Furness General Hospital

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This meant we looked for evidence that people were protected from abuse and avoidable harm. We assessed 8 quality statements.

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. We also checked people’s liberty was protected when this was in their best interests and in line with legislation.

At our last assessment we rated this key question requires improvement. At this assessment, the rating has remained the same. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was a risk that people could be harmed, but we saw improvements had been made in relation to infection prevention and control, patients received timelier assessments. Staff were appropriately trained in safeguarding adults and children.

The service had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly and people were protected and kept safe. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that.

However, we found shortfalls in the department as it faced challenges in medicines management and managing patient flow to the wider hospital. As a result, some patients spent time in areas that were not clinically appropriate. This was a breach of safe care and treatment.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

We have a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices.

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

All staff we spoke with could articulate what constituted an incident and how they would report it. Staff were encouraged by senior leaders to report incidents as the department promoted a no blame culture and told us incidents were essential for learning.

Managers investigated patient safety events appropriately and followed the Patient Safety Incident Response Framework (PSIRF). PSIRF, is a mandatory framework within the NHS in England for how health services respond to and learn from patient safety incidents. Reported incidents would be shared in staff meetings and any themes or trends would also be shared in the daily huddles that were held throughout each day.

We saw examples of learning from incidents. This included the introduction of an ambulance handover area to support handover of patient's and release ambulance staff.

All staff were aware of their responsibilities under duty of candour and were able to give examples of when they had applied these principles. There was an up-to-date policy covering duty of candour.

Risks were managed by senior leaders within the department and all senior leaders could articulate the highest risks in the department. The highest risk at time of the inspection was overcrowding in the department when the same day emergency care and frailty units closed.

We saw a positive culture of safety and learning. There was a no blame approach which empowered staff to report any issues without fear of negative consequences. Staff learnt from incidents and complaints as all information was shared by senior leaders. We saw examples of service users being listened to and their views being taken into account.

We work with people and our partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. We ensure continuity of care, including when people move between different services.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

All patients who were directed or ‘streamed’ to the emergency department were triaged by trained staff using the Manchester triage system (MTS). There was support from a senior doctor or clinician who could assess patients and refer directly to clinical specialties. Staff told us that there were pathways to stream patients directly to specialty assessment areas in the hospital, but there were inconsistencies as when the specialties would accept the patients.

The trust completed an audit review tool for paediatric triage, of which the last seven audits demonstrated there was an overall 90% compliance that paediatric patients were seen promptly.

Patients told us that they had experienced long waits waiting to be seen once they had been triaged. Staff told us that routine audits of triage were not always completed.

A member of nursing staff would maintain oversight of those patients in the waiting room. However, staff told us this was dependent on availability of staff and was not always in place; there was not any consistency in the oversight of patients waiting to be seen.

Senior staff were allocated to clinical areas to maintain oversight. There were board rounds and safety huddles undertaken throughout the day. Board rounds and huddles were led by senior clinicians and recorded as being completed. We observed that huddles and board rounds contained all pertinent information to enable effective oversight.

The service had 24-hour access to specialist mental health support. We reviewed previously undertaken mental health risk assessments and saw no errors or omissions. We saw that out of 1,247 total mental health presentations, including both adult and paediatric patients, all were triaged within 10 minutes of arrival in department.

We saw examples of electronic discharge summaries being completed which contained all relevant information about the patients stay in the department if they were discharged home.

Clinical responsibility for patients within the department was clearly defined. All patients within the department were cared for by the emergency department staff including those awaiting admission under other medical or surgical specialties. We were also given examples of patients who had been accepted onto surgical and medical assessment units being sent back to the department once those areas closed in the evening. This caused a significant unplanned demand on the department staff and space available for patients.

Bed management meetings were held 3 times per day. The purpose of these meetings was to maintain oversight and grip of patient flow across the hospital. We were not assured about the effectiveness of these meetings due to the lack of flow through the department and the issues of medical and surgical patients being returned the emergency department.

We work with people to understand what being safe means to them as well as with our partners on the best way to achieve this. We concentrate on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, and we make sure we share concerns quickly and appropriately.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

We saw that all staff were trained to the appropriate safeguarding role for their level. All staff knew how to make a safeguarding referral and would do so when appropriate. We also noted that feedback from safeguarding was included in staff meetings and daily staff huddles. Feedback was also shared by email to ensure all staff received it.

All staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. We saw multiple examples of patient notes being updated regarding their status and that the electronic record included any relevant safeguarding details. We also noted staff asking about family members who the patient may have caring responsibilities for.

We saw examples of staff assessing patients' capacity and documenting it within the patient notes. All clinicians were able to articulate how they would assess a patient with mental health issues including the appropriate risk assessment. Mental Capacity Act training was incorporated into the mandatory training modules.

