You are here

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

Reports


Inspection carried out on 12 July to 30 August 2018

During a routine inspection

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.


CQC inspections of services

Inspection carried out on 25 and 26 July 2017

During an inspection looking at part of the service

The Care Quality Commission (CQC) carried out an unannounced inspection at North Cumbria University Hospitals NHS Trust on 25 and 26 July 2017 to gauge the safety of current practices regarding nasogastric tubes and progress in delivering the action plan identified in response to HM Coroner’s concerns.

North Cumbria University Hospitals NHS Trust was subject to a comprehensive inspection in December 2016. We did not gather sufficient evidence to impact upon trust ratings from that inspection.

During this inspection we visited medical and surgical wards, paediatric units and intensive therapy units at both sites (Cumberland Infirmary, Carlisle and West Cumberland Hospital, Whitehaven).

This focussed inspection confirmed that the insertion and ongoing management of care of nasogastric tubes was safe, effective and well led.

However, we have asked the trust to take action to improve its documentation, exposure to clinical skills and to develop a specific policy for pregnancy regarding the insertion and ongoing management of nasogastric tubes.

Professor Edward Baker

Chief Inspector of Hospitals

Inspection carried out on 6- 9 and 21 December 2016

During an inspection looking at part of the service

We carried out a follow-up inspection from 6 to 9 December 2016 to confirm whether North Cumbria University Hospitals NHS Trust (NCUH) had made improvements to its services since our last comprehensive inspection, in April 2015. We also undertook an unannounced inspection on 21 December 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 trust, in April 2015, we rated services as ’requires improvement’. We rated safe, effective, responsive, and well-led as ‘requires improvement’. We rated caring as ‘good’.

There were four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations. These were in relation to staffing, safe care and treatment, person centred care, 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 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 improved in some areas. However, it remains rated as 'requires improvement' overall, with safe, responsive, and well-led rated as 'requires improvement', and effective and caring rated as 'good'.

Our key findings were as follows:

  • Nursing and medical staffing had improved in some areas since the last inspection. However, there were still a number of nursing and medical staffing vacancies throughout the trust, especially in medical care and surgical services, and services for children and young people, including the special care baby unit at Cumberland Infirmary (CIC).
  • The trust had systems in place to manage staffing shortfall as well as escalation processes to maintain safe patient care. However, a number of registered nurse shifts remained unfilled despite these escalation processes. The ‘floor working’ initiative within medical care did not support safer nurse staffing.
  • Despite ongoing recruitment campaigns the trust had struggled to recruit appropriate clinicians in some specialities, particularly in medical care and services for children and young people. Medical staffing within these specialities remained reliant upon locum support, and was therefore vulnerable to changes in locum worker preferences or departures.
  • However, within medical care services, particularly at West Cumberland Hospital (WCH), medical staffing had improved from the previous inspection with additional workforce assurance plans in place. This included securing long-term locum contracts, developing the composite workforce model, improving links with specialist trainees, and securing cross-site support from divisional clinician colleagues at CIC.
  • Compliance against mandatory training targets was an issue in some services.
  • Access and flow across the emergency department, medical care, surgical services, and outpatients remained a significant challenge.
  • The trust had failed to meet the target to see and treat 95% of emergency patients within four hours of arrival. It was also failing to meet a locally agreed trajectory to see and treat emergency patients within four hours of arrival which had been agreed in conjunction with regulators and commissioners.
  • We found that patients experienced overnight delays in the emergency department whilst waiting for beds to become available in the hospital.
  • Between 2015 and 2016 the trust cancelled 1,410 elective surgeries. Of these, 12% were not rescheduled and treated within 28 days. For the period November 2015 to November 2016 WCH cancelled 292 elective surgeries and CIC cancelled 573 for non-clinical reasons.
  • Referral to treatment time (RTT) data varied across specialities, particularly in surgical services.
  • Patient flow initiatives within the medical division were not fully embedded and required improved coordination, ward staff engagement, and more timely discharge plans to be implemented. Medical outliers accounted for a significant proportion of the inpatients beds at WCH.
  • From March to August 2016 there were a number of patients moving wards after 10pm at WCH.
  • Delays in obtaining suitable community care placements were causing access and flow difficulties, particularly in medical care services.
  • Within outpatients there were a number of clinics cancelled within 6 weeks of the due date of the clinic across the trust, and there were no plans in place to address this issue. Turnaround times for inpatient plain film radiology reporting did not meet Keogh standards, which require inpatient images to be reported on the same day.
  • There had been an improvement in record-keeping standards throughout the hospital. However, we identified some ongoing areas for improvement around accurate completion of fluid and food charts, risk assessments, and completion of Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR) forms, which did not provide evidence of a best interest decision or a mental capacity assessment being undertaken and recorded where appropriate.
  • The senior team was aware of the challenges and issues within the organisation and had developed strategies and tightened governance processes to meet these challenges. However, these needed embedding.
  • There was some improvement in strengthening of governance processes across the trust. However, within some services, particularly medical care and maternity, there were gaps in effective capturing of risk issues and in how outcomes and actions from audit of clinical practice were used to monitor quality.
  • Staff morale was variable and staff did not always feel that their contribution was recognised and appreciated. Staff found the speed and number of change processes being implemented across the trust to be hurried and unsettling. This had added to the existing pressures and caused additional stress.
  • A programme and range of staff engagement activities and initiatives had been implemented during 2016 but this was not yet fully embedded.
  • Due to the public consultation taking place at the time of our inspection, it was noted that a preferred option and decision was yet to be taken by Cumbria Clinical Commissioning Group on the future of maternity and children and young people’s services.

