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Archived provider: North Cumbria University Hospitals NHS Trust Requires improvement

On 22 November 2018 , we published a report on how well North Cumbria University Hospitals NHS Foundation Trust uses its resources. The ratings from this report are:

  • Use of resources: Requires improvement  
  • Combined rating: Requires improvement  

Read more about use of resources ratings

Inspection Summary


Overall summary & rating

Requires improvement

Updated 22 November 2018

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

  • We rated safe, effective, responsive and well-led as requires improvement and caring as good.
  • We rated six of the trust’s eight services as good and two as requires improvement. In rating the trust, we took into account the current ratings of the three services not inspected this time.

We rated well-led for the trust overall as requires improvement.

  • Registered nurse staffing shortfalls and registered nurse vacancies continued on all wards, however, this was most prevalent in the medical care group. Several registered nurse shifts remained unfilled despite escalation processes. Medical staffing cover remained challenging and locum cover was significant. Additional support was not always available for wards with more complex patient needs, such as one to one support due to behavioural problems or aggressive tendencies.
  • There had been several serious incidents where patients had suffered harm as a result of missed diagnosis, late escalation of deterioration or delay in receiving treatment. The emergency department had a designated mental health assessment area that did not meet best practice guidance for a safe metal health assessment room. It contained inappropriate equipment and several ligature risks. We raised this during the core service inspection and the department took action to change the room and make it safer when we retuned for the well led inspection. Mental health patients also experienced long waits in the department as they waited to see mental health specialists from the local mental health trust.
  • Mandatory training was not always completed by medical or nursing staff in a timely manner and compliance with mandatory training targets was low for both nursing and medical staff.
  • Some areas had achieved appraisal target rates, however, staff across the trust reported that the quality of appraisals was poor.
  • National and local guidelines were not fully embedded, some departments were not meeting the majority of the audit standards.
  • The electronic systems for recording staffing levels and patient acuity was not used consistently throughout the trust.
  • Prescribing policies were not followed and on occasions staff had difficulty following controlled drug procedures due to limited staffing. Intravenous fluids were not always secured as per the trusts medicines policy.
  • There were a large number of bed moves after 10pm where patients had been moved for non-medical reasons and there remained many medical outliers being cared for on non-medical wards.
  • Staff had a variable understanding and awareness of consent issues, the Mental Capacity Act and Deprivation of Liberty Safeguards.
  • Staff morale was variable in each area we visited however we did see some areas where it had improved from our previous inspection.
  • We were not assured that safeguarding training was delivered in accordance with Adult and Children Safeguarding Levels and Competencies for healthcare, intercollegiate guidance (2016).
  • Governance systems varied from ward to ward in terms of quality. We found that staff on several wards did not know what the risk register was and ward managers were were unable to voice what risks were on it.
  • Throughout the inspection staff told us that senior leaders lacked visibility in their clinical areas.
  • Audits of the WHO surgical safety checklist showed completion of the checklist had been inconsistent and had not been completed for every patient;
  • The foundation school had identified concerns about the adequacy of the training and experience of foundation programme doctors within surgery.
  • There was a large number of guidelines and procedures within the maternity service which were not in date, although there was an action plan in place to recover this position.

However:

  • Staff worked hard to deliver the best care they could for patients. Patients were supported by staff who were kind and compassionate despite being under pressure.
  • Patients were positive about the care they received and staff proactively involved patients and their family to consider all aspects of holistic wellbeing.
  • Staff confidently reported incidents and the division had made considerable efforts to reduce patient harms from falls and pressure ulcers.
  • Ward environments were clean and staff used personal protective equipment appropriately to protect themselves and the patient from infection exposure.
  • Patient outcomes in many national audits were good and there had been some reported improvements in others.
  • Multidisciplinary team working across the services was integrated, inclusive and progressive.
  • The trust had introduced a composite workforce model through the recruitment of trainee advanced clinical practitioners and physician associates to support the medical workforce within surgery;
  • Discharges were managed during daily and weekly ward meetings and multidisciplinary team meetings on wards and staff worked with the discharge liaison team;
  • Improving referral to treatment times had been set as a priority within the surgical division and at the time of inspection, national data showed referral to treatment times had improved for all surgical specialities;
  • Services for children and young people had taken appropriate action in response to issues identified at the previous inspection. There were sufficient medical and nursing staff to ensure children were safe, and appropriate mitigation in place to manage staffing pressures. The service met relevant standards recommended by the Royal College of Paediatrics and Child Health.
Inspection areas

