You are here

Provider: University Hospitals of Morecambe Bay NHS Foundation Trust Requires improvement

On 16 May 2019, we published a report on how well University Hospitals of Morecambe Bay NHS Foundation Trust uses its resources. The ratings from this report are:

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

Read more about use of resources ratings

Inspection Summary


Overall summary & rating

Requires improvement

Updated 16 May 2019

Our rating of the trust went down. We rated it as requires improvement because:

We rated safe, responsive and well led as requires improvement and effective and caring as good. The safe and effective ratings remained the same as our inspection in 2016. However, caring went down from outstanding to good and well-led and responsive went down from good to requires improvement.

  • In rating the trust, we took into account the current ratings of the services that we did not inspect during this inspection but that we had rated in our previous inspection.
  • We rated well led for the trust overall as requires improvement. This was not an aggregation of the core service ratings for well led

Our full inspection report summarising what we found and the supporting evidence appendix containing detailed evidence and data about the trust is available on our website – www.cqc.org.uk/provider/RTX/reports.

Inspection areas

Safe

Requires improvement

Updated 16 May 2019

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

  • There were policies and processes and documentation in place in relation to safeguarding in the trust. However, this was heavily weighted towards child safeguarding. The adult safeguarding had more of an emphasis on mental capacity act rather than safeguarding. There were gaps noted in the mental capacity act procedures for children between 16 and 18.
  • The trust did not always have enough nursing staff, with the right mix of qualifications and skills to keep patients safe and provide the right care and treatment. Nurse fill rates were low on some wards. We were not assured that the trust could meet the recommended nurse staffing guidelines for patients receiving non-invasive ventilation set out by the British Thoracic Society. To mitigate risk, wards over allocated clinical support workers where possible and had developed a training conversion scheme for clinical support workers wishing to become registered nurses.
  • The trust did not always follow best practice when storing medicines. We found out of date medicines, and open bottles without the date of opening clearly displayed within the medicine core service. Medicines stored in fridges did not always have the temperature recorded which was something we identified at our previous inspection. There was no monitoring of the temperature of rooms containing medicines fridges.
  • Senior doctors did not always review patients in a timely way. Stroke care was nurse led at weekends, and stroke consultants did not see stroke patients in the emergency department. In the acute medical unit only three quarters of patients were reviewed by a consultant within 14 hours of arrival.
  • Staff training compliance failed to meet trust target for Safeguarding Adults level 2 which included Mental Capacity Act and Deprivation of Liberty Safeguards training.
  • Staff across the trust were not consistently meeting the trust standard for mandatory training of 95% for all of the mandatory training modules. We identified this as an issue at our previous inspection.
  • Although ambulance handover was usually within 15 minutes, the department had experienced a significant number of black breaches, meaning patients were not handed over to the department staff for more than two hours. This posed a risk to patients waiting to be seen.
  • Urgent and emergency care had medical staffing vacancies and at the time of the inspection, there was only one part time consultant employed by the department. Consultant cover for the department was limited. The most senior full time substantive medical staff employed was associate specialist grade.

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.
  • Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date and easily available to all staff providing care. Monthly matrons’ records audits kept quality high.
  • Staff knew how to report an incident using the trust’s electronic system and were aware of the importance of doing this. When things went wrong, staff apologised and gave patients honest information and suitable support. There were clear routes for feedback and learning from incidents to be shared and some, but not all wards, were using this effectively.
  • Staff kept detailed records of patient’s care and treatment. Records were clear, up-to-date and easily available to all staff providing care. Staff had access to records which were managed and stored securely.
  • All areas visited were visibly clean and tidy.

Effective

Good

Updated 16 May 2019

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

  • The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.
  • Staff gave patients enough food and drink to meet their needs and improve their health. They used special feeding and hydration techniques when necessary. The service made adjustments for patients’ religious, cultural and other preferences.
  • Staff assessed and monitored patients regularly to see if they were in pain. They supported those unable to communicate using suitable assessment tools and gave additional pain relief to ease pain.
  • Managers monitored the effectiveness of care and treatment and used the findings to improve them. They compared local results with those of other services to learn from them.
  • Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
  • Staff always had access to up-to-date, accurate and comprehensive information on patients’ care and treatment. All staff had access to an electronic records system that they could all update.

However:

  • The urgent and emergency care service took part in Royal College of Emergency Medicine (RCEM) audits, it had not met any of the standards in the audits carried out in 2016/17 or 2017/18. Requested action plans had not been provided.
  • Urgent and emergency care was performing worse than the national standard of unplanned reattendance of patients.
  • Seven-day services were not fully embedded across the trust. Consultant ward rounds were generally Monday to Friday only with limited medical cover at weekends and out of hours. A shortage of therapy staff meant they were not able to provide seven-day services.
  • Appraisal rates across the trust were not meeting the trust target of 95%. The people information report, July 2018 present to the trust board, identified that only 76% of staff were up to date with their annual appraisal. This equated to 1261 staff across the trust being non-compliant with their annual appraisal.
  • Not all staff understood how and when to assess whether a patient had the capacity to make decisions about their care. They did not always follow trust policy and procedures when a patient could not give consent.