However:

  • 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 policy and activity around critical care patient transfer to other hospitals, including children and babies, when required were good.
  • The hospital had infection prevention and control policies in place, which were accessible, understood and used by staff. Patients received care in a clean, hygienic, and suitably maintained environment.
  • There were no cases of Methicillin Resistant Staphylococcus Aureus infection (MRSA) reported from November 2015 to October 2016. Trusts have a target of preventing all MRSA infections, so the trust met this target within this period. The trust reported nine MSSA infections and 23 C. Difficile infections over the same period.
  • Safeguarding processes were embedded throughout the trust.
  • 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.
  • The trust had developed a care of the dying patient (CDP) care plan that provided prompts and guidance for ward-based staff when caring for someone at the end of life.
  • Patients were positive about the care they received. Staff were committed to delivering high quality care. Staff interactions with patients were compassionate, kind, and thoughtful. Patient privacy and dignity was maintained at all times.
  • Patient feedback was routinely collected using a variety of measures, including real-time patient experience.
  • There had been significant changes in the senior executive team since our previous inspection. This included a new chief executive, medical director, and director of nursing. The chief executive had recognised the need to strengthen and develop clinical leadership within the organisation. The director of nursing had also been very proactive in trying to address the nursing workforce issues.
  • Although the executive team members were relatively new they appeared to be credible, and there were positive comments overall from staff regarding their visibility.

We saw several areas of outstanding practice including:

  • The trust was a National Patient Safety Awards finalist for ‘better outcomes in orthopaedics’.
  • The trust had the only surgeon between Leeds and Glasgow doing a meniscal augment knee surgery.
  • An Honorary Professorship from the University of Cumbria had been received by a consultant for work on applying digital technologies in health care for an elderly population in a rural setting; a part of CACHET.
  • There was a multinational, multicentre prospective study in the use of intramedullary nail in varus malalignment of the knee. The trust had the largest international experience of this technology for this application.
  • CIC was one of only 18 Hospitals in England and Wales referred to in the first NELA audit for contributing examples of best practice in care of patients undergoing emergency laparotomy. However, there were also areas of poor practice where the trust needs to make improvements.
  • There were real strength of MDT working and positive patient outcomes in the stroke service.
  • The ‘expert patient programme’ and ‘shared care initiative’ in the renal business unit exhibited real patient integration, empowerment, and care partnerships.
  • There was a variety of data capture measures in use to monitor ‘real-time’ patient experience and collate patient feedback.
  • There were innovative and progressive Frailty Unit projects at CIC.
  • The growth, expansion, and development of the MPU service at CIC.
  • The implementation of dance-related activities for vulnerable patient groups to stimulate social interaction, patient involvement, family partnerships, and exercise.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