Safe

Requires improvement

Updated 22 November 2018

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

  • Neither nursing nor medical staff were meeting mandatory training requirements with low compliance against the trust standard of 95%. Compliance with training in immediate life support was particularly low. In the emergency department we were not assured that staff had undergone appropriate life support, paediatric life support and trauma life support training as per Royal College of Emergency Medicine (RCEM) guidance.
  • In the emergency department during our initial inspection, the room used to accommodate patients with mental health conditions was not fit for purpose. There were ligature points and unsuitable furniture. However, after our inspection, the department took action quickly to make the room safer for patients. A second room which sometimes was used also had similar risks. This meant that patients with a mental health condition were at risk of harm because they were not being cared for in a safe environment.
  • We were not assured that the emergency department identified and responded quickly enough to deteriorating patients or patients with a number of conditions including sepsis, diabetic ketoacidosis (DKA) and stroke. There had been a number of serious incidents in the department related to these conditions and delays in treatment. The trust was aware of the problems and had implemented new processes however these were yet to be embedded.
  • The medicine management policies did not meet current guidelines in relation to monitoring the maximum and minimum temperatures on drug fridges. Storage temperatures were not checked meaning the staff were not assured that medicines were being stored at their optimum temperature and staff were not following correct procedures for dispensing medicines.
  • In the emergency department controlled drugs were not checked and disposed of in line with trust policies. Medicines such as fluids with different strengths, for example like glucose, that could easily get mixed up, were stored together and were not stored securely in a locked cupboard. We also found that staff were not prescribing medicines in line with trust policy, for example signatures were not legible.
  • Registered nurse staffing shortfalls and registered nurse vacancies persisted on all medical wards. Several registered nurse shifts remained unfilled despite escalation processes. Nursing staff sickness was also prevalent across wards with several wards having teams that were described as “burnt out”.
  • Medical staffing cover was a challenge and locum cover was significant. A high proportion of medical wards were under staffed both at night and through the day.
  • The trust used the SafeCare to enable coordination of staffing levels and skill mix to the actual patient demand. We saw that patient acuity was not regularly updated on the medical wards when patient complexity changed or updated following patient ward moves.
  • We were told staff had been instructed not to report staffing shortages in the incident reporting system as this would be captured in SafeCare, however, the use of the tool was not consistent across all wards in the trust.
  • Medical wards also noted that despite having patients with complex needs including those requiring one to one support that additional staff support was not always available.
  • Audits of the WHO surgical safety checklist showed completion of the checklist had been inconsistent and had not been completed for every patient;
  • The foundation school reported concerns about the adequacy of training and experience of foundation programme doctors in surgery;
  • We found within maternity services that ten percent of women did not receive one to one care in labour.
  • Safeguarding level three training did not meet the standards recommended by Royal Collage of Paediatrics and Child Health intercollegiate document. The trust had recently replaced the interactive face-to-face training with a four-hour online e-learning module. This meant medical and nursing staff did not have the opportunity to participate in scenario-based discussion, draw upon case studies, serious case reviews, or lessons from research and audit, as recommended in the intercollegiate document. Although the safeguarding team told us they could provide bespoke safeguarding training upon request, it was not clear how this would be delivered or monitored to show staff attendance at this.
  • The safeguarding children supervision policy was out of date and had not been reviewed since 2014.

