 service would benefit from a wide range of clinicians to be available such as dental, GP and pharmacists to negate the need for onward referral to other service providers.
People who called 999 for an ambulance experienced significant delays.

Ambulance crews also experienced long handover delays at most Emergency Departments. Crews also found it challenging managing different handover arrangements. Some emergency departments in Lancashire and South Cumbria struggled to manage ambulance handover delays effectively which significantly impacted on the ambulance service’s ability to manage the risk in the community. The ambulance service proactively managed escalation processes which focused on a system wide response when services were under additional pressure.

We saw significant delays for people accessing care and treatment in emergency departments. Delays in triage and initial treatment put people at risk of harm. We visited mental health services delivered from the Emergency Department and found these to be well run and meeting people’s needs. However, patients experienced delays in the Emergency Department as accessing mental health inpatient services remained a significant challenge. This often resulted in people being cared for in out of area placements.

We found discharge wasn’t always planned from the point of admission which exacerbated in the poor patient flow seen across services. Discharge was also impacted on by capacity in social care services and the ability to meet people’s needs in the community. We also found some patients were admitted from the Emergency Department because they couldn’t get discharged back into their own home at night.

Increased communication is needed between leaders in both health and social care, particularly during times of escalation when Local Authorities were not always engaged in action plans.

The Royal Lancaster Infirmary (RLI) provides a range of acute hospital services in the locality of Lancaster, England.

We carried out an unannounced focused inspection of The Royal Lancaster Infirmary urgent and emergency care services (also known as accident and emergency or A&E (Accident & Emergency)) between the dates of 8 and 9 March 2022.

We had an additional focus on assessment units including the surgical assessment unit (SAU), and the acute medical unit (AMU), the ambulatory care unit (ACU), the priority assessment discharge unit (PADU) and the same day emergency care (SDEC) as part of the emergency and urgent care pathways.

As this was a focused inspection, we only inspected parts of our five key questions. This was as part of a CQC national programme for urgent and emergency care system inspections. This inspection was partly undertaken due to the concerns this raised over how the organisation was responding to patient need and risk in the department and to determine how the flow of patients who started their care and treatment in the emergency department was managed in times of high pressure.

The emergency department was previously rated as requires improvement overall. For this inspection we considered information and data on performance for the emergency department and assessment units.

The service controlled infection risk well. Staff had training in key skills understood how to protect patients from abuse, and managed safety well. The service used systems and processes to safety prescribe and administer medicines. Staff assessed risks to patients, acted on them and kept good care records. The service managed safety incidents well and learned lessons from them.
The service provided care and treatment in line with national guidance and evidence-based practice and staff worked well together for the benefit of the patients. Patients were supported to make decisions about their care and had access to useful information. Key services were available seven days per week. Patients were given pain relief as they required it.
Staff treated people with compassion and kindness and took account of individual needs. Staff provided emotional support to patients, families and carers to minimise their distress.
The service planned care to meet the needs of local people. People could access the service when they needed it, however they could sometimes wait longer for treatment.
The service had a vision for what it wanted to achieve and a strategy to turn it into action. Most of the time leaders and teams used systems to manage performance effectively. Managers identified actions to reduce the impact of identified risks. All staff were committed to improving services continually.

However

People did not always receive the right care promptly due to pressures on capacity of the service.
The emergency department (ED) premises did not consistently meet the needs of the patients and staff to maintain safety, privacy and dignity.
The service did not always have enough medical, nursing and support staff, nursing with the right qualifications, skills, training and experience.
The service did not always manage patient safety incidents well.
Not all staff felt supported and valued, all the time. Staff felt concerns they raised were not always listened and responded to.
Medical staff from other specialities and assessment units did not always work well with the emergency department to achieve the best outcomes for patients.
The arrangements for prescribing, recording and storing of medicines were not consistently safe.
The service did not always follow national legislation and guidance for patients lacking capacity.

The Royal Lancaster Infirmary is a part of the University Hospitals of Morecambe Bay NHS Foundation Trust. It provides acute hospital services including urgent and emergency care, medical care, surgery, maternity, critical care, pediatrics and out-patients for people in the North Lancashire and South Cumbria areas.

We visited Royal Lancaster Infirmary as part of our unannounced inspection during 3 to 4 August 2021. Our inspection was unannounced after receiving concerns about patients being put at risk (staff did not know we were coming) to enable us to observe routine activity.

We visited medicines core services as part of the inspection.

Attendances at the emergency departments within the trust averaged around 10,000 per month.

The hospital had capacity for 203 medical beds and 106 inpatient surgical beds.

As part of the inspection, we spoke with ten patients. We observed care and treatment and looked at 19 care records and 15 prescription drug charts. We also spoke with staff members across the department including staff nurses, senior nurses, a pharmacy technician, junior doctors, consultants, care support workers, matrons, clinical service managers and the associate director of nursing, the associate director of operations, and the clinical director.

Following this inspection, under Section 31 of the Health and Social Care Act 2008, we sent the trust a letter of intent in respect to the regulated activity, treatment of disease, disorder and injury and diagnostic screen procedures. We took this action as we believed a person would or may be exposed to the risk of harm if we had not done so. The trust provided actions at the time of inspection that assured us people were kept safe.

The Royal Lancaster Infirmary is a part of the University Hospitals of Morecambe Bay NHS Foundation Trust. It provides acute hospital services including urgent and emergency care, medical care, surgery, maternity, critical care, paediatrics and out-patients for people in the North Lancashire and South Cumbria areas.

We visited Royal Lancaster Infirmary as part of our unannounced inspection during 20 to 22 April 2021. Our inspection was unannounced (staff did not know we were coming) to enable us to observe routine activity.

We visited urgent and emergency care, surgery and maternity core services as part of the inspection.

Attendances at the emergency departments within the trust averaged around 10,000 per month.

The hospital had capacity for 203 medical beds and 106 inpatient surgical beds.

The hospital provides elective day case surgery for orthopaedic surgery, ophthalmology, ear, nose and throat (ENT), maxillofacial, urology and general surgery. Surgery at the trust includes all main surgical specialties with the exception of cardiothoracic, neurosurgery, plastics and vascular which are provided by other local NHS foundation trusts.

The trust had 2,397 elective surgical admissions, 10,124 emergency admissions and 13,114 day surgery admissions between January 2020 and December 2020.

Maternity services at Royal Lancaster Infirmary consist of a consultant and midwifery led day assessment unit, a delivery suite with seven beds, two dedicated obstetric theatres and a 24 bedded antenatal and postnatal ward. There are also a range of consulting rooms for antenatal and postnatal clinics and a bereavement suite.

Community midwifery services provide antenatal, intrapartum and postnatal care including birth at home and enhanced and specialist midwives provide care to vulnerable women.

From June 2020 to May 2021 there were 1643 babies delivered across the three maternity locations provided by the trust.

During the inspection we found areas of concern that led to a further unannounced focused inspection in medicine for the stroke care pathway.