In urgent and emergency services

  • Meet the target to see and treat 95% of emergency patients within four hours of arrival, linked to meeting the locally agreed trajectory to see and treat emergency patients within the standard agreed with regulators and commissioners.
  • Ensure medical and nursing staff use the computer system fully as intended so that patient real-time events are recorded accurately, and this is demonstrated through audit.
  • Take further steps to resolve the flow of patients into and out of the hospital.

In Medicine

  • Ensure systems and processes are established and operated effectively to assess, monitor, and improve the quality and safety of the services provided, and evaluate and improve practice to meet this requirement. Specifically, review the escalation process involving ‘floor working’ to ensure that quality and safety of services are maintained
  • Ensure sufficient numbers of suitably qualified, competent, skilled, and experienced persons are deployed across all divisional wards. Specifically, registered nurses to ensure safe staffing levels are maintained, especially in areas of increased patient acuity, such as NIV care and thrombolysis.

In Surgery

  • Must ensure the peri-operative improvement plan is thoroughly embedded and that all debrief sessions are undertaken as part of the WHO checklist to reduce the risk of Never Events.

  • Improve compliance against 18 week RTT standards for admitted patients for oral surgery, trauma and orthopaedics, urology, and ophthalmology.
  • Improve the rate of short notice cancellations for non-clinical reasons specifically for ENT, orthopaedic, and general surgery.
  • Ensure patients whose operations are cancelled are treated within 28 days.

In Maternity and Gynaecology

  • Review staffing levels, out-of-hours consultant paediatric cover, and surgical cover to ensure they meet the Royal College of Obstetricians and Gynaecologists (RCOG) guidelines (including ‘safe childbirth: minimum standards for the organisation and delivery of care in labour’)
  • Ensure that systems are in place so that governance arrangements, risk management, and quality measures are effective.

In Services for Children and Young People

  • Ensure children and young people services meet all Royal College of Paediatrics and Child Health (RCPCH) - Facing the Future: Standards for Acute General Paediatric Services (2015 as amended).
  • Ensure nurse staffing levels in the Special Care Baby Unit (SCBU) adhere to establishment and meet recognised national standards.

In End of Life Care

  • Ensure that DNACPR forms are fully completed in terms of best interest assessments in line with the Mental Capacity Act.

In Outpatients and Diagnostic Imaging

  • Address the number of cancelled clinics in outpatient services.
  • Ensure RTT indicators are met across outpatient services.

It is apparent that the trust is on a journey of improvement and progress is being made clinically, in the trust’s governance structures and in the implementation of a credible clinical strategy. I am therefore happy to recommend that North Cumbria University Hospitals NHS Trust is now taken out of special measures.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 31 March 2015 to 02 April 2015

During an inspection looking at part of the service

North Cumbria University Hospitals NHS Trust serves a population of 340,000 people living in Carlisle, Whitehaven and the surrounding areas of West and North Cumbria. In total the trust employs 4,272 staff and has 629 inpatient beds across the Cumberland Infirmary in Carlisle, the West Cumberland Hospital in Whitehaven and the Penrith Birthing Centre.