However:

  • Staff understood their responsibilities in relation to reporting incidents and duty of candour. We saw evidence of action taken as a result of incidents.
  • Where substantive medical posts remained vacant the medical division had secured long-term locum contracts to support stability within the service.
  • We observed the site co-ordinator in the late evening, assessing and responding to patient risk and deploying staff and patients appropriately.
  • We were advised that the SBAR methodology (situation, background, assessment, recommendation) was used to assess which staff transfer to another ward.
  • The division had systems and processes in place to support staff in wards and theatres to assess and respond to patient risk;
  • The trust had introduced a composite workforce model through the recruitment of trainee advanced clinical practitioners and physician associates to support the medical workforce within surgery;
  • The trust had still been unable to recruit to full time, substantive consultant paediatricians to meet RCOG guidelines. However, managers had been able to recruit sufficient locum doctors to mitigate risks and meet minimum standards for delivery of safe care. Staff told us they felt babies received safe care and the service could rely on 24/7 paediatric cover and support.
  • The lead obstetric consultant at West Cumberland Infirmary organised weekly education sessions for all staff. These were shared across sites using video link.
  • All maternity staff, including community midwives, completed skills training and emergency drills including birthing pool evacuation and obstetric emergencies.
  • The trust had taken appropriate action to manage and mitigate risk in relation to medical and nurse staffing in children and young people’s services. There were 10 whole time equivalent (WTE) consultants in post and consultants were present on site 24 hours a day, seven days a week.
  • Evidence from a Royal College of Paediatrics and Child Health (RCPCH) audit showed the unit was achieving the relevant standards. Every child or young person was seen by a consultant within 14 hours and every child with an acute medical problem was seen by a clinician before discharge. In both standards, performance at Cumberland Infirmary was better than the national average.

Effective

Requires improvement

Updated 22 November 2018

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

  • Not all of the evidence based care guidelines were fully embedded and we had concerns about the impact of this on patients. The trust did not have a sepsis policy for children, although staff told us this was under development.
  • Medical and nursing staff were not meeting the trust standards for mental capacity training, or deprivation of liberty safeguards training. There was no separate consent training. We were not assured that patients falling under these categories were receiving the most up to date care.
  • Some of the nurses we spoke with were aware of fluctuating capacity but none had ever carried out a capacity assessment as they believed that this could only be done by doctors.
  • The emergency department had not taken part in all Royal College of Emergency Medicine (RCEM) audits since 2015/2016. Of those they took part in, they had not met all of the standards and in the Consultant, sign off audit, they had not met any standards.
  • The trust participated in the 2017 lung cancer audit and the proportion of patients seen by a Cancer Nurse Specialist was 86.8%, which did not meet the audit minimum standard of 90%. The 2016 figure was 71.8%.
  • The number of medical and staff receiving an annual appraisal did not meet the trust targets. Staff also reported the quality of their appraisal was poor.
  • General surgery patients had a higher expected risk of readmission for elective admissions when compared to the England average;
  • General surgery patients at Cumberland Infirmary had a higher expected risk of readmission for non-elective admissions when compared to the England average;
  • Patient Reported Outcomes Measures showed performance on groin hernias was generally worse than the England average;
  • We found several guidelines and procedures were out of date in both maternity and Children and young people’s services which did not meet current guidance. Staff told us there were several reasons for this including professional input and ratification by the trust board. We also found a number of paper copies of guidelines and procedures which were out of date. This meant there was a risk some could access the wrong information.

However:

  • Staff underwent preceptorship and mentorship when they joined the emergency department and were supported in their new roles by colleagues until signed as competent.
  • There was good multi-disciplinary working within and out with the emergency department as staff from support services and other departments worked to support patients to prevent admission and facilitate discharge.
  • Staff referred to several National Institute for Health and Care Excellence (NICE) guidelines and quality standards, and Royal College best practice guidelines in support of their provision of care and treatment. Local policies, which were easily accessible.
  • Several evidence-based, condition-specific care pathways had been created to standardise and improve patient care and service flow.
  • The trust took part in the quarterly sentinel stroke national audit programme. On a scale of A-E, where A is best, the trust achieved an overall SSNAP level of grade C from August to November 2017.
  • The trust had introduced a full time orthogeriatrician and the ‘consultant of the week’ working model which had improved co-ordination, review and consistency of care for this patient group;
  • The trust participated in the Northern Region tissue viability collaborative which had increased focus and improvement methodology for the reduction of pressure ulcers;
  • The 2016 Oesophago-Gastric Cancer National Audit (OGCNCA) showed the trust was a positive outlier for the age and sex adjusted proportion of patients diagnosed after an emergency admission;
  • Women were provided with options for pain relief in labour. Anaesthetist response times within 30 minutes for epidural analgesia continued to be 100%.
  • Midwifery and medical staff worked together ensuring women received care which met their needs and we saw a range of examples of multidisciplinary team working.
  • Medical and nursing staff adhered to guidelines from the Royal College of Nursing (RCN), the Royal College of Paediatrics and Child Health (RCPCH), the National Institute for Health and Care Excellence (NICE), and other professional guidelines such as the British Association of Perinatal Medicine (BAPM).
  • Children’s services participated in national audits such as diabetes, seizures and epilepsy in children and young people, and the neonatal audit programme. Outcomes for diabetes demonstrated evidence on ongoing improvement each year. For example, the median HbA1c value recorded amongst the 2014/15 sample was 74.5, which improved to 69.0 in 2015/16 and improved again to 63.0 in 2016/17.