We did not inspect all of the key lines of enquiry as our concerns were related to specific risks around the stroke care pathway. We inspected against parts of the safe, effective, caring and well-led key questions.

Following this inspection, under Section 31 of the Health and Social Care Act 2008, we imposed urgent conditions on the registration of the provider in respect to the regulated activity; Treatment of disease, disorder and injury and diagnostic screen procedures. We took this urgent action as we believed a person would or may be exposed to the risk of harm if we had not done so. Imposing conditions means the provider must manage regulated activity in a way which complies with the conditions we set. The conditions related to the stroke pathway at the Royal Lancaster Hospital and the Furness General Hospital. In light of this, we suspended the ratings for Medical care including care for older people.

Since the conditions were imposed, the trust responded immediately and put actions in place to improve the service. These were ongoing at the time of publication of the report.

Our rating of this location stayed the same. We rated it as requires improvement because:

Urgent and emergency Care

In the urgent and emergency care service there were not always enough staff with the right qualifications, skills, training and experience to provide care and treatment to children and staffing of children’s nurses was not in line with national guidance.
The urgent and emergency care service did not ensure that there was always safe management, storage and administration of medicines.
The urgent and emergency care and maternity service did not always provide care and treatment based on national guidance and evidence-based practice. There was a lack of clear information to evidence how the service monitored the effectiveness of care and treatment. The services could not always demonstrate how they used findings to make improvements and achieve good outcomes for patients.
Patients in the emergency department did not always have their privacy and dignity maintained.
Within urgent and emergency care, there was not an effective governance process, some specific risks had not been identified on the risk register and other risks remained the same as they were when we last inspected the service. Staff did not always feel respected, supported and valued by senior leaders.

Medical care

Following this inspection, under Section 31 of the Health and Social Care Act 2008, we imposed urgent conditions on the registration of the provider in respect to the regulated activities; Diagnostics and Screening and Treatment of Disorder, disease and Injury. We took this urgent action as we believed a person would or may be exposed to the risk of harm if we had not done so. Imposing conditions means the provider must manage regulated activities in a way which complies with the conditions we set. The conditions related to the stroke services at Royal Lancaster Infirmary and Furness General Hospital. In light of this, we suspended the ratings for Medical care including care for older people.
The trust did not have an effective risk and governance system for the whole stroke pathway.
The trust did not operate an effective clinical escalation system to ensure stroke care and treatment was assessed and implemented in a timely way.
The did not have an effective system to ensure that all clinical staff had the knowledge, competence, skills and experience to care for and provide treatment to patients presenting with symptoms of stroke.
Patients who had experienced a stroke were not always cared for in the most appropriate environment.
Staff in the medical service did not always assess swallowing abilities in a timely manner. They did not always use special feeding and hydration techniques when necessary.

Surgery

Most clinical audit outcomes were comparable to expected national standards within surgery. However, the service performed worse than expected for patient length of stay in the national hip fracture audit 2019 and the national bowel cancer audit 2020.
Within surgery, the service performed worse than national standards for waiting times from referral to treatment. The average length of stay for patients having trauma and orthopaedics surgery was worse than national average. Whilst the services had plans in place to improve this, these measures had not been fully implemented and had not yet led to any significant improvement in the services.

However,

Staff treated patients with compassion and kindness and took account of their individual needs and helped them understand their conditions. They provided emotional support to patients, families and carers.
There was enough staff to care for patients and women and keep them safe.
Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The trust engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

Maternity care

Outcomes for women within the maternity service were not always positive, consistent nor met expectations, such as national standards.
The maternity service did not always assess and monitor women to see if they were in pain, nor give pain relief in a timely way. Staff in the emergency department did not always reassess pain scores.
In the maternity service leaders did not consistently use reliable information systems to enable them to run services well. The service did not have effective governance processes and systems to manage risk, issues and performance. There was no clear vision and values for the service that was understood by staff.

However:

Staff treated patients with compassion and kindness and took account of their individual needs and helped them understand their conditions. They provided emotional support to patients, families and carers.
There was enough staff to care for patients and women and keep them safe.
Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The trust engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

Across this location:

Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well.
Staff provided good care and treatment, gave patients enough to eat and drink. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
The trust planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback.

Royal Lancaster Infirmary is operated by University Hospitals of Morecambe Bay NHS Foundation Trust. We inspected maternity services and services for children and young people at Royal Lancaster Infirmary.

We inspected the services provided by this trust as part of a focused inspection because we had concerns about the quality of services and we received information giving us concerns about the safety and quality of the services.

Where it is considered necessary to arrange a focused inspection outside of the regular core service inspection schedule, the focused inspection covers a targeted part of the service response to a specific concern. We do not assess or report on all the key lines of enquiry (KLOEs) in a focused inspection.

As we do not rate a trust following a focused inspection, we cannot update any provider level ratings following this inspection.

Throughout the inspection, we took account of what people told us.

We found the following areas of good practice:

The services provided mandatory training in key skills to all staff and made sure everyone completed it.
Staff had training on how to recognise and report abuse, and there were processes in place to escalate concerns.
Staff completed and updated risk assessments for each patient and took action and removed or minimised risks. Staff identified and quickly acted upon patients at risk of deterioration.
The services had enough staff with the right qualifications, skills, training and experience to keep women safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed and adjusted staffing levels and skill mix, and gave bank and agency staff a full induction.
Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date, stored securely and easily available to all staff providing care.
The services managed safety incidents well. Staff recognised and reported incidents and near misses. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support. Managers ensured that actions from patient safety alerts were implemented and monitored.
The services made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and development.
Local leaders had the skills and abilities to run the service. They understood and managed the priorities and issues the service faced. They were visible and approachable in the service for patients and staff.
Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. The service had an open culture where patients, their families and staff could raise concerns without fear.
Staff at all levels were clear about their roles and accountabilities and had regular opportunities to meet, discuss and learn from the performance of the services.
Local leaders used systems to manage performance effectively. Relevant risks were identified.

However, we also found the following issues that the service provider needs to improve:

Leaders did not consistently operate effective governance processes throughout the services.
Actions taken to mitigate risk were not always identified or actioned in a timely way.

The services collected data and analysed it. However validated data was not easily accessible to all staff to allow them to understand performance, make decisions and improvements.
We were not assured that processes to monitor equipment competencies were effective.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve. Details are at the end of the report.