The trust was also one of 11 trusts placed into special measures in July 2013 after Sir Bruce Keogh’s review into hospitals with higher than average mortality rates. Immediately before the Keogh review and since that time there have been significant changes to the senior team including a new Chief Executive, Chief Operating Officer, Medical Director and Director of Nursing. A new chair and new non-executive directors have also been appointed. The Board and senior team have been supported by both the Trust Development Authority and Northumbria Healthcare Foundation Trust as a ‘buddy’ organisation.

At that time the trust faced significant challenges, the range and nature of the improvements required within a geographically challenging environment added to the complexity of the challenges faced

Since that time the new senior team have worked well together to address the issues identified in both the Keogh Review and the issues highlighted in our last inspection of the trust on May 30 – 2 June and June 12 2014.

Key Findings from the 2014 inspection were as follows:

We found that the trust was continuing to make progress in improving services and mortality rates. Importantly, mortality rates were within expected limits and the trust had made good progress against the delivery of the action plan developed in relation to the Keogh review findings, however, despite the progress made in mortality rates and improved governance, there remained many issues of serious concern. The trust was experiencing major difficulties in recruiting doctors – particularly consultants. The shortfall in consultant cover was posing a significant challenge in maintaining safe and timely standards of care and treatment for patients.

Nurse staffing had improved overall, but still remained a challenge in terms of staffing all wards and departments appropriately and consistently.

In addition we found that governance and risk management systems required improvement, Care and treatment was not always robustly supported by evidence-based policies and procedures. The trust could not give assurance that all care and treatment was in line with NICE guidelines as monitoring systems were incomplete and inconsistently applied.

We also found that clinical audit was not fully supported, although the trust was trying to improve this situation across all services. (Clinical audit is an important element of monitoring, managing and improving care and treatment for patients).

Despite actions taken to improve responses to serious incidents and promote a culture that supported openness, transparency and learning, the trust had reported 10 never events since November 2012. (Never events are very serious, largely preventable patient safety incidents that should not occur if the relevant preventative measures have been put in place). At that time the recurring themes emerging from the never events indicated that the actions taken and the sharing of lessons learned were not systematically embedded or applied.

At this inspection it was evident that the trust had worked hard to sustain and secure further improvement as well as continue its efforts to include and engage staff in service development and improvement. However, it was also evident that despite vigorous efforts to address some longstanding recruitment issues and managerial challenges there was still much for the trust to do.

Our key findings from this inspection were as follows;

The main areas of concern remained the recruitment and retention of Medical and Nursing staff and the impact that these difficulties were having on the quality and timeliness of services provided to patients.

Medical staffing

Despite efforts by the trust to improve the numbers of medical consultants employed, There were numerous vacant consultant posts. At the time of our inspection there was a deficit of 55.8 wte posts.

Vacancies were covered by locum doctors in some areas; however the high vacancy rate was having an adverse effect on the timeliness of treatment for patients and meant support for junior doctors was not robust or effective in a number of core services.

In Cumberland Infirmary we had concerns regarding the out of hour’s anaesthetic cover; we raised this with the trust at the time of our inspection. The trust took immediate action to improve the cover provided.

Nurse staffing

Nurse staffing levels were calculated using a recognised dependency tool and regularly reviewed. There were minimum staffing levels set for wards and departments.

The trust had been actively recruiting nursing staff and although the numbers of nurses had improved, there were still vacancies in some key areas. This was a particular issue on the medical wards.

Nursing vacancies were often covered by bank staff, overtime and agency nurses and there was a trust wide escalation process in place to report staffing shortages, however, there were occasions when managers could not respond appropriately and secure the additional resources required . There were times when wards and departments were not adequately staffed.

The trust acknowledged that the current position was inappropriate and presented a risk to patient safety. In response the trust was seeking new and innovative ways of maximising its nursing resources and of attracting and appointing nursing staff. There was evidence of ongoing recruitment during our inspection.

Midwifery staffing

The midwife to birth ratio was 1 to 25 at Cumberland infirmary and 1 to 24 at West Cumberland hospital. This was better than the England average which was 1 to 28. 100% of patients had one to one care from a midwife during labour.