Caring

Good

Updated 22 November 2018

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

  • Feedback from people who used the service and those who were close to them was positive about the way staff treated people.
  • Patients provided us with positive feedback about their care during our inspection. We saw reception, nursing and medical staff supporting patients in a positive way.
  • Patients told us they received compassionate care and support for their emotional needs.
  • Staff were motivated to offer care that was kind and promoted people’s dignity. People’s privacy and confidentiality were respected during their treatment.
  • Staff discussed care with patients in a way that they could understand. People’s emotional and social needs were assessed by staff and included in their care and treatment.
  • Staff responded compassionately when people needed help and supported them to meet their personal needs as and when required.
  • Staff helped people and those close to them to cope emotionally with their care and treatment.
  • The medical division took part in the national cancer patient experience survey (NCPES) 2016. Eighty-eight percent said that overall, they were always treated with dignity and respect while they were in hospital.
  • Staff responded promptly to call bells or requests for assistance and had enough time for patients and they introduced themselves;
  • A bereavement midwife worked across both main sites and they provided a link to the hospital bereavement team. There was a clear bereavement policy in place.
  • Women were involved in their choice of birth at booking and throughout the antenatal period. Midwives supported women to make birth choices and produced birth plans to reflect them.
  • Children, young people, and families told us they received compassionate care and emotional support from nursing and medical staff.
  • Staff created a strong, visible, child and young person-centred culture. Medical and nursing staff were motivated and inspired to offer the best possible care to children, young people, and families, including meeting their emotional needs.

Responsive

Requires improvement

Updated 22 November 2018

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

  • Flow through the emergency department remained a challenge within the trust. Moving patients to beds on wards did not happen quickly and meant patients had long waits in the department from decision to admit to actual admission on a ward. The number of patients waiting more than four hours from decision to admit to admission was deteriorating. In the 12 month period between April 2017 and March 2018 performance had declined. Approximately 9% of patients in April 2017 waited, however, in March 2018 24% of patients waited longer than four hours from decision to admit, to admission to a ward.
  • The emergency department had no dedicated room for relatives to spend private time with a family member when they had died although there was a dedicated relatives’ room for the family to wait.
  • From May 2017 to April 2018, there were 1,750 patients moving wards at night at the Cumberland Infirmary.
  • The trust provided us with information and data on the medical outlier’s bed occupancy. Between January 2018 and June 2018, the number of patients classified as being medical outliers was 2,209.
  • Along with the local community trust there was a review of community bed provision. These developments were not synchronised and there was an anticipated period when there will be a marked reduction in community beds.
  • Although there was a variety of patient information leaflets available in wards, there were no leaflets available in different languages and not all staff know how to get them;
  • From April 2017 to March 2018 the trust’s referral to treatment time (RTT) for admitted pathways for surgery was consistently worse than the England average for the 12 month period.