Ann Ford

Deputy Chief Inspector of Hospitals (North)

Our rating of services went down. We rated it them as requires improvement because:

The rating for caring and responsive went down from our previous inspection in 2016. Caring went down from outstanding to good and responsive went down from good to requires improvement.
Within ED, we lacked assurance that the process for communicating when a patient required isolation was robust. Staff outside of the department and visitors may not be aware when precautions were required.
We found some gaps in the checking of emergency equipment in the four resuscitation trollies we looked at within the ED.
When the ED was busy, patient’s care needs were not always met, and there was a lack of evidence that comfort rounds and regular checks on patients were taking place.
We saw examples of patient’s privacy and dignity was compromised while they waited and received treatment in the ED.
All specialties were below the England average for RTT rates (percentage within 18 weeks) for admitted pathways.
The process for managing patient flow in the emergency department was not robust, especially for patients waiting in corridors on trolleys and in wheelchairs.
The emergency department was failing to meet performance targets. They failed to meet the standard in patients waiting more than 12 hours from the decision to admit until being admitted and four-hour target performance in every month from September 2017 to August 2018.
The mental health facilities in the emergency department did not meet the PLAN standard and mental health patients waited a long time for admission to the local mental health trust. However, the delays in patients being admitted by the local mental health trust were not under the control of UHMB.
No testing was initiated at triage which meant patients waited longer than necessary in the emergency department to be assessed by medical staff.
There were systems in place for leaning from complaints, however, from speaking with staff we were only provided with limited examples.

However:

The trust had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.
Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
The trust had systems and processes in place to ensure that the needs of local people were considered when planning the service delivery.
Managers at all levels in the trust had the right skills and abilities to run a service providing high-quality sustainable care.
The trust had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff, patients, and key groups representing the local community.
Whilst we could not be provided with mandatory training data by site and staff group. The data we were provided with and saw on site showed that compliance was at or just below the trust target of 95%. This was an improvement from the last inspection.
There was a focus on training and development within the department to provide staff with the skills to care for unwell patients.
We saw examples of good multidisciplinary team working and staff demonstrated a good understanding of mental capacity and deprivation of liberty safeguards.

We carried out a follow up inspection between 11 and 14 October 2016 to confirm whether University Hospitals of Morecambe Bay NHS Foundation Trust (UHMB) had made improvements to its services since our last comprehensive inspection, in July 2015. We also undertook an unannounced inspection on 26 October 2016.

To get to the heart of patients’ experiences of care and treatment, we always ask the same five questions of all services: are they safe, effective, caring, responsive to people’s needs, and well-led? Where we have a legal duty to do so, we rate services’ performance against each key question as outstanding, good, requires improvement, or inadequate.

When we last inspected this hospital, in July 2015, we rated services as as 'requires improvement'. We rated safe, effective, responsive, and well-led as 'requires improvement'. We rated caring as 'good'.

There were seven breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations. These were in relation to staffing, supporting staff, safety and suitability of premises, safe care and treatment, 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 made the required improvements and rated Royal Lancaster Infirmary as good overall, with caring and end of life services rated as outstanding and safe rated as requires improvement.

Our key findings were as follows:

There had been significant improvements across most services at this hospital since our last inspection in July 2015.
In critical care and end of life care services, there were a number of outstanding examples of compassionate care and emotional support shown by all levels and disciplines of staff who did not hesitate to go the extra mile to make a difference for patients and their loved ones.
Leadership of the hospital was good, managers were available, visible, and approachable; staff morale had improved significantly, and they felt supported. Staff spoke positively about the service they provided for patients.
There had been significant investment in leadership within end of lfe services.
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 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.
The trust reported no incidences of MRSA between September 2015 and May 2016. Eight cases of clostridium difficile were reported in the same period.
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.
Nursing and medical staffing numbers had improved since the last inspection. However, there were still several nursing and medical staffing vacancies throughout the hospital, especially in medical care services and the emergency department. There were also nurse staffing concerns in the neonatal unit. The trust had robust systems in place to manage staffing shortfall, as well as escalation processes to maintain safe patient care.
The hospital had improved compliance against mandatory training and appraisal targets in most services. Local support and supervision of junior staff had improved, and many areas had developed their own unit-specific competencies for training and development purposes.
There had been an improvement in record-keeping standards throughout the hospital, however, we identified some ongoing areas for improvement around legibility and trigger levels for early warning of deterioration, particularly in in medical care services and the emergency department.
The trust’s referral to treatment time (RTT) for admitted pathways for surgery services had improved since the last inspection. Information for September 2016 showed an improvement in the trust’s performance, with 75% of this group of patients treated within 18 weeks against the England average of 75%.
Access and flow, particularly in the emergency department and medical care services, remained a challenge. The emergency department performance had been deteriorating over the preceding 12 months. The Department of Health’s standard for emergency departments is that 95% of patients should be admitted, transferred, or discharged within four hours of arrival in the A&E. The last month that the trust delivered the 95% ED 4-hour performance standard was in August 2015. Lack of beds in the hospital resulted in patients waiting longer in the emergency department. Delays in obtaining suitable community care placements were causing access and flow difficulties, particularly in medical care services.

We saw several areas of outstanding practice including:

The medicine division delivered outstanding Referral to Treatment (RTT) outcomes across all specialisms despite pressures on the service overall.
The Listening into Action programme had delivered some clear, effective, and significant quality improvements for the organisation and for patients across the hospital.
The service was one of only three trusts which were successful in securing funding to pilot a maternity experience communication project. This was a patient-based, communication-improvement training tool for multi-professional groups in maternity services. The project had the potential to be adopted nationally if learning outcomes and measurable improvements could be made for women who were using maternity services.
The bereavement team, Chaplaincy, and specialist palliative care team worked together to promote compassionate care at the end of life. A particular innovation relating to this had been the development of death cafés. A death café provided an opportunity for people to talk more openly about death and dying. The trust had held death cafés for the public as part of 'dying matters week', and also had used them to support staff to talk more openly about death and to promote better communication with patients and relatives at the end of life.
There were a number of innovations relating to compassionate care for patients at the end of life. This included the use of canvas property bags with a dragonfly symbol so staff knew that those collecting them had been recently bereaved. In addition, bereavement staff sent out forget-me-not seeds to family members following the death of a loved one. Families were also able to get casts of patient’s hands. Thich was a service provided by an external organisation, with funding for this provided by the trust.
The trust had adopted the dragonfly as the dignity in death symbol. This was used as a sign to alert non-clinical staff to the fact that a patient was at the end of life or had died. A card with the symbol could be clipped to the door or curtain where the patient was being cared for. By alerting all staff this meant that patients and family members would not have to face unnecessary interruptions, and non-clinical staff knew to speak with clinical staff before entering the room. An information card had been produced for non-clinical staff explaining the difference between the dragonfly symbol (dignity in death) and the butterfly (dementia care).
A remembrance service was held by the Chaplaincy every three months for those bereaved. We were also told that ‘shadow’ funeral services had been delivered within the trust when patients had been too unwell to attend funerals of loved ones.
Relatives were sent a condolence letter by the bereavement service a few weeks after the death of a loved one and support was offered at this time.

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

Importantly, the trust must:

In urgent and emergency care services:

Monitor performance information to ensure 95% of patients are admitted, transferred, or discharged within four hours of arrival in the emergency department .
Ensure patients do not wait longer than the standard for assessment and treatment in the emergency department.

In services for children and young people:

Ensure there are sufficient nursing staff to ensure compliance with British Association of Perinatal Medicine (BAPM) and Royal College of Nursing (RCN) guidance.

