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Inspection Summary


Overall summary & rating

Good

Updated 9 February 2017

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 previous 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 overall 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 the 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 Furness General Hospital as 'good' overall, with caring 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 medical 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 trust's reporting system. They received feedback from reported incidents and felt supported by managers when considering lessons learned.
  • The hospital had in place infection prevention and control policies 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 of nursing and medical staffing vacancies throughout the hospital, especially in medical care services and the emergency department. 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's 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 trust breached the standard between October 2015 and September 2016. 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.
  • There were many examples of public engagement in the development and delivery of maternity services, such as co-designing the new maternity unit, interviews for recruitment of new staff, including midwives and matrons, and the development of guidelines and strategies.
  • The service was one of three trusts which were successful in securing funding to pilot a maternity experience communication-improvement project. This was a patient-based 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 thosecollecting 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. This was a service provided by an external organisation with funding 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 oneand support was offered at this time.
  • The trust had direct access to electronic information held by community services, including GPs. This meant that hospital staff could access up-to-date information about patients, for example, details of their current medicine.

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.

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 the trust policy;
  • Continue to ensure that staff complete mandatory training in accordance with trust policy;
  • Continue to ensure equipment checks are completed consistently in accordance with trust policy;
  • Ensure the regular update of patient group directions in accordance with trust policy.

In medical care:

  • Ensure all nursing and medical clinical documentation is completed legibly, in full and in accordance with recognised professional standards;
  • Ensure multi-factorial falls risk assessments are completed in all cases where risk is indicated and that this is evidenced in the electronic patient record or in the medical notes;
  • Ensure robust divisional oversight of the respiratory unit at Furness General Hospital (FGH) due to shortfalls in substantive senior medical presence onsite, vulnerability of senior medical staffing and reliance upon senior locum contracts;
  • Ensure that, where medicines are stored in fridges, temperature ranges are recorded in accordance with policy to ensure that 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 that appraisals are completed on an annual basis in accordance with local policy;
  • Ensure action plans put in place to address shortfalls in local and national patient outcome audits findings are monitored and reviewed in a reasonable time-frame 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 the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) is underpinned by consideration of procedural competence in making such application, to avoid potential legislative breaches;
  • Ensure all patients are aware of alternative treatment options (including risks and benefits) in addition to recommended treatment options;
  • Ensure the number of patient bed moves after 10pm is kept to a minimum to avoid patient and family anxiety and distress;
  • Ensure the remit of the nurse-led ambulatory care unit is fully understood by all key personnel to ensure its safety and efficiency in delivering patient care;
  • Ensure the effectiveness of the new governance framework is measured and adaptationsare made accordingly;
  • Ensure the effectiveness of current staff engagement themes and consider other formats which may support divisional strategy and staff harmony;
  • Ensure reasonable measures are put in place to support staff wellbeing and ensure all staff know what support is available to them.

In surgery:

  • Continue to improve Referral to Treatment Times (RTT) for patients and continue to implement trustwide initiatives to improve response;
  • Prioritise hip fractures (within 48 hours);
  • 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;
  • Improve the completion of NEWS;
  • Improve environmental cleanliness;
  • Improve the monitoring of fridge temperature and take action if temperatures exceed the expected range;

In critical care:

  • There was no provision for dedicated critical care pharmacy cover at the FGH site, despite recommendation of such by GPICS (2015). The critical care unit should take action to create plans that adhere to this guidance;
  • The unit should take action to improve physiotherapy staffing and be clear about how it supports rehabilitation for patients in line with GPICS (2015);
  • Patients discharged from critical care should receive a ward follow up visit by critical care nurses within 36 hours of discharge, planned as part of the appointment of a supernumerary coordinator and in accordance with the GPICS (2015) standard;

  • The unit should continue to monitor discharges out of hours, and develop actions to improve (reduce) the number of FGH critical care discharges out of hours.

In maternity and gynaecology:

  • Ensure that outcome measures are developed to monitor the effectiveness of the strategic partnership with Central Manchester and Lancashire NHS Trusts;

  • Ensure that care records (including cardiotocograph (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:

  • The hospital should ensure there is a review of all children and young people’s mortality and morbidity;
  • The hospital should ensure that documentation refers to Gillick competency and that staff are properly trained and confident to assess Gillick competency;
  • The hospital should continue to ensure that communication takes place with partner agencies about the placement of CAMHS patients.