Caring

Good

Updated 16 May 2019

Our rating of caring went down. We rated it as good because:

  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
  • Staff provided emotional support to patients to minimise their distress.
  • Staff involved patients and those close to them in decisions about their care and treatment.
  • There was consideration and thought given to the emotional needs of patients. Spiritual and pastoral support was available to patients from the hospital chaplaincy service.

However:

  • When the emergency department was busy, patient’s care needs were not always met and there was a lack of evidence that comfort rounds and regular checks on patients were taking place.
  • We saw examples of where patient’s privacy and dignity were compromised while they waited and received treatment in the emergency department.
  • We observed that chaperones were not routinely offered to patients when being examined or receiving care.
  • Not all patients had access to call bells.
  • We observed alarms on medical equipment being ignored by staff within the emergency department.

Responsive

Requires improvement

Updated 16 May 2019

Our rating of responsive went down. We rated it as requires improvement because:

  • The trust had an ongoing challenge with the Deprivation of Liberty Safeguards (DoLS) applications due to the high numbers of applications being made to the local authority. A mental capacity act DoLS re-audit was completed in July 2018, which highlighted that the patient safety incidents were not always complete when a DoLS application was made (identified as only 75% at the time of the audit). It also identified that capacity assessments were not always completed prior to a DoLS application.
  • All specialties were below the England average for referral to treatment times (RTT) rates (percentage within 18 weeks) for admitted pathways.
  • From July 2017 to June 2018, there were 1,863 patients moving wards at night at the Royal Lancaster Infirmary.
  • There was work to be completed to bring the trust overall appraisal rate in line with the trust target rate.

However:

  • The trust planned and provided services in a way that met the needs of local people.
  • The trust took account of patients’ individual needs.
  • The trust treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff.
  • The management of medical patients on non-medical wards was good and patients received timely reviews and treatment from a consultant.

Well-led

Requires improvement

Updated 16 May 2019

Our rating of well-led went down. We rated it as requires improvement because:

  • There were significant challenges with the urgent and emergency core service where it has been rated as requires improvement across all three hospital sites, including within the caring domain at the Royal Lancaster Infirmary site. At our previous inspection in 2016, we rated urgent and emergency at the Royal Lancaster Infirmary site as requires improvement in safe and well-led and good in effective, caring and responsive. At this inspection, the rating had gone down to requires improvement for all five domains.
  • The rating for caring across the trust went down to good from outstanding at our last inspection.
  • We saw limited evidence of challenge and documenting actions agreed to address adverse performance from the non-executive team within the minutes of board meetings.
  • We reviewed the trust management board minutes for October, November and December 2018. We found there was a tendency to review presentations rather than reports at these meetings. Actions from the agenda items were not clear.
  • We saw examples of where the pace of actions/implementation was slow and there was an opportunity for the trust to move at pace on areas identified as high risk, for example the financial situation and areas of improvement from the staff survey.
  • The non-executive directors reported that the care groups had a much better understanding of their operational and financial performance risks than previously. However, they expressed some frustration at the pace of change in formulating and implementing solutions.
  • There was little evidence of formal staff engagement to monitor staff wellbeing and staff morale within urgent and emergency care.
  • There was limited evidence of where governors had held non-executive directors to account.
  • We found some discrepancies within the fit and proper persons (FPPR) files which was predominantly because the trust was working on two systems. There was also an error with the disclosure and barring service (DBS) check within one file where the person had commenced in post in April 2018, but the DBS check was only valid from October 2018. This had been due to an error within human resources (HR).
  • We saw limited assurance in relation to how learning and actions were shared both across the care groups and up to the trust board. A vast amount of information was presented by the many different care groups and committees/sub committees at the monthly quality committee meeting. It was not always clear that the pertinent risks and issues were presented in a way that all staff could understand the key risks from the volume of information were provided.
  • Succession planning at board level was in place. However, the trust recognised there was more to do in respect of senior and middle management. A talent management programme was being implemented alongside a more structured approach to appraisal.

However:

  • The trust has been held as an exemplar of governance by NHSI and in the last year and had provided peer support to the two other hospital trusts. The trust supported NHS England with a national review of complaints and the new system architecture.
  • The trust had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff, patients and key groups representing the local community.
  • Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. We saw real improvements in culture from previous inspections.
  • The trust had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.
  • The trust collected, analysed, managed and used information well to support all its activities, using secure systems with security safeguards.
  • The trust engaged well with patients, staff, the public and local organisations to plan and manage appropriate services and collaborated with partner organisations effectively.
  • The trust was committed to improving services by learning from when things went well and when they went wrong, promoting training, research and innovation.
  • The trust’s vision was prominent in literature and displays and the behaviours developed from this were embedded in practice. The care group strategy was clear and linked well to the wider trust and ICS priorities.

Assessment of the use of resources

Use of resources summary

Inadequate

Updated 16 May 2019

Combined rating

Combined rating summary

Requires improvement