Action the hospital SHOULD take to improve

In urgent and emergency care services:

Ensure observations are recorded appropriately to allow the assessment and early recognition of the deteriorating patient
Ensure nursing documentation is completed in accordance with trust policy.

In medical care:

Ensure all risk assessments (particular reference to venous thromboembolism and multi-factorial falls risk assessments) are completed for all patients where appropriate, and evidence of the same is documented consistently.
Ensure medicines documentation records patient allergies, venous thromboembolism risk, and oxygen prescribing.
Ensure National Early Warning Score (NEWS) triggers are followed or, in the event of deviation, ensure trigger levels are adjusted, with clinical rationale documented to evidence.
Ensure all nursing and medical clinical documentation is completed in full and in accordance with recognised professional standards.
Where medicines are stored in fridges, ensure temperature ranges are recorded in accordance with policy to ensure the safety and efficacy of the medicine is not compromised.
Ensure all staff complete all elements of their mandatory training requirements, and ensure accurate compliance figures are maintained.
Ensure all staff benefit from the appraisal process and these are completed on an annual basis in accordance with local policy.
Ensure there is a reasonable and proportionate induction process, or access to relevant induction information, for all locum medical staff attending the hospital on an ad-hoc or short-term basis.
Ensure action plans put in place to address shortfalls in local and national patient outcome audits are monitored and reviewed in a timely manner to ensure compliance is measured.
Ensure there is a review of patient comments and Patient Led Assessment of the Care Environment (PLACE) findings regarding food quality, and consider measures which may be implemented to improve nutritional care;
Ensure staff awareness and knowledge of Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) is underpinned by consideration of procedural competence in making such applications, to avoid potential legislative breaches.
Ensure where family attendance is required at care meetings sufficient notice is given;
Ensure the patient and family members are given appropriate time and opportunity, in the right arena, to voice opinion on care and treatment plans.
Ensure that, where external staff are required to support in 1:1 observation of patients, they are suitably trained to perform the task.
Ensure the number of patient bed moves after 10pm is kept to a minimum, to avoid patient and family anxiety and distress;
Ensure the effectiveness of the new governance framework is measured and adapted accordingly.
Ensure the effectiveness of current staff engagement themes, and consider other formats which will support divisional strategy.
Ensure reasonable measures are put in place to support staff wellbeing, and ensure all staff know what is available to them.

In surgery:

The trust must ensure care pathways are reviewed in accordance with the trust policy.
The trust should ensure hand hygiene audits take place monthly and that improvements are made.
Nursing documentation should include whether a patient has had food or drinks whilst in the emergency department.
Continue to improve Referral to Treatment Times (RTT) for patients and continue to implement trust-wide initiatives to improve response.
Increase orthogeriatrician’s input on surgical wards.
Ensure all transfers between locations are performed in line with best practice guidance and policy. Where practice deviates from the guidance, a clear risk assessment should be in place.
Continue to engage staff and encourage team working, to develop and improve the culture within the wards and theatre department.
Continue with staff recruitment and retention.
Ensure medicines reconciliation is completed in a timely way.
Ensure medication fridge temperatures are checked within trust policy timescales.

In critical care:

In 2015 we reported that the unit had limited space and during this inspection we noted again that the unit was over twenty years old and would not meet current national standards for new buildings and environment. The trust should continue to monitor environmental standards and challenges in critical care and continue with strategic plans for refurbishment and expansion.
Take action to improve physiotherapy staffing and be clear in how it supports rehabilitation for patients in line with GPICS (2015).

In maternity and gynaecology:

Ensure that outcome measures are developed to monitor the effectiveness of the strategic partnership with Central Manchester University Hospitals NHS Foundation Trust and Lancashire Teaching Hospitals NHS Foundation Trust.
Ensure that care records, including cadiotocograph (CTGs), are legible, complete, timed, and dated.
Continue to monitor the cultural assessment survey for obstetrics and gynaecology, and improve values around organisational culture.

In services for children and young people:

Ensure that all children with an acute medical problem are seen by a consultant paediatrician within 14 hours of admission.
Ensure the environment of the children’s unit and neonatal unit are fit for purpose.
Ensure there is a review of all children and young people’s mortality and morbidity.
Ensure that documentation refers to Gillick competency and ensure that staff are properly trained and confident to assess Gillick competency.
Continue to ensure that communication takes place with partner agencies about the placement of CAMHS patients.

In outpatients and diagnostic imaging:

Continue to build relationships and develop closer team working for medical staff in radiology and breast services across all locations, to develop a one trust culture.
Continue to ensure sufficient numbers of suitably qualified, competent, skilled. and experienced persons are deployed in order to meet the needs of the patients. This is particularly in relation to radiology, dermatology, and allied health professionals.
Continue work started to ensure that all premises used by the service provider are suitable for the purpose for which they are being used, properly used, properly maintained, and appropriately located for the purpose for which they are being used. This is particularly in relation to services provided from medical unit one.
Ensure it meets referral to treat targets in outpatient clinics and address backlogs in follow- up appointment waiting times.

Professor Sir Mike Richards

Chief Inspector of Hospitals

The Royal Lancaster Infirmary is one of three locations providing care as part of University Hospitals of Morecambe Bay NHS Foundation Trust. It provides a full range of hospital services including emergency care, critical care, a comprehensive range of elective and non-elective general medicine (including elderly care) and surgery, an oncology unit, a neonatal unit, children and young people’s services, maternity services and a range of outpatient and diagnostic imaging services.

University Hospitals of Morecambe Bay NHS Foundation Trust provides services for around 360,000 people across North Lancashire and South Cumbria with over 700 beds. In total, the Royal Lancaster Infirmary has 426 beds.

We inspected University Hospitals of Morecambe Bay NHS Foundation Trust as part of our comprehensive inspection programme in February 2014. Following our inspection in February 2014 we rated the Royal Lancaster Infirmary as ‘Requires Improvement’ overall. We judged the hospital as ‘Requires improvement’ for safe, effective, responsive and well led and ‘good’ for caring. CQC was specifically concerned about staffing levels particularly in medical services (Ward 39) but also in other clinical areas such as the surgical wards, radiology, dermatology and paediatrics, where there was a shortage of specialist staff. We also found the trust’s governance and management systems were inconsistently applied across services and the quality of performance management information required improvement.

We carried out this inspection to see whether the hospital had made improvements since our last inspection. We carried out an announced inspection of Royal Lancaster Infirmary on 15 July 2015. In addition an unannounced inspection was carried out between 4pm and 7:30pm on 29 July 2015. As part of the unannounced visit we looked at the care provided on Ward 39 and the acute surgical assessment unit.

Overall we rated Royal Lancaster Infirmary as ‘Requires Improvement’. We have judged the hospital as ‘good’ for caring. We found that services were provided by dedicated, caring staff and patients were treated with dignity and respect. However improvements were needed to ensure that services were safe, effective, well led and responsive to people’s needs.