In outpatients and diagnostic imaging:

  • The trust should 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;
  • The trust should 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;
  • The trust should continue work to ensure that all premises used are suitable for the purpose for which they are being used, are properly used, are properly maintained and are appropriately located for the purpose for which they are being used. This is particularly in relation to services provided from medical unit one;
  • The trust should ensure that it meets referral to treatment targets in outpatient clinics and that it addresses backlogs in follow up appointment waiting times.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 9 February 2017

Effective

Good

Updated 9 February 2017

Caring

Outstanding

Updated 9 February 2017

Responsive

Good

Updated 9 February 2017

Well-led

Good

Updated 9 February 2017

Checks on specific services

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 respect ofchecking of equipment, medicine management, assessing and responding to risk, embedding governance and risk processes, and joint working and culture. During this inspection we found good progress had been made in these areas and we rated Furness General Hospital 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, and the infant abduction policy had been tested.
  • There were processes in place for checking equipment and arrangements for managing medicines.

  • Medical, nursing and midwifery staffing levels were similar to 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 coordinated to take account of women with complex needs, and 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 were used and acted upon to develop and deliver 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 and Lancashire NHS Trusts, further work was required to effectively capture and monitor outcomes.

Medical care (including older people’s care)

Good

Updated 9 February 2017

The service had been inspected as part of our comprehensive visit in July 2015. Overall, medical care at FGH was then rated as 'requires improvement'. During this inspection we found the service had made significant improvements.

  • There had been a reduction in patient harm related incidents, particularly pressure ulcers and falls.

  • Although there were still several nursing and medical staffing vacancies, the trust had robust systems in place to manage staffing shortfall and had extended its recruitment reach with the appointment of a number of international nurses.

  • The service had improved compliance against mandatory training and appraisal targets. Local support and supervision of junior staff had improved and many areas had developed their own unit specific competencies for training and development purposes.

  • Overall, medicines management and medicines record keeping was good, however, we identified that reconciliation was not always completed in a timely manner.

  • There had been a marked improvement in record keeping standards, however, we identified some ongoing areas for improvement around legibility and trigger levels for early warning of deterioration.

  • The service had developed an action plan to address and progress areas for improvement that had been highlighted in the 2015 inspection.

During this inspection we rated medical care services as 'good' overall, with caring rated as 'outstanding' and safe rated as 'requires improvement' because:

  • Staff understood their responsibilities to raise concerns and report incidents. The division had reported a reduction in patient harm related incidents. Senior staff managed nurse staffing shortfalls proactively and there were robust escalation processes in place to deal with nurse staffing concerns.
  • Staff delivered evidence-based care and the division was actively involved in local and national audits. There were some positive patient outcomes recorded in heart failure, diabetes and myocardial infarction audits and there was good evidence of collaborative and effective multi-disciplinary team working.
  • The division was passionate about delivering quality, compassionate patient care, and this passion permeated throughout all staff groups and at all levels. Staff cared for their patients' holistic needs and had no hesitation in 'going the extra mile' to make a difference for the benefit of patients and their families. Patients had individual care plans and felt safe. Patients were positive about the care received and would recommend the service as a place to receive care.
  • The division reported excellent referral to treatment time figures across all specialisms. The division was responding to the internal and external demands placed upon it by developing a number of services and care pathways to reduce unnecessary hospital admissions. There was a positive drive to engage with partner organisations to both maintain and further services for the benefit of the population in the short, medium and long term. Staff made reasonable adjustments in response to individual patient needs and to accommodate vulnerable patient groups.
  • Managers led the service well. The divisional strategy reinforced the trust vision and aligned with ongoing work with partner organisations. Staff felt a real and palpable shift in divisional culture referring to a ‘team’ approach and an openness, which they described as putting them all “on the same page”. New organisational governance structures had been set up within the division and there was evidence to show how these supported divisional governance processes. There were many very good examples of improvement projects and innovative strategies which brought about changes in clinical practice and work efficiencies, improved patient care and delivered organisational benefits.