We did not observe any interactions that required restraint or restrictive practice but we were assured that these areas were covered within staff training and the appropriate policy.

We work with people to understand and manage risks by thinking holistically so that care meets their needs in a way that is safe and supportive and enables them to do the things that matter to them.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff communicated with patients so that they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties. We saw that staff had access to a full range of interpretation services.

We saw examples of staff proactively encouraging patients to provide feedback on the service.

Staff completed risk assessments for each patient on admission / arrival, using a recognised tool and reviewed this regularly, including after any incident.

There was a flag on the electronic patient record system that alerted staff if a patient had a safeguarding or mental health concern. We saw examples of patient passports being used within the emergency department to enable awareness to staff of specific patient need.

Staff used a nationally recognised tool to identify deteriorating patients and escalated them. Observations of vital signs were recorded by staff and the national early warning score (NEWS2) was calculated. These were recorded electronically. The service had a clear escalation policy for the deteriorating patient. There was a daily spot check of NEWS2 scores that was completed by the nurse in charge, but this was not routinely audited as part of the departmental audit programme.

Staff knew about and dealt with any specific risk issues such as possible sepsis. There is national guidance for how quickly patients should receive treatment for sepsis based on their presentation. Following review of the sepsis audit we saw that between March 2025 and May 2025, the department achieved 82% compliance for sepsis management.

We detect and control potential risks in the care environment and make sure that the equipment, facilities and technology support the delivery of safe care.

We scored the service as 2. The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Patients felt the waiting area was busy and lacked space to accommodate the amount of people attending the emergency department. We observed patients waiting for long periods of time on trolleys without any pressure relieving equipment.

During our assessment we observed patients on trolleys situated in assessment areas including the space dedicated for ambulance handovers. This meant patients were waiting in an area close to an external door and with high footfall. We also noted these areas did not have adequate facilities for personal care and exposed to the cold weather elements when the door automatically opened.

The service participated in clinical environmental inspection audits. We requested the last six months of audits following inspection and were only provided with April and June 2025 which showed that compliance was 74%.

We observed that all handovers were undertaken in a designated area where patient confidentiality could not be maintained. Staff told us that there was no other space within the department that could be used.

All areas of the emergency department were physically clean. However, there were areas of paint loss on walls in corridor areas which would prevent effective cleaning.

The designated mental health assessment room and adjacent facilities were fully Psychiatric Liaison Accreditation Network (PLAN) compliant. However, it was also used for medical patients which meant that patients would be moved around the department should the room need to be used for its intended purpose..

One paediatric cubicle within the majors area of the department was located next to the mental health assessment room and was not easily observable. It being used for an adult patient at the time of inspection which may have compromised immediate access for paediatric patients.

Clinical and non-clinical waste was managed appropriately.

Staff we spoke with told us that the space was not adequate for the increasing demand but due to the existing footprint there was no space available to increase the size of department.

We undertook reviews of equipment within the department and found multiple out of date items within the ‘difficult airways’ trolley in resuscitation. When raised with staff they informed us that they hadn’t been removed as they couldn’t be reordered. This was raised with the trust and information provided following inspection confirmed that all equipment was now available.

We make sure there are enough qualified, skilled and experienced people, who receive effective support, supervision and development and work together effectively to provide safe care that meets people’s individual needs.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

Nursing staff kept up to date with their mandatory training. At the time of our assessment, mandatory training compliance for nursing staff within the urgent and emergency care service was 92%. This was above the trust target of 90%. However, mandatory training compliance for medical staff was 87% and below the trust target. Trust overall compliance for training was 85% which was below the trust target of 90%. The mandatory training offer for staff was comprehensive and met the needs of patients and staff. The training covered topics such as infection prevention control, moving and handling, fire safety, equality diversity and inclusion, health and safety and information governance.

All nursing staff we spoke with had undertaken core competencies when first employed within the emergency department. Newly appointed staff were able to describe a period of being supernumerary when first in the emergency department.

Senior leaders calculated and reviewed the number and grade of nurses, nursing associates and healthcare assistants needed for each shift using a safer staffing tool. This assessed acuity and dependency twice a year to provide evidence-based decision making on workforce requirements. Staff reported staffing numbers were not sufficient particularly when other assessment services sent patients back to the department as they closed at 8pm. This also coincided when more people attended the accident and emergency department. Staff reported the care and treatment provided was not as effective as there were more patients requiring care and treatment. Following inspection, we requested more information on how this was considered with staffing numbers, but nothing further was provided.

We noted that the department did not have a consultant in paediatric emergency medicine (PEM). This had been escalated previously and the trust was considering paediatric staffing requirements over the winter period at the time of inspection.