Our key findings were as follows:

Cleanliness and infection control

The trust had infection prevention and control policies in place which were accessible to staff.
We observed good practices in relation to hand hygiene. ‘Bare below the elbow’ guidance was followed and personal protective equipment, such as gloves and aprons, was used appropriately while delivering care.
‘I am clean’ stickers were used to inform staff at a glance that equipment or furniture had been cleaned and was ready for use.
Patients received care in a clean, hygienic and suitably maintained environment. Staff were aware of and applied infection prevention and control guidelines.
However, in the emergency department ,we saw some dusty equipment and shelving. We also found that inside a cupboard containing medical supplies was dirty. Some cubicle floors were dirty and there was debris on the floors. We inspected six mattresses and noted that four of them had holes in the covers and there was evidence of staining on the inside and onto the foam mattress itself. We later observed staff conducting a full audit of the mattresses.
Between December 2014 and June 2015 there had been one case of MRSA in medical care services. There had been six cases of Clostridium difficile (C.diff) reported in the medical division in the same period. Four of these were avoidable. Meetings had taken place regarding these incidents that included looking at lessons learnt.
Between April 2014 and February 2015 there had been three avoidable cases of C.diff in the surgical and critical care division at Royal Lancaster Infirmary. There had been no learning from these events that had resulted in additional measures to prevent infection.
According to the submitted and verified intensive care national audit and research centre data (ICNARC), the critical care unit performed as well and sometimes better than similar units for unit acquired methicillin-resistant staphylococcus aureus (MRSA) and clostridium difficile infection rates.

Nurse staffing

Care and treatment were delivered by committed and caring staff who worked hard to provide patients with good services.
Although we found staffing levels were adequate at the time of our inspection, there was no flexibility in numbers to cope with increased capacity and demand, or short-notice sickness and absence.
The trust had actively recruited nursing staff from overseas to try to improve staffing levels. However, there were still staffing shortfalls that were covered by bank and agency staff. Senior staff said they tried to use the same bank and agency staff to ensure that they had the required skills to work on the ward. Agency staff were given an induction before commencing work on the wards.
Nurses recruited from overseas were supernumerary while they awaited registration with the Nursing and Midwifery Council. However, in surgical services there was a lack of clarity about their role and responsibilities.
Staffing establishments had improved since the last inspection however on some wards, nurse staffing remained a challenge. Ward 39 in particular, remained a concern. Senior staff felt that the staffing establishment on the ward was unsustainable for the number of beds (50 beds) as they had been asked to reduce the number of clinical support workers. They were unsure how the new staffing figures for clinical support workers had been decided as they had not been involved in the review.
A review of staffing over a one month period showed that the skill mix on ward 39 did not always fall in line with the trust’s ‘red rules’ initiative. The principals of this initiative included one registered nurse should deliver care to no more than eight patients and the minimum skills mix on a ward should be 60% registered nurses to 40% health care assistants.

Medical staffing

Medical treatment was delivered by skilled and committed medical staff.
The trust had identified areas where medical staff shortages presented risk to patient care and treatment and were working hard to recruit and retain consultants.
There had been an increase in the number of cardiology consultants from two to six. These consultants worked across the trust on a six week rotation basis. This had improved patient care and facilitated earlier discharges. It had also reduced the angiogram waiting list from 18 months to three weeks. However, there was a lack of consultants in some specialist services such as respiratory and gastroenterology.
Over the past 6 months the locum cover had been as high as 51.5% in some areas. The specialities that had high use of locum cover included elderly care, diabetes, dermatology and rheumatology services.
There were ongoing vacancies within the radiology service. Managers said they were actively recruiting and had introduced the use of extended roles for advanced practitioners to help manage the case load. The service leads felt there had been some improvements in staffing but the recruitment of experienced radiology staff remained a challenge.
There was a sufficient number of medical staff to support outpatient services. The majority of clinics were covered by specialist consultants and their medical teams. However, staff said paediatric clinics were frequently cancelled with less than six weeks’ notice due to the consultant rota and lack of junior and middle grade doctors.
Anaesthetic cover was provided by an ST3 (specialist registrar year 3) or above, who was resident on call and provided cover for ITU and the obstetric epidural service; this was supported by a non-resident consultant intensivist. It was acknowledged that this fell short of national guidelines. However, there was no evidence to suggest there were any serious incidents or complaints relating to delays in obtaining an anaesthetist.

Mortality rates

The trust was highlighted as a ‘risk’ for the in-hospital mortality indicator - Cerebrovascular conditions in the CQC Intelligent monitoring report May 2015.
Mortality and morbidity meetings were held either weekly or monthly and were attended by representatives from teams within the relevant divisions. As part of these meetings, attendees reviewed the notes for patients who had died in the hospital within the previous week. Any learning identified was shared and applied.

Nutrition and hydration

Patients had a choice of nutritious food and an ample supply of drinks during their stay in hospital. Patients with specialist needs in relation to eating and drinking were supported by dieticians and by the speech and language therapy team.
Patient records included an assessment of patients’ nutritional requirements based on the malnutrition universal screening tool (MUST).
However, in medical care services, people were not always supported appropriately with their nutritional needs. For example, a patient on ward 39 required feeding via a gastro-enteric tube. There was a clear plan in place which outlined what the food and fluid intake should be for this patient including specified volumes and times for delivery. On checking the daily fluid monitoring chart the daily intake recorded did not match the amount stated on the plan for three days.
Where patients were identified as being at risk, there were fluid and food charts in place. However, the recording of fluid balance charts was inconsistent, particularly in medical care services.
Parents told us there was a good selection of food on the menu for children and young people. Children were also offered snacks and food was available as it was required.

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

Importantly, the trust must:

Ensure that all premises used by the service provider are suitable for the purpose for which they are being used and properly maintained. This is particularly in relation to physiotherapy services and medical care services provided from medical unit one.
Ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed in order to meet the needs of the patients. Staff should receive appropriate support, training and appraisal as is necessary to enable them to carry out their role.
Ensure that staff understand their responsibilities under and act in accordance with the requirements of the Mental Capacity Act 2005 and associated code of practice.
Ensure that staff follow policies and procedures around managing medicines, including intravenous fluids particularly in medical care services and critical care services.
Ensure that the resuscitation trolleys on the children’s ward are situated in areas that make them easily accessible in an emergency. All staff must be clear on who has responsibility for the maintenance of the resuscitation trolley on the delivery suite.
Ensure that they maintain an accurate, complete and contemporaneous record in respect of each service user.
The provider must ensure that the Five Steps to Safer Surgery (World Health Organisation) safety checklist is consistently followed and fully embedded in obstetric theatre practice.
The provider must ensure that all staff comply with hand hygiene requirements.
Ensure referral to treatment times in surgical specialities improve

In addition the trust should:

In urgent and emergency services:

Ensure all areas in the emergency department are clean and free from dust and debris and that mattresses are fit for purpose..
Take action to improve waiting times and ambulance handovers.
Ensure action plans following CEM audits clearly state the steps required to secure improvement.
Improve staff engagement, knowledge and awareness of the strategy for the service.