Mortality and morbidity

The trust has sustained the improvement in its mortality rates. There were no risks identified with Dr Foster Hospital Standardised Mortality Ratios (HMSR). The Summary Hospital Mortality Indicator (SHMI) was 0.98 and within the expected range.

The trust continued to review its mortality data each week as part of its Safety Panel at a corporate level The safety panel provided a monthly report to the Safety & Quality Committee.

Incident reporting

The Trust has reported 3 Never Events since March 2014. All events were subject to an investigation and remedial actions and learning points identified and shared with staff via a Safety Newsletter that shared findings, discussed new initiatives and encouraged learning.

The trust had a comprehensive process for investigating serious incidents. All the incident reports we reviewed had comprehensive timelines, clear methodology descriptions and varied use of root cause analysis tools. The investigation reports we viewed were of a good standard.

Although Staff were aware of the incident reporting system and how to use it, the NRLS report indicates that the trust has a patient safety incident reporting ratio of 6.80 per 100 admissions. This is at the lower end of performance for a trust of this size and indicates a poor level of incident reporting.

Safeguarding

Policies and procedures were in place that outlined the trust’s processes for safeguarding adults and children. Safeguarding policy and procedures were supported by staff training and the numbers of staff who had received training had increased, particularly in services for children and young people. 95% staff requiring Level 3 Safeguarding & Protecting Children Training having received it at 31/03/2014. The areas for improvement were noted as medical staff within obstetrics and gynaecology, A&E and Dermatology.

There was evidence of the appropriate referral and escalation of safeguarding concerns for both adults and children.

Mandatory training

The trust provided a good range of mandatory training and had set itself a target of 80% of staff completing all mandatory training in the year. However performance was varied and improvements in the numbers of staff completing mandatory training required improvement across both a number of core services and professional groups.

Cleanliness and infection control

Both hospitals were visibly clean and there were ample supplies of hand washing facilities and personal protective clothing (such as aprons and gloves) to support good hygiene and infection control practice.

Staff in the main followed good practice guidance and monthly hygiene audits demonstrated good levels of compliance.

Infection rates were within acceptable limits The infection rates for Clostridium difficile (C.diff), including the wards within the medical unit, had been below the England average, with only one case reported between April 2013 to November 2014.. However, the trust saw significant increases in the numbers of C.diff cases in September and December. The cases related to two areas; an elderly care ward and general surgery. The cases had been investigated and the trust was taking remedial action to address these issues at the time of our inspection.

There had been an outbreak of Norovirus that had resulted in a number of beds being closed. The outbreak had been subject to a root cause analysis and remedial action planning.

Nutrition and hydration

Patients had a choice of nutritious food and an ample supply of drinks during their stay in hospital. Patients with specialist needs in relation to eating and drinking were supported by dieticians and the speech and language therapy team. There was a system in place that identified patients who needed assistance with eating and drinking. Support with eating and drinking was given to patients in a sensitive and discreet way.

Case Note Availability

As a result of targeted work there had been a significant improvement in the availability of patient records in the outpatients department. Performance had improved by over 20% with 95% of patient case notes available for their outpatient consultation.

Patient Outcomes

Good patient outcomes were demonstrated through patient reported outcomes measures (PROMs) data between April 2013 and March 2014 which showed that the percentage of patients with improved outcomes following groin hernia, hip replacement, knee replacement and varicose vein procedures was either similar to or better than the England average.

The average length of stay for elective and non-elective patients across all specialties was better the England average. The rate of normal births was in line with the England average and maternal readmission rates were in line with the England average.

A local audit of End of Life Care had taken place as a base line for the pilot of the new End of Life Care plans. This showed that patients had access to anticipatory medications for pain and distress at the end of life.

Due to there being only one consultant for TOP, patients could wait up to three weeks for an appointment following referral by their GP against a recommendation of five working days and actions to develop the service further in order to reduce the waiting times were on-going.

