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Inspection Summary


Overall summary & rating

Good

Updated 16 May 2019

Our rating of services stayed the same. We rated them as good because:

  • Patients received care and treatment from staff who were caring, compassionate, respectful and maintained their dignity.
  • Both medical and nursing staff told us the emergency department had an open supportive culture and staff felt leaders were open, helpful and listened to their concerns.
  • When things went wrong, staff felt able to report them and discuss them and were confident they would receive the support they needed.
  • The flow of the emergency department was well managed and there were robust systems in place to monitor deteriorating patients waiting for assessment and treatment in the department.
  • There were paediatric nurses embedded in the emergency department and there were clear pathways for paediatric patients to wards and medical staff to the department.
  • Learning from complaints was embedded and there were systems in place to ensure feedback was given to staff.
  • Risks were identified on the risk register and reviewed regularly.
  • Staff were kept up to date with governance concerns via meetings and newsletters.
  • The trust had systems to identify capacity and demand issues. This was reviewed regularly, and concerns escalated and managed by the team.
  • The trust had introduced an updated version of the National Early Warning Score (NEWS2) to measure whether a patient’s condition was improving, stable or deteriorating indicating when a patient may require a higher level of care. We saw that when a patient’s score increased staff had taken the appropriate action to escalate.
  • The care group leadership team were visible and approachable, and managers had good oversight of their areas. Staff said they were well supported to do their job and felt comfortable sharing any concerns with their immediate line manager.
  • Staff told us there had been a marked improvement in the culture of the organisation and that the behavioural standards had made a positive difference.
  • Registered nurse staffing levels had improved since our last inspection and were good on the medical wards we visited. On the day of inspection, we found that actual registered nurse staffing levels met planned levels on most wards.
  • There was good multidisciplinary team working and staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • The service managed flow through the hospital well and there were no extra capacity beds open at the time of our inspection. Plans were in place to further improve flow with the reconfiguration of the acute medical unit.
  • The service took account of patients’ individual needs. Arrangements were in place to support the needs of patients living with dementia or with a learning disability.
  • 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:

  • We were not assured about the quality of care patients received because the trust had not performed well against Royal College of Emergency Medicine (RCEM) standards.
  • The department was not meeting national performance standards for patients being admitted or discharged within four hours, or moved to a ward within 12 hours of a decision to admit being made. The four-hour target performance in every month from September 2017 to August 2018 had not been met.
  • There were no rooms suitable to manage patients suffering from a deterioration in mental health within the ED. We had concerns about patients self-harming despite the department having ligature cutters for staff.
  • Patients experienced delays at handover and there had been a high number of black breaches.
  • Staff within the emergency department were not meeting mandatory training standards including safeguarding vulnerable adults and children. Additionally, staff had not undergone additional training to ensure they had the additional skills and competencies to look after children and not all staff had undergone an annual appraisal within the last 12 months.
  • There was no designated room meeting the PLAN standard to ensure patients living with a mental health condition were in a safe and suitable environment within the emergency department. The trust had no plans to create a room that met PLAN standards.
  • Patients living with a mental health condition, waiting for beds at psychiatric facilities sometimes waited significantly longer than 12 hours in the department.
  • Five specialties were below the England average for RTT rates (percentage within 18 weeks) for admitted pathways within surgery.
  • The department was failing to meet performance targets. They failed to meet the standard for inpatients waiting more than 12 hours from the decision to admit until being admitted in nine out of 12 months.
  • The department only had one resuscitation room, although there were plans to rectify this and building work had started to increase the number of resuscitation rooms at the time of our inspection.
Inspection areas

Safe

Good

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:

  • The care group leadership team were visible and approachable and managers had good oversight of their areas. Staff said they were well supported to do their job and felt comfortable sharing any concerns with their immediate line manager.
  • The trust was committed to improving services and we found a willingness from staff to implement changes which would lead to better services for patients. Training, research and innovation were promoted and valued by the service and we saw examples of service improvement at all levels.
  • Staff cared for patients with compassion and provided them with emotional support. Staff involved patients and those close to them in decisions about their care and treatment. Patients and relatives spoke very highly of medical staff and said that doctors took the time to explain things properly.
  • There was good staff engagement and managers across the trust promoted a positive culture that supported and valued staff. Staff told us there had been a marked improvement in the culture of the organisation and that the behavioural standards had made a positive difference.
  • Registered nurse staffing levels had improved since our last inspection and were good on the medical wards we visited. On the day of inspection, we found that actual registered nurse staffing levels met planned levels on most wards.
  • Staff had good knowledge and understanding of the trusts safeguarding policies and their role and responsibilities in relation to protecting patients from abuse. Staff had training on how to recognise and report abuse and knew who to contact if they needed further advice.
  • Staff kept detailed records of patients’ care and treatment and measures were in place to ensure that staff assessed and responded to patient risk.
  • Staff gave patients enough food and drink to meet their needs and improve their health. Patients told us they were happy with the food choices available and that their portion sizes were good. Special dietary needs were catered for.
  • There was good multidisciplinary team working and staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They knew how to support patients who lacked the capacity to make decisions about their care and this was well documented.
  • The service managed flow through the hospital well and there were no extra capacity beds open at the time of our inspection. Plans were in place to further improve flow with the reconfiguration of the acute medical unit.
  • The service took account of patients’ individual needs. Arrangements were in place to support the needs of patients living with dementia or with a learning disability.