In medical care services:

Ensure that call bells are easily accessible for patients so they can call for help when required.
Ensure there are clear plans in place to reduce the number of falls occurring within the service.
Improve the management of people with a stroke in line with national guidance.
Consider improving arrangements for clinical supervision to ensure they are appropriate and support staff to effectively carry out their responsibilities, offer relevant development opportunities and enable staff to deliver care safely and to an appropriate standard.
Take action to improve reduce the number of patients staying on medical wards that are not best suited to their needs and to reduce the number of moves between wards.

In surgical services:

Ensure there are systems in place to identify themes from incidents and near miss events to promote safe care.
Ensure all theatres are completing audits to monitor compliance with the 5 steps to safer surgery process.
Ensure all staff understand the process for raising safeguarding referrals in the absence of the safeguarding lead.
Reduce and improve readmission rates.
Ensure all procedures are performed in line with best practice guidance. Where practice deviates from the guidance, a clear risk assessment should be in place.
Continue to engage staff and encourage team working to develop and improve the culture within the theatre department.

In critical care services:

Ensure that there is timely access to medical care for patients out of hours and that any delays do not result in patient harm.
Consider how it is going to improve performance in reducing the number of delayed and out of hours discharges of patients from critical care.
Ensure that any delayed discharges from critical care do not result in a breach of the government’s single sex standard.
Ensure that all entries in patient records are appropriately signed and dated.
Consider the provision of a supernumerary clinical coordinator on duty 24/7.

In maternity and gynaecology services:

Ensure that the actions of the Kirkup recommendations are implemented within timescales and embedded across the trust
Ensure there are clear lines of responsibility and accountability at ward manager and matron level within maternity so that staff feel supported and barriers to communication and change are removed
Implement the recommendations of and monitor compliance with, the PHSO Report 'Midwifery supervision and regulation: recommendations for change' (2013) with regard to Trust/Midwifery Supervisory investigations, so that parent(s) receive a joint set of recommendations and a single timeframe resulting from the investigation
Ensure that the ‘Five steps to safer surgery’ (World Health Organisation) is embedded in obstetric theatre practice.
Ensure that a physical test is carried out in line with trust policy to ensure that the infant abduction procedures work correctly and that staff understand how they work

In children and young people’s service:

Ensure that there are clearly defined and formalised job plans in place for consultant paediatricians.
Consider reviewing the investigation process of patient safety incidents with full consideration given to the reporting professional’s account of events and concerns.
Ensure there is sufficient and appropriate access to oxygen points on the neonatal unit in line with BAPM standards.

In end of life care services:

Ensure there is a clear and accessible system in place to identify and monitor risks within end of life care services.
Continue to take action to improve those areas identified by the NCDAH.
Ensure all DNACPR forms are completed to the appropriate standard.

In outpatients and diagnostic imaging:

Continue to build relationships and improve closer team working to develop a one trust culture.

Professor Sir Mike RichardsChief Inspector of Hospitals

Professor Sir Mike Richards

Chief Inspector of Hospitals

Context

University Hospitals of Morecambe Bay NHS Foundation Trust became a foundation trust on 1 October 2010. It provides a comprehensive range of acute and support hospital services for around 350,000 people across north Lancashire and south Cumbria, with over 740 beds.

The trust operates from three main hospital sites: the Furness General Hospital in Barrow, the Royal Lancaster Infirmary and Westmorland General Hospital in Kendal. The Queen Victoria Hospital in Morecambe provides outpatient services and Ulverston Community Health Centre provides nutrition, dietetics and breast screening. This inspection report will focus only on the acute services provided at the Royal Lancaster Infirmary.

There have been significant changes to the trust board since 2012. The entire board of Directors has changed since 2012 with 14 new appointments made, including the Chief Executive. In the seven months prior to our inspection four executive directors had taken up post.

University Hospitals of Morecambe Bay NHS Foundation Trust has been selected as one of the early trusts to be inspected under CQC’s revised inspection approach. The trust was selected for inspection as a trust where there were known risks to service delivery.

Overall inspection findings at Lancaster Royal Infirmary (RLI)

We found that staff at the hospital were committed to providing safe and effective care for patients. There were good examples of compassionate and person-centred care cross all the core services.

The hospital was clean throughout, however there were instances of staff not adopting best practice in hand hygiene and cross infection practices in both the surgical and paediatric services.

In 2013, net recruitment of nursing staff (recruitment – leavers) showed a positive gain of 135 nurses. Regular updates on nurse recruitment were presented to the Board through the Risk Committee; risks were managed through the daily staffing call and the use of bank and agency staff. However, during our inspection we identified a number of areas where staffing difficulties were having an adverse impact on patient care and safety. This was of particular concern on the medical wards. Staffing levels had been an issue on the medical wards for some considerable time. We inspected the medical wards in October 2013 and found that there were not enough staff to provide appropriate and safe care to patients. As a result, we served a warning notice to the trust.

We visited the trust again in January 2014 to assess its progress against a warning notice issued regarding staffing on Ward 39. Although the nurse staffing levels had improved by the provision of new staff and agency nurse support, we found that there were still concerns regarding the staffing levels and skill mix on the ward, and that some patients were not benefitting from high quality care as a result.

We concluded that the trust had failed to comply with the earlier warning notice.

Staffing concerns were also identified in other clinical areas such as the surgical wards, radiology, dermatology and paediatrics, where there is a shortage of specialist staff.

Staffing issues within the hospital have been recorded on the trust’s risk register for some considerable time; however, the trust has been unable to address these concerns effectively.

Specialist support services for people at the end of their life were good and patients spoke highly of the care they were given by the palliative care and oncology teams. However, the specialist service is only available during normal office hours.

Outpatient departments are still experiencing difficulties in obtaining patient records in time for clinic appointments and with scheduling appointments.

Staff are well-led at the frontline and have confidence in their managers to raise issues of concern. However, staff have less confidence in the Executive Team, as management responses and improvement actions are seen as lacking vigour and pace.

The trust’s governance and management systems are inconsistently applied across services and the quality of performance management information requires improvement. We also found that performance information and learning from incidents was not effectively used to drive changes and improvement.

There have been improvements in both the maternity and accident and emergency services as a result of targeted and focused work by the trust, and patients are positive about their experiences of these services.

We visited the Trust in order to assess their progress against two warning notices we issued regarding staffing on ward 39. At this inspection we found that the Trust had failed to comply with the warning notices served. We are currently considering what further action to take and this report is published in the interim.

On the 5th of February 2014 we will be undertaking a detailed wave 2 inspection of the Trust and will use any further information that we gather from across the Trust to feed into our decisions about the action we will take. We have also written to the Trust to ask them for detailed assurances about how they will immediately rectify the issues of staffing levels on ward 39.