Access and flow

The trust remained under pressure from the numbers of emergency admissions through its accident and emergency (A&E) departments.

In 2014/15, Cumberland Infirmary only met the Department of Health target for emergency departments to admit, transfer or discharge patients within four hours of arrival, once in July 2014 with a range over the year between 69.1% to 96.6%. Over the year, 12 patients waited for more than 12 hours from the decision to admit to being admitted. Individual breaches of the four hour target were investigated and the majority were due to patients waiting for a bed in the ward areas. The trusts position had not improved since our last inspection and remained an area of concern.

The A&E department at West Cumberland Hospital had also struggled to meet the Department of Health target, over the second half of the year, performance between October 2014 and March 2015 was poor with only 86.3% compliance in February 2015. There were a number of four hour target breaches with patients in the department for over seven hours. The breach reports indicated the majority of delays were due to patients waiting for a bed in the ward areas.

Emergency admissions affected the number of available beds particularly in medicine. Patients were often placed in wards and areas that were not best suited to their needs.

Although the trust had systems in place to make sure that patients placed in areas away from the relevant specialist area were seen regularly by an appropriate doctor, this was not always carried out in timely way. In addition, patients often experienced a number of moves from ward to ward, sometimes during the night. This was not a positive experience for patients.

Surgical patients were also affected because operations were cancelled if inpatient beds were not available.

Providing responsive services

The Trust was consistently failing to achieve the majority of access targets. These include the A&E 4 hour waiting target, 18 week referral target for treatment for admitted and non-admitted pathways, the urgent referral 2-week targets and the cancer 62-day referral and screening targets. The cancer 31-day target was generally achieved.

This meant that patients were not receiving care and treatment in a timely way and performance in these key areas required significant improvement.

Vision and Strategy

It was evident that the leadership team were committed to service improvement for the benefit of patients and were keen to include staff in the improvement journey. The trust had made significant improvements in the risk management and governance processes. The trust had demonstrated improvement to 6.5 by June 2014 against the Monitor Quality Governance framework although did not yet meet the requirements.

However, whist the Trust has clearly articulated a clinical strategy including its preferred options for its most fragile services, these had not yet been agreed as part of the required system wide transformation programme by the CCG. Detailed planning and implementation work expected to address some of the key operational challenges had not therefore been possible.

Duty of Candour

The trust was aware of its role and responsibilities in relation to the Duty of Candour requirements and had begun to embed processes that were supported by a Duty of Candour checklist. The Trust updated its Being Open process following the introduction of Duty of Candour regulation in November 2014. Monitoring arrangements indicated that in 100% of serious harm incidents; the Trust has met the Duty of Candour requirements. This was less so for moderate harm incidents, with the December 2014 compliance being as low as 40%.

Fit and Proper Persons

The trust was prepared to meet the requirements of the Fit and Proper Persons regulation (FPPR). This regulation ensures that directors of NHS providers are fit and proper to carry out this important role. The trust policy on pre-employment checks covered criminal record, financial background, identity, employment history, professional registration and qualification checks. It was already part of the trust’s approach to conduct a check with all relevant professional bodies (for example, medical, financial and legal) and undertake due diligence checks for senior appointments.

Importantly, the trust must:

  • Ensure that medical staffing is sufficient to provide appropriate and timely treatment and review of patients at all times including out of hours.
  • Ensure that medical staffing is appropriate at all times including medical trainees, long-term locums, middle-grade doctors and consultants.
  • Ensure that nursing staffing levels and skill mix are appropriate particularly in medical care services
  • Take action to improve the levels of mandatory training compliance.

  • Take action to improve the rate of appraisals completion.