However:

  • The Cumberland Infirmary has been one of nine disablement service centres across England selected to provide enhanced services to veterans who lost a limb because of their service in the armed forces.
  • Services were planned in a way to meet the needs of the local population.
  • Services were configured to ensure patients with specific conditions did not have unnecessary waits before being seen.
  • The medical care group took part in the national cancer patient experience survey (NCPES) 2016. Eighty-eight percent said that overall, they were always treated with dignity and respect while they were in hospital.
  • Patients living with dementia were identified to staff by a butterfly symbol to enable them to provide additional support;
  • Discharges were managed during daily and weekly ward meetings and multidisciplinary team meetings on wards and staff worked with the discharge liaison team;
  • Patients could attend the department with concerns or issues with their pregnancy. They could self-refer, or through their GP, or the emergency department. Midwives took calls and could give an approximate waiting time or a specific time to attend to minimise waiting in the department.
  • The maternity service demonstrated learning from complaints and had implemented a maternity afterthoughts service. This was a service where women discussed with a midwife any aspects of a complex or difficult birth before they left the unit.
  • The facilities and environment in the children’s ward and outpatient department were suitable for children and young people, with age appropriate facilities and play activities. There were separate areas for teenagers.
  • Care and treatment was coordinated with other services and other providers, and the facilities and premises were appropriate for children and young people. The service also provided facilities for parents to remain with their child during the night.

Well-led

Requires improvement

Updated 22 November 2018

Our rating of well-led stayed the same. We rated it as requires improvement because:

  • Senior emergency department management were not always visible and there was some confusion among staff about who to escalate concerns to, above their line manager. Additionally, managers presented to us as less than confident about the staffing make up of the department.
  • Governance arrangements reported to senior management outside of the emergency department did not always accurately reflect the experience of front line staff.
  • The medical care group risk register dated June 2018 showed numerous items had remained on the risk register for several years and still required actioning. Whilst detailed in terms of risk description, the register appeared unreliable, duplicating many common themes and lacking detail in terms of actions taken and progress over the period of time since the risk was identified. There was a disconnect between senior managers and local ward staff in relation to identification of risk.
  • Staff considered the amount and speed of change in the organisation, whilst they recognised this as necessary, felt it added to existing pressures and did not bring about the immediate perceived benefits.
  • Although the senior management team informed us that recruitment had recently been made, they acknowledged the difficulties in covering the anaesthetic rota at West Cumberland Hospital;
  • The foundation school had identified concerns about the adequacy of the training and experience of foundation programme doctors in surgery.
  • There remained no formal strategy for the future of maternity services due to the review of maternity provision across Cumbria. Managers confirmed the service vision was to provide the right care at the right time and in the right place.

However:

  • Staff spoke of a supportive culture where colleagues worked together to deliver the best possible care for the patient and support each other through busy or stressful times. Staff knew their hard work was appreciated by colleagues.
  • Junior nursing and medical staff described their senior peers to be supportive, approachable and willing to spend time with them when necessary.
  • The medical care group had good links with numerous volunteer organisations, charities and national support groups.
  • The surgical division had a management structure in place with clear lines of responsibility and accountability;
  • New medical and midwifery leads were respected by staff and obstetric consultant engagement had improved. There was increased cross site working in all teams. However, some staff felt locums and middle grade clinicians could work more cohesively with the teams.
  • Maternity governance, risk management and quality were the responsibility of medical and midwifery governance leads who worked across both main sites. A second midwife had been appointed to work in risk and quality to ensure actions arising were taken forward and lessons learned.
  • The maternity service had a clear governance framework with staff assigned specific roles that ensured quality performance and risks were known about and managed.
  • The trust, in alliance with CPFT, had created a joint operational plan entitled’ This is us’. Core objectives, aims and priorities for services for children and young people receiving acute and community across North Cumbria were included with the strategy. The introduction of a paediatric short stay assessment unit was already in its first phase of development and had introduced a more rapid review of patients. Staff spoke positively about the changes and had felt involved in the process.
  • The child health business plan reflected the changing nature of childhood illness which meant fewer children require an inpatient hospital stay, while those who are admitted tend to have a shorter length of stay than in the past. This was reflected in the development of the short stay paediatric assessment units at both sites.

Assessment of the use of resources

Use of resources summary

Requires improvement

Updated 22 November 2018

Combined rating

Combined rating summary

Requires improvement