We visited the Royal Lancaster Infirmary (RLI) following an earlier inspection that established that they were non compliant with Outcome 17 complaints. We had also received information that one of the wards at the hospital was understaffed which was having an impact on the care and welfare of people who used the service (patients).

We visited the hospital both during the day and at night. We spoke with 20 patients and over 20 members of staff on the ward where concerns had been raised. We also spoke to senior managers and members of the Trust board.

Patients we spoke with told us that there was not sufficient staff on the ward we visited. Many told us that they had to wait for long periods of time before they received assistance or support. All agreed that staff were doing the best they could under difficult circumstances. Patients said:

"They're [the staff] very busy, it's very difficult for them."

"I've been left in a wet bed."

"They're that busy they have no time."

"Sometimes we are ignored."

"It's dangerous really isn't it?"

We spoke with staff who told us they were upset as they were unable at times to provide the care that they thought was appropriate. Staff said:

'Staffing is absolutely abysmal.'

'Patients don't get the amount of care they should get."

'You want to do your best but you can't.'

'I'm not able to do my job to the best of my ability. I can't give anymore or do any more.'

'It's very stressful working here. Not enough staff, too much pressure.'

We found that patients were not receiving care and support in a timely manner. This was because the ward did not have enough staff. Senior managers were able to demonstrate the different ways they were attempting to rectify this problem but had failed to adequately communicate this to staff who worked on the ward.

When we looked at the management of complaints by the RLI and the University Hospitals of Morecambe Bay Trust (the Trust) we found that they had improved their systems and had more efficient and effective processes in place.

This inspection focused purely on the maternity service at The Royal Lancaster Infirmary and Furness General Hospital. We have written a report for each separate location and therefore to get an overview of the maternity service provided by The University Hospitals of Morecambe Bay NHS Foundation Trust (UHMBT) both reports should be read in conjunction with each other.Everyone we spoke with said their privacy and dignity was always respected and felt safe when care and treatment was being provided. We observed staff knocking on side room doors or asking people with their curtains drawn around their bed and waiting for permission before entering.

One person told us that during their labour they were, 'Never left alone'. They also said of the delivery suite staff, 'They were very good and included us in everything, kept us informed, went above and beyond'.

People were happy with the care they received. One person who had a complex delivery including induction of labour and a forceps delivery told us, 'It was a good experience. Staff were confident and reassuring'. Another person we spoke with told us, 'It's my third baby here and even though this one was an emergency caesarean section it was a better experience this time'.

All staff could explain how to escalate risk and use the risk register. Learning from near misses was shared widely and evidence of this was seen on notice boards and posters. There was a monthly 'Lessons Learned' document which staff referred to and was seen on some notice boards and in clinical areas.

The Head of Midwifery stated that staffing and skill mix were continuously reviewed and there was evidence that staff were moved around the service to facilitate service provision and quality of care. Women were at times diverted to other Maternity units to enable provision of safe care.

This inspection report has been generated to amend two areas of non compliance from an inspection of maternity services which was undertaken in July 2011. At that time CQC found that Furness General Hospital maternity unit was non compliant for outcomes 8 cleanliness and infection control and 10 safety and suitability of premises. The Royal Lancaster Infirmary was found to be compliant in both these outcomes. We inspected Furness General Hospital (FGH) and the Royal Lancaster Infirmary maternity units on 13 and 14 August 2012. At that inspection the two areas of non compliance at FGH were reviewed and FGH was found to be compliant. See the CQC website www.cqc.org.uk for the relevant inspection reports.

We carried out this inspection as a desk top based review for this service on the 01 March 2013 using information gathered to assess if the service had achieved full compliance with outcome 5 Meeting Nutritional Needs. We did not visit the service. The evidence we had gathered from different sources indicated that the service was now compliant with outcome 5 which we had found to be non compliant. Our inspection of April 2011 found that that whilst tools were in place to ensure nutritional risk assessment and recording nutrition and hydration the effectiveness of these and the standards of individual practices on the wards was not always of a consistently good standard. As a result people were not always being well supported individually to have adequate nutrition and hydration. People using the service could not be confident that they would be supported to eat their meals according to their ability and to maintain their dignity and independence or that their nutritional intake would be monitored.

Recent evidence received from a number of different sources indicated there were now systems in place for gathering, recording and evaluating information about the quality of nutritional support and that staff were receiving relevant training. People who used the service were being supported at mealtimes and their nutritional needs were being assessed and the information identified by these assessments was being acted upon.

This unannounced inspection along with a second one at Furness General Hospital on the 14 August 2012 focussed on the accident and emergency departments including the medical assessment unit (MAU), the clinical decision unit (CDU), ward 6 male medical short stay, ward 5 female medical short stay and ward 3 a general medical ward at the Royal Lancaster Infirmary (RLI). We made general observations of the environment and the day to day activities that were going on around us

We spoke with six people who used the service at RLI. We also spoke with one person on ward 35 (orthopaedic) who had been admitted through the accident and emergency department (A&E). They told us that they had arrived in A&E on a Friday at quarter to midnight. By 3am they said they had been admitted onto ward 35 and had surgery the following morning. They said that the staff had been 'great' and had 'delivered good care'. The people we spoke with were positive about the treatment, care and support they had received.

One person told us, 'everybody has been so good' and that 'the doctor talked me through it and the nurses told me why I was coming to this ward.'

Another told us,' 'I can't express how good they have been with me everywhere I have been and so nice with it....they put me at ease and have a sense of humour.'

As part of our inspection we spoke with local stakeholders such as the local councils Overview & Scrutiny Committee who have a duty to look more closely into public services outside their own organisation which includes local NHS hospitals. They said they had not received any concerns from the public about the accident and emergency departments in recent months. They told us they had regular meetings with senior staff at University Hospitals of Morecambe Bay Trust which kept them up to date with any changes in service provision at the trust.

We also spoke with the Local Involvement Networks (LINks) who had not received any issues or concerns from the public about the emergency departments in recent months.

We inspected Royal Lancaster Infirmary (RLI) to check compliance with two warning notices served in February 2012 and to follow up compliance actions from the last inspection report. We had issued warning notices and compliance actions across RLI and Furness General Hospital (FGH) for the provision of accident and emergency care. A separate report has been written for FGH. Although the previous reports highlighted some different issues for each site there were common themes identified so it is beneficial to read this report in conjunction with the one for FGH.

This report concerns The Royal Lancaster Infirmary Maternity unit.

Women we spoke with were all pleased with the level of care they had received.

One woman told us "I had to be transferred from Kendal as I was in labour a long time and wanted an epidural. I was told about the transfer and all about the epidural. I was really happy with the whole process. I would come back here again."

Another woman said "I know who is looking after me. I have been given plenty of information through the post and when I was admitted. I feel safe. I had read about the problems here but happy with the care I have had."

