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Royal Lancaster Infirmary Requires improvement

We are carrying out a review of quality at Royal Lancaster Infirmary. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 16 May 2019

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.
Inspection areas

Safe

Requires improvement

Updated 16 May 2019

Effective

Good

Updated 16 May 2019

Caring

Good

Updated 16 May 2019

Responsive

Requires improvement

Updated 16 May 2019

Well-led

Good

Updated 16 May 2019

Checks on specific services

Medical care (including older people’s care)

Good

Updated 16 May 2019

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

  • There were good mechanisms in place to report, feedback and learn from incidents and staff were aware of the importance of doing so;
  • Infection control measures were effective. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection;
  • Patient records were of a good standard, up to date, legible and accessible;
  • The service managed flow through the hospital well. There were no extra capacity beds open at the time of our inspection and measures were in place to facilitate the timely discharge of patients to their homes;
  • The service participated in local and national audit. Where results were below the national average or expected standard, action plans were in place to address this;
  • Staff demonstrated good knowledge and understanding of their responsibilities under the Mental Capacity Act 2005. Supporting documentation was of a good quality and well completed.
  • Patients were cared for with compassion. Feedback from patients confirmed that staff treated them well and with kindness. We saw that patients’ dignity and privacy was maintained.
  • The service was responsive to individual patients’ needs. Learning disability and mental health nurses worked on wards to provide bespoke care and wider ad-hoc learning opportunities for other ward staff. People with a learning disability or dementia had their preferences recorded and respected, and their carers could visit them whenever they chose. Carers were actively encouraged to be involved during the patient’s hospital stay.
  • The care group leadership team had good oversight and knowledge of their strengths and weaknesses and leaders at ward level were visible and approachable. Managers had the right skills and abilities to run their service.
  • Care group provision of IT and other equipment was good, and staff told us they had the right tools to do their jobs.
  • Staff morale was high. They supported each other well and we saw examples of good teamwork. We saw staff from different professions working well together and staff told us they were proud of their work.

However:

  • Despite the trust’s ongoing work to improve its staffing position there were still areas where there were not the right numbers of staff with the right mix of skills to provide the right care;
  • Medicines were not always safely stored, and we found some that were out of date;
  • The physical environment meant that stroke patients were not all housed in the same building and there was potential for delays in transfer;
  • The trust was not meeting its targets for mandatory training, safeguarding training and appraisals;
  • The effectiveness of the care group governance system was questionable, and leaders were concerned that the flow of information ‘from ward to board’ was not working.

Services for children & young people

Good

Updated 9 February 2017

Following our previous inspection in 2015, children and young people’s services were rated as 'requires improvement'. Issues were identified with the reviewing of incidents, medical staffing levels, the design and layout of the neonatal unit, insufficient resuscitation trolleys on the children’s unit and the abduction policy had not been tested.

At this inspection we found that the majority of these issues had been resolved with the exception of the design and layout of the neonatal unit. Incidents were reviewed appropriately, medical staffing levels had improved, although we found that not every child was seen within 14 hours of admission, there were sufficient resuscitation trolleys and the abduction policy had been tested.

Overall, we rated the services for children and young people at RLI as 'good'. Effective, caring, responsive and wellled were rated as 'good'. We rated safe as 'requires improvement'.

  • Staff were aware of their responsibility to report incidents and appropriate systems were in place. Staff received feedback about incidents and learning was shared.
  • Staff were clear about their responsibilities if there were concerns about a child’s safety. Safeguarding procedures were understood and followed. Staff had completed the appropriate level of training in safeguarding and received safeguarding supervision.
  • A paediatric early warning system was used for early detection of any deterioration in a child’s condition and appropriate transfer arrangements were in place for those children requiring more specialised care.
  • Staff had access to evidence based policies which were compliant with national guidance.
  • There was a programme in place for local and national audit.
  • Feedback from children, young people and their parents was positive.
  • Services were planned to meet people’s needs. Facilities were provided for parents.
  • There were governance systems in place to ensure that quality, performance and risks were managed and information could be cascaded between senior management and clinical staff.

However:

  • Not all children were seen within 14 hours of admission in line with Royal College of Paediatric and Child Health (RCPCH) standards.
  • Staffing was not always compliant with British Association of Perinatal Medicine (BAPM) and Royal College of Nursing (RCN) guidance.
  • The layout of the children’s unit meant that staff could be isolated when working in the assessment unit.
  • The Neo Natal Unit (NNU) had insufficient space and there was not always a member of staff present in the special care room.

Critical care

Good

Updated 9 February 2017

Following our last inspection in July 2015, we found that overall the critical care service provided at the Royal Lancaster Infirmary required improvement.