The department was not compliant with the Facing the future stands for staffing and was not effectively mitigating this risk. One paediatric nurse per shift was rostered, however this was not consistently achieved due to rota changes, sickness and other absence. General nurses cared for children in the absence of a paediatric nurse and most had completed the required training.

The service had enough medical staff and a minimum of 18 hours resident consultant cover during the week and 16 hours of resident consultant cover at the weekend. This was supported by the on site trauma team lead who also covered 24 hours per day 7 days per week.

Leaders covered staffing gaps with agency workers, and called in additional staff where possible, particularly during periods of high demand. Staff were only allocated from elsewhere in the hospital if they had the right skills, knowledge and competency to work in the department. All non-permanent staff we spoke with told us that they had a full orientation on their first shift in the emergency department.

We assess and manage the risk of infection, detect and control the risk of it spreading and share any concerns with appropriate agencies promptly.

We scored the service as 2. The evidence showed some shortfalls. The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

We noted an inconsistent use of ‘I am clean’ stickers which showed when a piece of equipment was last cleaned. The stickers were either missing or showed a date from the previous month.

We did not observe any staff cleaning items of equipment between use which meant there was an increased possibility of cross contamination.

The department used disposable curtains, however, these were inconsistently dated so it was not always possible to see how long they had been in place for.

We saw staff failing to use personal protective equipment (PPE) correctly, we saw staff coming out of cubicles and not removing their PPE before commencing additional tasks. We also noted a lack of hand washing from all grades of staff within the department.

We reviewed audit results following inspection and found that environmental audits had been undertaken with 64% compliance in April and 85% compliance in June. We also reviewed hand hygiene and PPE audits and saw 46% compliance in April and 79% in June.

We noted that medical staff compliance with ‘Aseptic No Touch Technique’ (ANTT) mandatory training was only 30%.

However, the department was visibly clean and we saw completed cleaning charts detailing when the cleaning had been undertaken.

We make sure that medicines and treatments are safe and meet people’s needs, capacities and preferences by enabling them to be involved in planning, including when changes happen.

2. We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

People’s regular medicines and allergies were recorded upon arrival to the department and Summary Care Records were used to support this process. Risk assessments for venous thromboembolism (VTE) were completed. Staff advised compression stockings stocking had not been applied for one patient. However, we were told these would be available when the patient moved to an inpatient ward.

The emergency department had dedicated support from a pharmacy technician (Monday to Friday 9am to 5:30 pm) who focused on starting medicines reconciliation and identifying patients taking critical medicines, to help ensure that doses were not missed. Dedicated pharmacist support was not available, although advice could be sought from the medical assessment unit pharmacist.

The trust audited medicines reconciliation monthly. The audits showed decreasing performance from 70% in February 2025 to 52% in June 2025. The trust had linked this to the additional work involved in implementing the new automated medicine cabinets. There was an upturn in performance in July 2025 to 58.9%.

We saw that patients received pain relief in a timely manner. The trust’s paediatric monthly audit of pain and vital signs showed an average compliance of 88% across the 6 months to June 2025, fluctuating around trust compliance target of 90%. In a 2024 benchmarking audit the ED performed above average for ‘staff helped to take pre-existing medication’ (Furness General Hospital ED 77%, average 73%.) However, they performed just below average with regards to ‘sufficient information given on new medication’ (Furness General Hospital ED 89%, average 92%).

The trust had identified a risk that patients seen in Same Day Emergency Care (SDEC) may miss doses of critical medicine if their care was transferred back to ED. This was because patients could not be transferred electronically but had to be discharged and readmitted to ED. Staff were managing this risk by telephoning ED to advise staff of the patient transfer, so that their medicines could be promptly prescribed.

The trust had a sepsis management policy, which staff working in the emergency department followed. The policy was overdue for review (review date January 2024). However, we were told that this was now in progress. The trust did not complete antimicrobial stewardship audits in ED but a sepsis audit was completed. This showed that that the percentage of patients who received antibiotics within 1 hour was below the 90% target but improving (combined audit across both hospitals) from 77% in March 2025 to 89% in May 2025. Data quality was recognised as a concern and steps were being taken to improve this, overseen by the trust deteriorating patient group.

The trust used an electronic audit system to facilitate sharing of audit findings and provide oversight of action plans. Following the recent implementation of a new automated medicine cabinet, medicines storage and controlled drugs audits showed improved compliance across the emergency department.

Controlled stationary such as, paper prescriptions were stored securely and monitored to ensure they were handled in line with trust policy.

Governance structures were in place for the management and review of patient group directions (PGDs). PGDs are written instructions to facilitate the supply or administration of medicines to patients, without a prescription.

The service had systems in place to support learning from safety alerts and incidents.

Decision making processes were in place to ensure people’s behaviour was not controlled by excessive and inappropriate use of medicines.