As part of our inspection we spoke with local stakeholders such as the local council's Overview & Scrutiny Committee who have a duty to look more closely into public services outside their own organisation which includes local NHS hospitals. They said they had not received any concerns from the public about the Royal Lancaster Infirmary or Furness General Hospital maternity unit in recent months. They told us they had regular meetings with senior staff at University Hospitals of Morecambe Bay Trust which kept them up to date with any changes in service provision at the trust.

We also spoke with the Local Involvement Networks (LINks) who had not received any issues or concerns from the public about maternity services at The Royal Lancaster Infirmary or Furness General Hospital.

We inspected The Royal Lancaster Infirmary (RLI) maternity unit to check compliance with a warning notice served in August 2011 and to follow up compliance actions from the last inspection report. We had issued a warning notice and compliance actions across RLI and Furness General Hospital (FGH) maternity units. A separate report has been written for FGH maternity unit. Although the previous report highlighted some different issues for each site there were common themes identified, therefore it is beneficial to read this report in conjunction with the one for FGH.

The trust had made good progress in addressing our concerns contained in the warning notices and compliance actions from last year. It was evident that the trust was working with staff to develop a safe, women centred, evidence based maternity service. Good practice points were noted across both sites.

Clinical staff involved in the inspection gave us honest, helpful and well considered explanations. They were able to support their answers with robust examples and both written and verbal evidence. They demonstrated excellent skills in relationship building throughout the two days and were warm and welcoming.

Work is still ongoing, which is to be expected, around cultural change, staffing levels and data management systems but significant progress has been made to address these.

We conducted an on site investigation into the emergency pathway at Royal Lancaster Infirmary (RLI) site from 6 February to 9 February 2012 under the powers of section 48, Health and Social Care Act 2008. The remit of this investigation was to review the urgent care pathway. An investigation differs from a responsive compliance review in that it normally necessitates a much wider and deeper look at a range of concerns potentially across all locations within a single provider such as an NHS hospital. During the investigation the team identified a number of concerns that demonstrated a breech in the regulations.

The investigation team collected feedback from a wide number of people living in the local area who had used the services provided by the trust. This will be reported in more detail in the investigation report which is due to be published in July.

People reported varying experiences when they received treatment and care at the hospital.

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 focused during our visit upon the experiences of the people using the accident and emergency department at Royal Lancaster Hospital and on getting their opinions on the care and support they had received. We talked with patients and their relatives as well as nursing and support staff, trust management staff and paramedics. We made general observations of the environment and general activities and what was going on generally during our visit.

The main focus of our contact with people and the questions we asked focused upon patient safety, the staffing levels and the capacity of the department to function under pressure. We also wanted to see if people had access to staff who could make prompt diagnosis and provide treatment.

People using the department confirmed that they were given information about their conditions and treatment and generally kept informed about what was happening. If they were having to wait for admission they reported that they were told why this was the case. One person told us they did not mind the wait for a bed because they had been seen and attended to quickly when they came in. People using the department told us that staff were "polite" and also "helpful". People confirmed that staff explained to them what was going to happen next with treatment and procedures and about future appointments at outpatients clinics.

One person told us, " I have seen the doctor and he has told me what the plan is and that I need to stay overnight". They were satisfied with how they had been treated and supported by doctors and nursing staff. Although they and other patients commented that the department was "way too small" and also that "the nurses never stop". Another patient waiting for a bed told us they had no complaints about their care in the department and felt that staff "do a good job".

We talked with people who were waiting to be seen using the triage system and people confirmed that they were given target times by which they could expect to be seen. A triage system is a process for sorting injured people into groups based on their need for or likely benefit from immediate medical treatment. Triage is used in hospital emergency departments when limited medical resources must be allocated.

We focused during our visits upon the experiences of the women using the maternity services across the Trust and on getting their opinions on the care and support they had received. We talked with mothers, their relatives, clinicians and midwifery practitioners and people expressed a range of largely positive views. Mothers we talked with confirmed that there were good levels of information provision across all three maternity units with mothers being given choice about the kind of care available to them.

The mothers we talked to told us that they understood their care and treatment and told us they were kept up to date about what was happening and given explanations about what was happening during their pregnancies and also during labour so they could make informed decisions. All the mothers we talked with expressed satisfaction with the care and support they had received from the midwives during their stay on the maternity units. All those mothers we talked to on the post natal wards told us the midwives had 'always' asked them what they wanted during their labour and given them explanations. All those we talked to confirmed that once in established labour they had not been left on their own by midwives. We were also told that doctors and consultants spent time with them and explained why changes to their plan were needed.

One mother told us staff had been 'brilliant' and had 'acted quickly when things changed' and that 'all the options were discussed with us'. Another commented on the fact that they had felt able to ask their consultant questions 'all the way through being pregnant'.

Another mum who had been transferred between units told us 'It was a very quick response, and they (staff) explained as much as they could'.

Mothers also commented that they could see staff were busy at times during their stays and one in Furness General Hospital told us 'They were very busy when I came in, despite that they were always there for me'.

We visited three wards on the day of our visit, Ward 23, which is the stroke unit, and orthopaedic wards 35 and 36. We focused in particular aspects of people's experience of discharge planning. We talked with patients, their relatives and staff and people expressed a range of views indicating that experiences were not consistent across the three wards.

Patients on all three wards did make positive comments about the care and support they received but especially on the stroke unit where one person told us that the best thing was 'the support I have been given, the back up has been marvellous'.

A patient on ward 35 told us they were 'not very happy with accident and emergency' but said the doctors and nurses were "brilliant in here".

The majority of people we talked to understood, their care and treatment although sometimes they were not kept up to date about what was happening. One patient told us despite having been assessed by a doctor no one had really told them what they could or could not do after the hip operation. But they and their relative both told us that when it got to the 'rehab assessment stage then we had good explanations from nurses, the physiotherapists and occupational therapists. Need to close the quotes

Overall people were positive about their care and general experience whilst patients in the hospital and this was evident comments made during our conversations with them, including

'I am very satisfied with my care, I have no complaints and the back up has been marvellous'.

'I have been very impressed with the nurses and their tolerance and patience with people with dementia or other behavioural problems, it was very good.'

'Physiotherapy is good and they come every day'.

Less positively a smaller number of people had negative experiences, telling us, 'Some nurses are rather flippant'.

We did find that patients on the orthopaedic wards commented on how busy the staff were and how this had affected them.

'The nurses are very good but sometimes you have to wait for attention because they are so busy'.

'I was taken to the toilet but was often left for long periods of time because staff are too busy to take me off again'

Some people had negative things to say and this was noticeable particularly about food across all the wards we visited.

One told us, 'the food is not very good and I'm not eating so well but of course that might be because of what I've gone through'.

Another said 'The soup is very good but the rest of the food is atrocious'.

Another said 'I did not like anything that was on the menu and nothing else was offered '

'Food not as good as it should be'.

All Inspections

Ann Ford

Deputy Chief Inspector of Hospitals (North)

Importantly, the trust must:

Professor Sir Mike Richards

Professor Sir Mike Richards

Context

Overall inspection findings at Lancaster Royal Infirmary (RLI)