During this inspection we rated this service as 'good' overall, with 'good' ratings in safe, effective, responsive and well-led, and a rating of 'outstanding' for caring because:

  • Patients were at the centre of decisions about care and treatment. The weight of positive comments gave evidence of a caring and compassionate team. Staff were positive and motivated and without exception delivered care that was kind and promoted peoples dignity, and focused on the individual needs of people.
  • During our inspection we found that nurse staffing was good with sufficient staffing levels for provision of critical care. Recruitment was underway to provide a supernumerary coordinator and practice educator in line with Guidelines for the Provision of Intensive Care Services (GPICS) (2015). Supernumerary induction for new nursing staff was good with an organised approach to nurse appraisal and nursing achievement of competence in critical care skills. This was an improvement to findings in 2015 where we found that although nurse staffing levels had improved from the 2014 inspection findings, there was no supernumerary coordinator or funded practice educators in post.
  • Medical staff we spoke with discussed the historical shortfalls in anaesthetic staffing levels for out of hours cover. We had noted in 2015 that the intensive care services, obstetrics, anaesthetics and emergency surgical services across the trust did not have enough anaesthetic staff to meet the required national recommendations and standards. However, this was well understood by the executive team and clinical staff. An additional five consultants at RLI and three consultants at FGH have been funded to ensure safe staffing levels and mitigate risks. A recruitment strategy was in place.
  • Pharmacy cover was good at RLI and met the standards outlined in GPICS (2015) with a critical care pharmacist and senior technician support. We had reported in 2015 that medicines were not stored securely in the unit; however this had improved with provision of new storage cabinets and performance of a regular safe storage of medicines audit.
  • The emergency resuscitation equipment and patient transfer bags were checked daily with a good system in place as per trust policy. There was good provision of equipment in critical care with robust systems for medical device training. The risks associated to loss of service if equipment was broken and needed replacement were on the risk register.
  • The unit was visibly clean; standards of infection prevention and control were in line with trust policy. Staff we spoke with told us that isolation of patients was risk assessed and documented. Liaison with the infection control team supported assurance that patients with infections received best practice and the small proportion of patients that may need specialist ventilated isolation facilities would be transferred if required. Patients with infections were isolated as per policy, however the two isolation rooms were not designed in line with Health Building Note (HBN 04-02) and did not have ensuite shower rooms or ventilated lobby areas.
  • There was on-going progress towards a harm free culture. Incident reporting was good with low incidence of harm and infection. There was a proactive approach to the assessment and management of patient-centred risks and staff took responsibility for driving improvement to reduce risk of patient harm or acute deterioration. The programme for care of patients with tracheostomy across wards was comprehensive.
  • In 2015 we reported there was no Critical Care Outreach Team across both units at UHMB. The trust did not have a dedicated CCOR team and this continued to be on the risk register, however during our inspection we noted good provision of principles in line with GPICS (2015), NICE CG50 and against the seven core elements of Comprehensive Critical Care Outreach,(C3O 2011). Staff we spoke with told us that there was an ‘educational model’ of outreach embedded across the trust. We observed three occasions of a rapid response to acute emergencies by the team.
  • The team in critical care services were well-led. A genuine culture of listening, learning and improvement was evident amongst all staff we spoke with. Staff we spoke with across the team were passionate about their roles and proud of the trust. The investment in leadership programmes was good and it was clear the learning was shared, staff had a shared purpose and made an impact in practice. Governance arrangements were embedded in the directorate.
  • We found that ICNARC data showed that patient outcomes were comparable or better than expected when compared with other units nationally, this included unit mortality.
  • Follow up clinics were in place at the RLI for critical care patients, as recommended by NICE CG83 and GPICS (2015), who had experienced a stay in critical care of longer than 4 days. Emotional support was given as part of the follow up appointment, post critical care admission and additional psychological support was assessed on an individual basis. The use of patient diaries had been embedded in practice since our last inspection.
  • Patients received timely access to critical care treatment and consultant led care was delivered 24/7. A low number of critical care elective admissions were cancelled and there was a low number of readmissions to the unit. Patients were not transferred out of the unit for non-clinical reasons. Staff worked hard to not discharge patients to wards during the night with low number of out of hours discharges, comparable with other similar units.
  • Over half of all discharges to ward areas were delayed beyond 4 hours due to the pressures on hospital beds, however this did not prevent the patient from receiving the care and treatment they needed and staff paid attention to patient dignity when single sex accommodation breaches occurred. ICNARC data did indicate that the unit position was comparable nationally with other units against the 8 hour reported target in the CMP.
  • Staff we spoke with in critical care and theatres did not express concern about risk to patients when ‘outlier’ admissions took place and staff had not reported any incidents of harm as a consequence. This was an improved arrangement since our last inspection, with a 50% reduction in annual admissions, (from 46 to 24). Critical care training had been increased for staff in theatres. Nurse skill mix in the critical care unit was not compromised to cover the theatre recovery activity, as had been previously reported.