However:

  • Some medicines and record-keeping documentation standards required improvement, in particular, around legibility of written entries, adherence to best practice standards and a consistency in completing records, charts and other documents in full.
  • There was vulnerability in registered nurse staffing and a disproportionate reliance on locum senior medical staff to cover the respiratory unit at FGH. Nonetheless, the division actively recruited to vacant posts and was keen to convert locum positions into substantive appointments.
  • The division had some static patient outcome measures in stroke and respiratory services at FGH. These findings were across a number of domains and were below national average benchmarks. The division had action plans in place to address areas for improvement.
  • Seven day services were not fully embedded and the division fell below national averages on a number of key metrics in the NHS Services, Seven Days a Week Four Priority Clinical Standards. The division was involved with the trust task group which was looking at seven day working across the organisation.
  • A combination of factors, including extended length of stay, increasing bed occupancy levels and delays in obtaining suitable community care placements, was causing access and flow difficulties at FGH. This had led to significant numbers of patient moves after 10pm and a number of medical outliers encroaching into other services. Divisional managers were working with partners, looking at all variables affecting patient flow.
  • To achieve the divisional strategic objectives the service identified staff engagement as one of its key priorities. Clinical leaders recognised that there was a risk of staff becoming fatigued and less resilient to the pressures of working demands in the current climate. Staff considered the division managers could do more in terms of recognition and support for their wellbeing.

Urgent and emergency services (A&E)

Requires improvement

Updated 9 February 2017

We rated the emergency department as 'requires improvement' because:

  • The emergency department's performance had been deteriorating over the last 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 trust breached the standard between October 2015 and September 2016. Lack of beds in the hospital resulted in patients waiting longer in the emergency department. Bed occupancy levels were 115 -130% across the trust.
  • Guidance issued by the Royal College of Emergency Medicine (RCEM) states that a face-to-face assessment should be carried out by a clinician within 15 minutes of arrival or registration. The median time from arrival to initial assessment was worse than the England median in all months over the 12 month period.
  • Between June 2015 and May 2016, the trust’s unplanned re-attendance rate to the emergency department within seven days was generally worse than the national standard of 5% and generally better than the England average.
  • Between September 2015 and August 2016 there was an upward trend in the monthly percentage of ambulance journeys with handover times of over 30 minutes. The department was continuing to fail to meet the standard. A ‘black breach’ occurs when a patient waits over an hour from ambulance arrival at the emergency department to being handed over to the emergency department staff. Between the end of September 2015 and the end of September 2016 the Furness General Hospital had 444 black breaches.
  • Between August 2015 and September 2016 the trust’s monthly percentage of patients waiting between four and 12 hours from the decision to admit until being admitted was worse than the England average.
  • Between August 2015 and July 2016, the trust’s monthly median total time in A&E for admitted patients was consistently similar to the England average. Performance against this metric showed a trend of decline.
  • The department was not meeting the trust’s target for staff completing mandatory training. Following our previous CQC inspection, in July 2015, an 'action the hospital must take to improve' was to ensure that staff received appropriate support, training, supervision and appraisal. Although support and appraisal rates had improved, mandatory training remained below the trust target for completion.
  • The outcomes of care were not always monitored regularly or robustly, using the National Early Warning Score (NEWS) system. Failue to do this might prevent early recognition of a deteriorating patient.

  • Nursing assessments and care pathways were not always completed or regularly reviewed.

Surgery

Good

Updated 9 February 2017

The overall surgery rating from our 2015 inspection was 'requires improvement'. During the 2016 inspection we found that the actions identified during that earlier inspection had been completed. There were systems in place to identify themes from incidents and near miss events. We saw improved audits for '5 steps to safer surgery' and had discussions with staff about the process and procedure for raising safeguarding referrals. There were risk assessments and escalations plans in place for situations where practice deviated from guidance.

We rated surgical services as good at this inspection because:

  • Staff knew the process for reporting and investigating incidents using the trust’s reporting system. They received feedback from reported incidents and felt supported by managers when considering lessons learned. All wards used an early warning scoring system and risk assessments for the management of deteriorating patients. Infection prevention and control was managed effectively on most wards. We saw staff treating patients with compassion, dignity, and respect throughout our inspection.
  • Staff received Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) training as part of their induction. All the staff we spoke with had received training and knew about safeguarding policies and procedures. The division had a dementia champion and could access an independent mental capacity advocate (IMCA) when best interest decision meetings were required.
  • Wards and theatre skill mix was variable during shifts, but measures were in place to ensure the safety of patients until staffing numbers could be improved. The ratio of qualified nursing staff to patients was one to eight. We reviewed the nurse staffing levels on all wards and theatres, and found that levels of skill mix were appropriate at the time of inspection.
  • The hospital had an escalation policy and procedure to deal with busy times, and senior staff attended bed meetings to monitor bed availability on a daily basis. Staff treated patients in line with national guidance and used enhanced recovery (fast track) pathways.
  • Local policies were written in line with national guidelines. Staff told us appraisals were undertaken annually and records for Furness General Hospital showed that 82% of staff across surgical wards and theatres had received an appraisal.
  • Allied Health Professionals worked closely with ward staff to ensure a multi-disciplinary team approach to patient care and rehabilitation. We saw that orthogeriatricians had input into the care pathway of elderly patients.
  • Evidence-based care and treatment national audits identified mixed outcomes for all audits. The National Bowel Cancer Audit Report (2015) showed better than the England average for four measures. The National Oesophago-Gastric Cancer Audit (2015) showed patients diagnosed after an emergency admission was 0%, placing the trust within the lowest 25% of all trusts for this measure.The Patient Reported Outcomes Measures (PROMS) for groin hernia metrics and knee replacement metrics were about the same as the England average whilst hip replacement metrics had mixed performance. Ward managers and matrons were visible and available on the wards so that relatives and patients could speak with them.
  • The trust’s referral to treatment time (RTT) for admitted pathways for Surgery had been worse than the England average performance between October 2015 and August 2016. However, the latest figures, 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%.

  • Complaints were dealt with informally at ward level and escalated as necessary to ward managers and matrons in line with trust policy. Complaints were discussed at monthly staff meetings where training needs and learning was identified.
  • There had been concerns about bullying in theatres in 2015. These concerns had been investigated and actions implemented to prevent bullying and harassment in the workplace. Investigations we saw were timely, detailed, and appropriate. Staff told us there was now a higher morale and a better working environment, following resolution of individual behaviours and a change of staffing.
  • Staff said that speciality managers were available, visible, and approachable, leadership of the service was good, staff morale had improved a great deal and they felt supported at ward level. Staff spoke positively about the service they provided for patients and emphasised quality and patient experience.

Intensive/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 Furness General Hospital required improvement.

During this inspection we rated this service as good overall, with good ratings in safe, effective, caring, responsive and well-led because:

  • During our inspection we found that nurse staffing levels were 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 upon findings in 2015 when we found that, although nurse staffing levels had improved from the 2014 inspection findings, there were no supernumerary coordinator or funded practice educators in post.
  • Medical staff we spoke with discussed the historic shortfalls in anaesthetic staffing levels for out of hours cover. We had noted in 2015 that 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 ha been funded to ensure safe staffing levels and mitigate risks. A recruitment strategy was in place.
  • We observed good medical handover and staff we spoke with told us that the system in place for responding to acutely unwell patients outside of ITU was good.
  • We had reported in 2015 that medicines were not stored securely in the unit, however, this had improved at the 2016 inspection and we did not observe any breaches in pharmacy storage standards or any poor compliance with regular safe storage of medicines audits. Similarly, improvement in general storage in the unit was observed with well-organised, locked access, storage rooms available on the entrance corridor to the secure main unit. The main unit was tidy and stores were well organised.
  • 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 with loss of service, should equipment be broken and require replacement, were on the risk register.
  • The unit was visibly clean and appeared light and spacious for the four patients in the main bay. Sstaff we spoke with told us that there had been capacity to flexibly increase to five bed spaces in the main area, but recently agreement had been made to close that area to create more floor space. The strategy included future planning for a larger combined critical care unit.

  • 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 the assurance that patients with infections received best practice care and, should patients need specialist ventilated isolation facilities they would be transferred. This would apply to only a small proportion of patients. Patients with infections were isolated as per the trust's policy, however, the two isolation rooms were not designed in line with Health Building Note (HBN 04-02) and did not have en suite shower rooms or ventilated lobby areas.

  • There was ongoing 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. There was further work ongoing to identify specific admission wards at FGH, in line with work at the RLI site.
  • In 2015 we reported that there was no Critical Care Outreach Team (CCOR) across either critical care unit at UHMB. The trust did not have a dedicated CCOR team and this continued to be noted on the risk register. However during our 2016 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 one occasion of a rapid response to an acute emergency by the team during the inspection.