  • Improve patient flow throughout both hospital’s to ensure patients are cared for on the appropriate ward for their needs and reduce the number of patient bed moves, particularly in the medical division.
  • Improve the rate of incident reporting

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 30 April - 2 May & 12 May 2014

During a routine inspection

North Cumbria University Hospitals NHS Trust serves a population of 340,000 people living in Carlisle, Whitehaven and the surrounding areas of West and North Cumbria. In total the trust employs 4,272 staff and has 629 inpatient beds across the Cumberland Infirmary in Carlisle, the West Cumberland Hospital in Whitehaven and the Penrith Birthing Centre.

We carried out this comprehensive inspection because North Cumbria University Hospitals NHS Trust had been placed in a high risk band 1 in CQC’s Intelligent Monitoring System. The trust was also one of 11 trusts placed into special measures in July 2013 after Sir Bruce Keogh’s review into hospitals with higher than average mortality rates. At that time, there were concerns around inadequate governance and pace and focus of change to improve overall safety and experience of patients; slow and inadequate responses to serious incidents and a culture that did not support openness, transparency and learning; staffing shortfalls and other workforce issues across staff groups that may have been compromising patient safety. In addition the review found a lack of support for staff and effective, honest communication from middle and senior management level; failure in governance to ensure adequate maintenance of the estate and equipment, and significant weaknesses in infection control practices.

Immediately before the Keogh review, and since that time, the trust has been led by an interim (recently permanent) Chief Executive and a largely interim management team. Support has been provided by both the Trust Development Authority and Northumbria Healthcare Foundation Trust as a ‘buddy’ organisation. Northumbria trust has seconded staff to strengthen the management team and provide additional capacity to secure improvements to services.

We undertook an announced inspection of the trust between 30 April and 2 May 2014, and made unannounced inspection visits between 8.30am and 4pm on 12 May 2014.

Overall, this trust was found to require improvement, although we rated it good in terms of having caring staff.

Our key findings were as follows:

  • We recognised that the trust had worked hard and had made some progress since entering special measures in July 2013. Importantly, mortality rates were now within expected limits. However, the trust had 52 required actions as part of its Keogh Mortality Review action plan and, as of March 2014, all but four had been delivered. The remaining four actions had revised dates for delivery during 2014, as approved by the trust board.
  • The range and nature of the improvements required within a complex and geographically challenging environment had added to the complexity of the challenges facing the trust.
  • Despite the progress made in mortality rates and improved governance, there remained many issues of serious concern. The trust was experiencing major difficulties in recruiting doctors – particularly consultants. The shortfall in consultant cover was posing a considerable challenge to the trust with regards to maintaining safe and timely standards of care and treatment. Nurse staffing had improved overall, but still remained a challenge in terms of staffing all wards and departments appropriately and consistently.
  • There were other significant challenges that were taking some time to resolve as they require cultural and behavioural changes by the trust’s workforce. Staff at all levels gave a very mixed picture regarding the culture within the trust. Some were positive about the new senior team and felt the Chief Executive was visible and accessible. However, many staff who spoke with us stated that raising concerns was not always viewed positively and we heard many examples of staff feeling unable to speak openly or be involved in proposed changes. The lack of effective, honest communication from middle and senior management level remained an issue. Staff reported being fearful of raising issues with managers and a number of staff were visibly upset when raising their concerns with us and were concerned that their names would be made known to managers in relation to concerns raised. It was clear that some executive messages were becoming distorted before reaching the ward and departmental staff, leaving staff with mixed messages and unclear direction.
  • Changes had already been made to the care pathways for patients with high risk trauma and orthopaedic or complex surgical needs. This had resulted in more patients being transferred and/or cared for at the Cumberland Infirmary in Carlisle. However, this had left an imbalance and some discontent among staff about the effective use of resources in relation to routine elective work between the two acute hospitals.
  • Care and treatment was not always robustly supported by evidence-based policies and procedures. The trust could not give assurance that all care and treatment was in line with NICE guidelines as monitoring systems were incomplete and inconsistently applied.
  • Patient flow was poorly managed, resulting in poor experiences for patients. This was evident in delays at A&E where some patients had extended stays in the department and on occasions overnight. There were delays in discharge from critical care beds to the wards as beds were unavailable. We noted a number of incidents when patients were transferred between wards late at night. Some beds were not being used because of the lack of staff to provide care. This was an added dimension to the difficulties regarding patient flow and access to appropriate care settings.
  • Despite actions taken to improve responses to serious incidents and promote a culture that supported openness, transparency and learning, the trust had reported 10 never events since November 2012. Never events are very serious, largely preventable patient safety incidents that should not occur if the relevant preventative measures have been put in place. The recurring themes emerging from the never events indicate that the actions taken and the sharing of lessons learned were not systematically embedded or applied across the trust.
  • Infection control had significantly improved, although there were some concerns regarding the transfer of patients to the mortuary and the laundry facilities in the Special Care Baby Unit at the Cumberland Infirmary. General handwashing and timely general waste disposal could be improved.
  • Clinical audit was not fully supported, although the trust was trying to improve this situation across all services.Clinical audit is important in monitoring, managing and improving care and treatment for patients.
  • Outpatient services were failing to meet the six and 18-week targets for referral to treatment. Concerns about the effectiveness of clinics related directly to medical staffing issues and the supply of medical records, which was having a detrimental effect on the efficiency of the service.
  • Throughout our inspection we witnessed patients being treated with compassion, dignity and respect. Staff interacted positively with patients and /or their relatives and demonstrated caring attitudes. They were very supportive to both patients and those close to them and offered emotional support to provide comfort and reassurance.