However:

  • The service did not always follow best practice when prescribing, giving, recording and storing medicines. Staff did not always act when medicines fridges were out of the correct temperature range and did not always record a date opened for medicines that have a shortened expiry when they are opened or stored outside of a fridge.
  • We had concerns that there was minimal medical staffing at night and no additional support for medical staff on duty at night to keep patients safe. There was no hospital at night nursing team or critical care outreach team on this site to support the medical team.
  • Seven-day services were not fully embedded. Consultant ward rounds were generally Monday to Friday only with limited medical cover at weekends and out of hours. A shortage of therapy staff meant that they were not able to provide seven-day services.
  • While the care group risk register was up to date and included named individuals responsible for mitigation, individual wards and areas did not have oversight of their risk. When asked, ward leaders were vague and could not articulate what the risks were for their area.

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.

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.

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

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.

Outpatients and diagnostic imaging

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.

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 had systems in place to ensure compliance. The 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.
  • Nurse staffing was managed using recognised tools and professional judgment. To maintain safe staffing levels, the service monitored staffing levels and reviewed these daily using nationally recognised tools alongside clinical judgment.
  • 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 services were effective because processes were in place to ensure that guidance used by staff complied with national guidance, such as that issued by National Institute for Health and Care Excellence.
  • The service followed best practice when prescribing, giving, recording and storing medicines. Patients received the right medication at the right dose at the right time.
  • Staff identified patients at risk of nutritional and dehydration risk or requiring extra assistance at pre-assessment stage. Patients were offered support when required.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. We observed positive, kind and caring interactions on the day units and between staff and patients.
  • The care group had stable management structures in place, with clear lines of responsibility and accountability. We saw evidence of learning, continuous improvement and innovation within surgical services at the location.
  • The service had systems for reporting, monitoring and learning from incidents. Staff we spoke with knew how to report incidents, learning was disseminated to learn from incidents and prevent recurrence.
  • Patients we spoke to felt involved in their care and had been provided with information to allow them to make informed decisions.
  • 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:

  • Staff training compliance for safeguarding children and adults level 2 training and Level 3 Mental Capacity and Deprivation of Liberty Safeguards training failed to meet the trust target.
  • Nursing and medical staffing fill rates were below planned establishment.
  • The trust failed to meet four of the National Hip Fracture Database standard metrics.
  • The number of nursing and medical staff within surgery who had received an appraisal was below trust compliance targets.
  • The average length of stay for elective and non-elective patients at Furness General Hospital was higher than the England average.
  • Five specialties were below the England average for RTT rates (percentage within 18 weeks) for admitted pathways within surgery.

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:

  • The department was not meeting national performance standards for patients being admitted or discharged within four hours or moved to a ward within 12 hours of decision to admit being made.
  • There were no rooms suitable to manage patients suffering from a deterioration in mental health. We had concerns about patients self-harming despite the department having ligature cutters for staff.
  • Patients experienced delays at handover and there had been a high number of black breaches.
  • We were not assured about the quality of care patients received because the department had not performed well against Royal College of Emergency Medicine (RCEM) standards.
  • Staff were not meeting mandatory training standards including safeguarding vulnerable adults and children. Additionally, staff had not undergone additional training to ensure they had the additional skills and competencies to look after children and not all staff had undergone an annual appraisal within the last 12 months.

However:

  • Patients received care and treatment for staff who were caring, compassionate, respectful and maintained their dignity.
  • Both medical and nursing staff told us the department had an open supportive culture and staff felt leaders were open, helpful and listened to their concerns.
  • When things went wrong, staff felt able to report them and discuss them and were confident they would receive the support they needed.
  • Staff felt valued by their colleagues and by the management team within the department.