  • 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 dignity, and focused on the individual needs of people.
  • The team in critical care services was well-led. A genuine culture of listening, learning and improvement was evident amongst all staff we spoke with. Staff across the team were passionate about their roles and proud of the trust. The investment in leadership programme was good and it was clear that learning from it was shared, staff had a shared purpose and they made an impact in practice. Governance arrangements were embedded in the directorate.
  • We found that ICNARC data showed that patient outcomes were comparable to or better than expected when compared with other units nationally; this included unit mortality.
  • In line with recommendations by NICE CG83 and GPICS (2015), follow-up clinics were in place H for critical care patients who had experienced a stay in critical care of longer than four days. Emotional support was given as part of the follow-up appointment, and post critical care admission and additional psychological support were 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 avoid discharging patients to wards during the night, and there was a low number of out of hours discharges, comparable with other similar units.
  • Less than half of all discharges to ward areas were delayed beyond four hours due to pressures on hospital beds, with 25% - 40% reported in ICNARC in 2015/16. This did not prevent patients from receiving the care and treatment they needed, and staff paid attention to patient dignity when Department of Health (DoH) single sex accommodation breaches occurred. ICNARC data did indicate that the unit position was comparable nationally with other units against the eight hour reported target in the CMP.
  • Staff we spoke with in critical care and theatres did not express concern about the patients when ‘outlier’ admissions took place and staff had not reported any incidents of harm as a consequence. The FGH unit had reported an increase in annual admissions of around 40 in 2015/16. Staff we spoke with attributed the outliers to bed pressures across the trust. Critical care training had been increased for staff in theatres as part of an LiA project. Nurse skill mix in the critical care unit was not compromised to cover the theatre recovery activity, as had been previously reported, and all admissions were short stay and rarely level 3.

However:

  • There was no provision for dedicated critical care pharmacy cover at the FGH site, despite recommendation of such by GPICS (2015).
  • 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, nor did it deliver care that was in line with GPICS (2015) in the cases of six patients, and there was reduced opportunity to develop standards of patient rehabilitation in critical care.

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 found in respect of the reviewing of incidents, high numbers of paediatric consultant vacancies, and lack of job plans. Consultant paediatricians had also raised concerns about bullying and those concerns not been acted on by senior leaders.

At this inspection we found that these issues had been resolved.

We rated the children and young people’s services as 'good' because:

  • 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.
  • Consultant paediatricians were on site 24 hours a day, seven days a week.
  • 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 that information could be cascaded between senior management and clinical staff.

End of life care

Outstanding

Updated 9 February 2017

In the last inspection of Furness General Hospital, 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 being 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, underpinned by staff, that patients would be cared for in a dignified, timely and appropriate manner.
  • There were examples of innovation across the service. During 'dying matters week' the trust had introduced death cafés, aiming to raise the profile end of life care. This also 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 ensuring that 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 and clear reporting procedures were in place.

  • The bereavement 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, in cases in which 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, and 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 was learning from incidents in order to drive improvements.
  • Mandatory training was in place and attendance at this by the specialist palliative care nurses exceeded the trust target.
  • The care of the dying patient (CDP) document was in use throughout the trust.
  • The trust had introduced EPaCCS (electronic palliative care co-ordination system). This enabled recording and sharing of patients' care preferences and details about their care at the end of life

Outpatients

Good

Updated 9 February 2017

We rated outpatients and diagnostic imaging services as 'good' because:

  • During our previous inspection we had identified concerns about 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 that there had been significant improvements in the availability of case notes. Staff were positive about the improvements in efficiency and effectiveness for outpatient services, such as the availability of test results and timely access to information.
  • We found that, since the 2015 inspection, there had been some improvements in diagnostic imaging staffing numbers. 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 had noted that there was no information available in the departments for patients who had a learning disability, nor any 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.
  • 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.
  • Staff were competent and supported to provide a good quality service to patients. Competency assessments were in place for staff working in the radiology department along with preceptorship for all new staff to the department.
  • We found that access to new appointments throughout the departments had improved.
  • Overall, staff felt engaged with the trust and felt that there had been some improvements in service delivery since our last inspection. There were systems to report and manage risks. Staff were encouraged to participate in changes within the department, and there was departmental monitoring at management and board level in relation to patient safety. The service held monthly core clinical governance and assurance meetings with standard agenda items such as incident reporting, complaints, training, and lessons learned.

However:

  • There remained a shortage of some staff groups including occupational therapists, radiographers, and radiologists. Some staff raised concerns about the sustainability of the team under prolonged staffing pressures.
  • Some referral to treatment targets were missed, and follow-up appointments continued to suffer backlogs and delays.