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
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Take action to improve the levels of mandatory training compliance.
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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