University Hospitals of Morecambe Bay NHS Foundation Trust is a large acute hospital provider serving the population of South Cumbria and North Lancashire. The trust was established in 1998 and gained teaching status in January 2006. It has been a foundation trust since 2010. Services provided at the trust are commissioned by two clinical commissioning groups based in Lancashire and Cumbria.
The trust provides services from three principal sites to a population of 365,000, covering South Cumbria, North Lancashire and surrounding geographical areas. The hospital sites we inspected were: Furness General Hospital in Barrow; Royal Lancaster Infirmary in Lancaster and Westmorland General Hospital in Kendal.
We carried out this inspection to follow up on the improvements required in response to the findings of our inspection in February 2014. At the time of our February 2014 inspection we had significant concerns regarding the trust’s ability to assure safe and well managed services for patients. There were particular concerns relating to medical services and critical care services as well as significant concerns regarding the trusts strategic approach to service provision, its leadership capacity and its governance systems. The safety and well led domains were rated as inadequate.
Our inspection findings led to a recommendation that the trust be placed in ‘special measures’. Special measures is a status applied by regulators of public services in England to providers who fall short of acceptable standards. In response an improvement director was appointed by Monitor to support the trust in making the required improvements. The trust developed a detailed action plan to address the identified shortfalls. Since that time we have worked closely with the trust and Monitor regarding the implementation of the required improvements.
We carried out a further inspection between July 14 and July 17 2015 (inclusive) to assess and evaluate the impact of the improvements made on the safety and quality of services provided to patients, and to evaluate how well the trust was led and managed. We looked at all the core services provided by the trust which are;
- Accident and emergency
- Medical care (including older people’s care)
- Critical care
- Maternity and family planning
- Services for children and young people
- End of life care
We also looked at the progress the Trust had made in implementing the recommendations made by Public Health England (PHE) following a review of the Breast Screening Service undertaken in response to concerns raised by staff. In addition, we reviewed the progress the trust was making in implementing the recommendations made following the enquiry in to maternity services by Dr Bill Kirkup.
The trust had made progress in all the areas we identified in our inspection in February 2014. However, there were still a number of areas that required further and ongoing improvement. Key concerns related to the recruitment of nursing and medical staff. There were also a number of midwife vacancies. The trust acknowledged that further work was required and there were plans and initiatives in place to secure additional staff at the time of our inspection.
Our key findings were as follows;
Leadership and staff engagement
The Executive Team had stabilised and was working well together to secure service improvements, a new Chief Operating Officer had been appointed. Senior managers were more visible and accessible to staff and staff were positive about this development.
The trust had approved its Quality Improvement Plan 2014-2017, ‘Better Care Together’. This document detailed clear objectives with expected outcomes and indicators for the improvement trajectory.
To support the delivery of ‘Better Care Together’ and staff engagement overall, the trust had commenced the ‘Listening into Action’ programme. The first year of Listening into Action (LiA) resulted in clinical teams leading 16 quality improvement schemes through a 20 week improvement cycle. A further 13 teams are now being supported through the next improvement cycle and 10 priorities have been identified for accelerating LiA as the key approach for engagement and improvement in 2015/16 onwards.
The trust had also appointed a ‘freedom to speak up guardian’ in response to the Freedom to Speak Up Review into whistleblowing in the NHS. The intention was to support staff so they could raise concerns in the public interest with confidence that they would not suffer detriment as a result. This work was in progress at the time of our inspection.
However, there were areas regarding staff engagement and support that still required improvement. One area of particular concern was the Workforce Race Equality Standard (WRES) submission which highlighted that BME staff had a disproportionate employee experience compared to non-BME colleagues. These views were confirmed in our meetings and focus groups with BME staff. Some staff felt they were very well supported, however others alleged a bullying culture where they felt marginalised and unable to raise concerns without there being repercussions. We raised this matter with the trust who confirmed that they were aware of the issues and, in response, had met with BME staff representatives to hear their concerns and had committed to working with staff to agree what actions needed to be taken to improve this. The trust had reviewed its leadership on diversity and inclusiveness, and as a result had appointed a designated Board lead and leads for both workforce and service issues. There were plans in place to involve and include staff from a BME background in all of the work streams intended to secure improvements and promote an open and just culture.
However, there were concerns regarding the culture in the paediatric service in Furness General Hospital. Senior clinicians reported a bullying culture where concerns were slow to be heard and addressed.
The trust had a Leadership Development Strategy that was approved on the 24 June 2015. This document described the trust’s strategic approach and included values-based leadership, staff engagement/Listening into Action, Human Factors and alignment with the NHS Healthcare Leadership Model. A scoping exercise for Clinical Leadership Development was planned for the summer, to complement the Kirkup recommendations on reviewing clinical leadership training. A bespoke development programme for ward and clinical team leaders had been commissioned, with the second cohort now undertaking this programme.
Governance and risk management.
Governance and risk management systems had improved considerably since our last inspection. A comprehensive Risk Management Strategy (2015-16) was in place that set out the roles and responsibilities for risk management. The appendices of the strategy gave clear guidance on how to undertake a risk assessment for inclusion on the risk register.
The Board Assurance Framework (BAF) had been reviewed in relation to its structure and appropriateness for the organisation. The BAF was reviewed and presented to the board at the April 2015 Board meeting. The framework was aligned to the trust vision, values, objectives and priorities. Controls, mitigation, assurance, gaps in assurance, rating and rationale for rating were clearly documented. The BAF linked to the corporate risk register identified appropriate risks and there was evidence of the Board reviewing corporate risks in both January and April 2015. This was an improvement since our last inspection.
