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Royal Lancaster Infirmary

Overall: Requires improvement read more about inspection ratings

Ashton Road, Lancaster, Lancashire, LA1 5AZ (01539) 716689

Provided and run by:
University Hospitals of Morecambe Bay NHS Foundation Trust

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Overall inspection

Requires improvement

Updated 22 July 2022

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.

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.

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