However:

  • In 2015 we reported that the unit had limited space and during this inspection we noted again that the unit would not meet current national standards for new buildings and environment. There was an estates strategy which outlined the plans for unit upgrade and expansion. Issues around estates and environment were on the directorate risk register and had been identified as a ‘not met’ against National D16 commissioning service specifications for critical care services, during an assessment by the LSCCCN.
  • We observed good compliance with hand hygiene by all nursing staff, with regular 100% audit results of compliance. However there was poor access to sinks in the unit, which did not comply with health building note HBN 00-09, (infection control in the built environment; hand hygiene facilities, clinical wash-hand basin provision).
  • Patients discharged from critical care should receive a ward follow up visit by critical care nurses within 36 hours of discharge, it was reported that this could not be provided consistently by staff in the unit and was affected by activity and staffing resources. Staff we spoke with were planning improvement as part of the appointment of a supernumerary coordinator.
  • We observed that physiotherapy cover in the unit did not provide enough opportunity to be involved in unit activity, deliver care to eight patients that was in line with GPICS (2015) and reduced opportunity to develop standards of patient rehabilitation in critical care.

End of life care

Outstanding

Updated 9 February 2017

In the last inspection of Royal Lancaster Infirmary, in July 2015, we rated end of life care services as 'good'. During this inspection we rated the end of life care service as 'outstanding' because:

  • The trust had clear leadership for end of life care services that was supported at a senior level within the organisation. There was active involvement strategically from the deputy chief nurse and executive leadership at board level.
  • End of life care services were very well led. There was a clear vision and strategy that focused on all people are treated with dignity, respect and compassion at the end of their lives.
  • We saw evidence of proactive executive involvement in terms of the development of the end of life care strategy.
  • There was very good public and staff engagement
  • There was a commitment by the trust and this was underpinned by staff that patients were cared for in a dignified, timely and appropriate manner
  • There were examples of innovation across the service. Leading Dying Matters week, the trust had introduced death cafés with an aim to raise the profile end of life care. This included the development of the bereavement service.
  • Patients were cared for holistically and there was strong evidence of spiritual and emotional support being recognised for its importance within the trust. This was apparent through the development of ‘death cafés’ where issues relating to death and dying were talked about openly.
  • The staff throughout the hospital knew how to make referrals and people were appropriately referred to and assessed by the specialist palliative care team in a timely manner, therefore individual needs were met.
  • Staff had access to specialist advice and support 24 hours a day from a consultant on-call team for end of life care.
  • The chaplaincy and bereavement service supported families’ emotional needs when people were at the end of life, and continued to provide support afterwards.
  • The mortuary was clean and well maintained, infection control risks were managed with clear reporting procedures in place.
  • The bereavement palliative care service had been nominated for a compassionate care award in 2015.
  • The survey of bereaved relatives results were positive in relation to dignity and respect afforded to patients.
  • The trust had recently introduced a Hospital Home Care Team service, where patients could be transferred to their own homes and supported by trust staff where care packages were difficult to access in the community.

  • An ‘ease of access to hospital’ group had been developed by the trust which included representation from the bereavement and chaplaincy service where initiatives were in place to improve access to the mortuary.
  • DNACPR (do not attempt cardio-pulmonary resuscitation) records were generally completed well and the trust was making use of audits and learning from incidents to drive improvements.
  • Mandatory training was in place and attendance by the specialist palliative care nurses exceeded the trust target.
  • The care of the dying patient (CDP) document in use throughout the trust.
  • The trust had introduced EPaCCS (electronic palliative care co-ordination system). This enables recording and sharing of people’s care preferences and details about their care at the end of life.

Maternity and gynaecology

Good

Updated 9 February 2017

At the last inspection in July 2015, we rated maternity and gynaecology services as 'requiring improvement' for being safe and well-led, particularly in relation to checking of equipment, medicine management, assessing and responding to risk, embedding governance and risk processes, joint working, and culture. During this inspection, we found good progress had been made in these areas and rated maternity and gynaecology servicse at Royal Lancaster Infirmary as 'good' because:

  • Staff understood their responsibilities to raise concerns and record patient safety incidents. There were processes to ensure reviews or investigations were carried out and action taken.
  • Staff were aware of the procedures for safeguarding vulnerable adults and children, the infant abduction policy had been tested.
  • There were processes for checking equipment and arrangements for managing medicines.
  • Medical, nursing and midwifery staffing levels were similar or better than the national recommendations for the number of babies delivered on the unit each year.
  • Systems were in place for assessing and responding to risk. Staff received training that enabled them to identify and act in the instance of a critically ill woman. There was improvement in the use and completion of the surgical safety checklist compared to the last inspection.
  • Women’s care and treatment was planned and delivered in line with current evidence-based practice, which was audited to ensure consistency of care and treatment pathways.
  • Care outcomes were meeting expectations in most areas, and where improvements were required the service had identified action.
  • Women were positive about their treatment by clinical staff and the standard of care they had received. They were treated with dignity and respect.
  • Services were planned, delivered and co-ordinated to take account of women with complex needs, there was access to specialist support and expertise.
  • The leadership team understood the challenges to the service and actions needed to address these. Improvement had been made to ensure staff and teams were working together to promote a culture of learning and continuous improvement. A culture of openness was evident.
  • There were many examples of how people’s views and experience was used and acted on to develop and delivery maternity care.