Nurse staffing levels had improved. Ward staffing establishments were calculated using a recognised dependency tool and regularly reviewed. There were minimum staffing levels set for all wards and departments. The ‘red rules for safety’ initiative was being implemented across all wards and departments.
The principals of this initiative included one registered nurse should deliver care to no more than eight patients and the minimum skills mix on a ward should be 60% registered nurses to 40% health care assistants.
The staffing issues in the High Dependency Unit had been comprehensively addressed and there was sufficient numbers of nurses to meet the needs of patients at all times. In other wards and departments throughout the trust staffing levels met the needs of the patients at the time of our inspection; however, the skill mix on ward 39 and ward 20 at Royal Lancaster Infirmary was still variable and did not always meet the ‘red rules’ requirements of one registered nurse to eight patients. E-rostering data excluded bank and agency. Safer staffing data demonstrated that ward 39 and ward 20 had sufficient staffing for the month of June 2015. There were times when skill mix had been reduced this was due to additional health care support staff being employed to support dependent patients on these wards. The data demonstrated that staff were used flexibly over a 24-hour period. In Furness General Hospital staffing levels met the needs of the patients at the time of our inspection, however, on reviewing staffing rotas over the previous month there were concerns regarding the staffing levels and skill mix on some wards. It was evident that there were still nurse vacancies in some specialities. There was an escalation process in place for managers to respond to staffing challenges, however there were times when wards were not always appropriately staffed.
In May 2015 the trust reported a registered nurse vacancy rate of 13.1%. The trust was engaged in the ongoing recruitment of staff at the time of our inspection.
The trust also continued to develop additional solutions to respond to staff shortages, including Physician’s Assistants, Advanced Practitioners and Non-Medical Consultant roles. In addition, the trust had successfully appointed a cohort of 36 Apprentices in Clinical Healthcare and was currently advertising for a further 36 apprentices to commence in September 2015. The trust continued to work with external recruitment agencies to undertake bespoke recruitment overseas.
There were a number of concerns regarding medical staffing including middle grade cover in surgery at Westmoreland Hospital; In addition there were concerns regarding the sustainability of the paediatric consultant on call cover and lack of junior doctor cover in the service for children and young people. There were ongoing challenges in addressing the concerns within the breast screening unit and there were consultant vacancies within End of Life Care with no post at Furness General Hospital.
The trust however performed within expectation for 11 categories out of 13 in the GMC National Training Scheme survey.
The trust was actively reporting patient safety incidents. The most recent NRLS report (March 2015) detailed a ratio of 43.49 patient safety incidents reported per 1000 bed days. The average for all acute trusts is 35.1. This indicates good performance by the trust in this regard.
The trust had a process for the management of serious incidents and held a weekly ‘Patient Safety Summit’ to review all incidents causing moderate harm or above, alongside any significant near misses. The weekly summit had the responsibility of identifying trends that were then allocated to task and finish groups, completing root cause analysis investigations and providing a quarterly summary to the ‘SIRI Panel’. The SIRI Panel provided a quarterly report to the Quality Committee. The Quality Committee in turn reported to the Board.
Paediatric medical staff remained concerned about their lack of involvement in the ‘rapid review process’ in relation to Serious Incidents Requiring investigation (SIRI) and felt excluded from the process in incidents relating to babies referred from maternity services.
Implementing recommendations and securing improvement.
Public Health England (PHE) had undertaken a review of the Breast Screening Service in response to concerns raised by staff. The review concluded that film reading and clinical practice at the assessment stage in the breast screening service was currently operating within national minimum standards, however the working environment within the service was extremely poor and if not addressed urgently the service would be unlikely to be able to continue to provide a safe service.
The trust had made progress in implementing the technical and recording recommendations made in response to the PHE review. However, the pace at which the required management changes were being implemented was slow and had become very protracted. It was acknowledged that the trust did have some complex staffing issues to address, however the pace of change meant that professional relationships and the culture within the Breast Screening Unit remained a cause for concern.
The trusts maternity service had been subject to an independent enquiry established to review the management, delivery and outcomes of care provided by the maternity and neonatal services between January 2004 and June 2013. (Kirkup Enquiry). The trust had developed a comprehensive plan to respond to the recommendations made in the report and there was evidence that the trust was making progress in this regard. However, there was still work to do, in particular, embedding the improved governance and risk management systems, improving the maternity dash board and aligning investigation processes. Joint working across the maternity and paediatric services had improved; however, there was still work to be done to assess the impact of the improved arrangements on the functionality of teams.
Importantly, the trust must:
- Ensure that all premises used by the service provider are suitable for the purpose for which they are being used and properly maintained. This is particularly in relation to physiotherapy services and medical care services provided from medical unit one.
- Ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed in order to meet the needs of the patients.
- Staff should receive appropriate support, training and appraisal as is necessary to enable them to carry out their role.
- Ensure that staff understand their responsibilities under and act in accordance with the requirements of the Mental Capacity Act 2005 and associated code of practice.
- Ensure that staff follow policies and procedures around managing medicines, including intravenous fluids particularly in medical care services and critical care services.
- Ensure referral to treatment times in surgical specialities meet the national target.
- Ensure that the resuscitation trolleys on the children’s ward are situated in areas that make them easily accessible in an emergency. All staff must be clear on who has responsibility for the maintenance of the resuscitation trolley on the delivery suite.
- Ensure that they maintain an accurate, complete and contemporaneous record in respect of each service user.
It is apparent that the trust is on a journey of improvement and progress is being made both clinically and in the trust’s governance structures. I am therefore happy to recommend that University Hospitals of Morecambe Bay NHS Foundation Trust is now taken out of special measures. This is subject to establishing a partnership arrangement with another provider specifically to support the ongoing improvement required in maternity services.
Professor Sir Mike Richards
Chief Inspector of Hospitals