There were areas of practice where the trust needs to make improvements.

Importantly, the trust must:

  • Ensure there is a culture that supports openness, transparency and learning through effective, honest communication from middle and senior management level, robust responses to serious incidents and open engagement with all staff regarding future plans.
  • Ensure that board assurance is supported by robust sources of information and is presented informatively.
  • Address staffing shortfalls, in particular the numerous consultant vacancies. Nurse staffing levels must also be appropriate in all areas, without substantive staff feeling obligated to work excessive additional shifts.
  • Follow national guidelines of having an anaesthetist available at all times for obstetrics at the West Cumberland Hospital, and a second theatre for obstetrics and gynaecology use.
  • Address the impact of the changes to routine elective work between the two acute hospitals appropriately.
  • Ensure that policies and procedures to support safe practice are robust and that they include a major incident plan for surgery.
  • Show evidence of compliance with relevant NICE guidance and that clinical audit is consistently used to assess practice and support improvement.
  • Ensure clinical risk management provides robust systems to monitor, mitigate and learn from incidents to support service improvement and patient safety.
  • Improve waiting times in A&E and the patient flow to ensure patient transfers are not unnecessarily delayed, patients are not moved at inappropriate times of the day or night or inappropriately accommodated in A&E overnight.
  • Support outpatients to effectively meet national targets, and ensure patient records are available to support patient consultations.
  • Provide clinical supervision to all staff.
  • Address all estates and equipment deficits.

In addition the trust should:

  • Ensure there is an epidural service at the Cumberland Infirmary.
  • Ensure specialist triage nurses in A&E are available for all children presenting.
  • Improve infection control in the mortuary and the Special Care Baby Unit at the Cumberland Infirmary, and improve general handwashing and timely general waste disposal.
  • Continue to improve responses and reviews of complaints.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Use of resources

These reports look at how NHS hospital trusts use resources, and give recommendations for improvement where needed. They are based on assessments carried out by NHS Improvement, alongside scheduled inspections led by CQC. We’re currently piloting how we work together to confirm the findings of these assessments and present the reports and ratings alongside our other inspection information. The Use of Resources reports include a ‘shadow’ (indicative) rating for the trust’s use of resources.


Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up.

Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.


Joint inspection reports with Ofsted

We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.


Organisation Review of Compliance