However:

  • Not all care records were fully completed, dated and signed. This included inconsistent recording on cardiotocographs (CTG) which was not in line with the trust fetal monitoring policy. These areas were audited and recommendations made.

  • Although there was a plan, which set out the principles and governance arrangements for a strategic partnership with Central Manchester University Hospitals NHS Foundation Trust and Lancashire Teaching Hospitals further work was required to effectively capture

Outpatients and diagnostic imaging

Good

Updated 9 February 2017

We rated this service as 'good' because:

  • During our last inspection we noted that space was limited and working areas were cramped in breast and physiotherapy services. We noted this time that space remained limited in some areas and the service provision was physically constrained by the existing environment. The trust had made plans for structural and estate changes.

  • During our last inspection we identified concerns with the timely availability of case notes and test results in the outpatients department. At this inspection staff and managers confirmed that the trust had reduced the use of paper records and implemented an electronic records system for most outpatient areas. This was still being rolled out across all departments but we found there had been significant improvements in the availability of case notes.
  • Since the last inspection we found that there had been some improvements in staffing. CT scanning staff had previously raised concerns about shortage of staff and their access to knowledge and skills competencies. When we inspected this time the department continued to work with vacancies but a new rota system enabled the department to make improvements.
  • During our last inspection we noted that there was no information available in the departments for patients who had a learning disability or written information in formats suitable for patients who had a visual impairment. We saw this time that there was a range of information available in different formats and staff had involved the public and groups including vulnerable people in producing information for use by patients.
  • The service had previously experienced issues with effective team working and had challenges in building team resilience and communication. We found examples of strong local and senior leadership and staff from all departments commented on management improvements. Staff were proud of opportunities they had been involved in to drive forward service improvements and innovation.
  • Outpatient and diagnostic services were delivered by caring, committed and compassionate staff.
  • Patients were overwhelmingly positive about the way staff looked after them. Care was planned and delivered in a way that took account of patients’ needs and wishes. Patients attending the outpatient and diagnostic imaging departments received effective care and treatment. Care and treatment was evidence based and followed national guidance. We found that access to new appointments throughout the departments had improved.
  • The Breast Screening Service at this hospital had been the subject of an external review by an independent body.  During this inspection we observed that recommendations from the review had been implemented and maintained

Surgery

Good

Updated 16 May 2019

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

  • The service provided mandatory training in key skills to all staff and made sure everyone completed it. Services were safe because there were systems to ensure staff who were non-compliant were given opportunities to undertake mandatory training and safeguarding training.
  • The service controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection.
  • The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness.
  • The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service.
  • 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.

However:

  • The service did not follow best practice when prescribing, giving, recording and storing medicines. We found inconsistent practice across wards regarding the management of medicines.
  • Not all staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • Not all staff understood how and when to assess whether a patient had the capacity to make decisions about their care. They did not always follow trust policy and procedures when a patient could not give consent.
  • Staff training compliance failed to meet trust target for Safeguarding Adults level 2 which included Mental Capacity Act and Deprivation of Liberty Safeguards training.
  • The number of staff within surgery who had received an appraisal was below trust compliance targets.
  • All specialties were below the England average for RTT rates (percentage within 18 weeks) for admitted pathways.

Urgent and emergency services

Requires improvement

Updated 16 May 2019

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

  • We had concerns over nurse staffing levels and the oversight of patients in non-designated areas.
  • We found gaps in daily safety checks of equipment and medicines and had concerns over the security of electronic and paper records.
  • The facilities in the department for patients with a mental health problem were not suitable.
  • The departments Royal College of Emergency Medicine (RCEM) audit data showed poor performance in a number of areas and we lacked assurance that robust action plans were in place to address this.
  • The department was not meeting national performance standards and there had been a high number of black breaches.
  • We saw examples of care that did not maintain patient’s privacy and dignity. We observed when the department was busy, staff found it difficult to deliver the standard of care they would like.
  • We saw limited examples of learning from complaints and lacked assurance that the governance processes ensured effective management and oversight of all identified risks.
  • 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 the trust.