We initially inspected the Cumberland Infirmary in March 2013. We found that they were non-compliant in three areas: Care and welfare, staffing and records. The areas of concern we saw were around the poor management of patient flow with patients being moved from ward to ward on several occasions and patients waiting for substantial periods in the accident and emergency department awaiting admission. We also found that there were inadequate staffing levels in most areas of the hospital which meant that some patients did not receive basic levels of care such as personal hygiene. Patient's told us that staff were often too busy to help them. Staff told us that they were under immense pressure and in some instances were working long hours to make sure they could care for patients adequately. Staff were not keeping accurate records that reflected the care that they had given to patients.

Due to the complex nature of the problems highlighted in our initial report the Trust put together a detailed and robust action plan which included all the areas of concern. They set timescales and demonstrated what they were going to do to achieve compliance with the essential standards of quality and safety. The plan showed that the Trust would aim to be compliant in the three areas of concern by the end of March 2014.

In May 2013 the Trust was part of the Sir Bruce Keogh Review into hospital mortality rates. The Keogh review highlighted similar issues at the Cumberland Infirmary.

Because of the substantial amounts of improvement needed following our inspection in March we returned to the Cumberland Infirmary in early September 2013 to monitor the progress of the Trust. We wanted to assess whether the targets outlined in the Trust's action plan were being implemented and what impact that had on improving the patient experience and the care being given.

We spoke with over 100 people and visited 16 wards. We spoke with patients all of whom told us that their basic care needs were being met. They told us:

"The staff work very hard."

"They have been good with me."

"This is a clean, friendly and loving ward."

"I was in a year ago, it's like a completely different hospital, in a good way!"

Many of the staff we spoke with said that though they remained concerned about staffing levels the level of concern was not as high as it had been previously and they could see signs of improvement. Communication between the Trust Chief Executive Officer (CEO) and senior staff had improved and staff working on the wards and departments were more aware of how the Trust was trying to rectify problems. We saw some wards/departments where staffing levels had improved and where new staff had been recruited and were waiting to start work. Staff told us:

"We are using agency, bank and overtime to cover [the ward] things are improving but there is still pressure."

"There are lots of newly qualified nurses coming, it's do-able"

"We remain under pressure."

We found that there had been improvements across the three areas of non compliance. This meant that the Trust was meeting the objectives outlined in its action plan and the levels of concern had reduced. The Trust did remain non compliant in all three areas but because of the improvements seen our judgement of the impact on the health and safety of patients had reduced. We noted that the Trust continued to work with the Cumbria Clinical Commissioning Group (CCG) and the national Trust Development Authority (nTDA) as part of improving care for patients.

We will be re-inspecting the Trust in due course to see if compliance has been fully achieved in line with the Trust's action plan.

We returned to the A&E department to review compliance actions around cleanliness and infection control, safety and availability of equipment, supporting of workers and quality monitoring. The compliance actions were set following our inspection in June 2012.

We spoke with people who used the service. They told us that they were satisfied with the service they received one person said "They've explained everything that is happening." and added "We have nothing to complain about." Another person said "They're doing the best for me but I would welcome a cup of tea." We spoke with staff who told us that "Things have improved in some areas." Staff also commented that senior managers "Seemed to listen." but would welcome closer engagement with senior members of staff.

We found that there had been improvements made since our previous inspection. People were cared for in a clean, hygienic environment and protected from unsafe or unsuitable equipment. Staff were supported to deliver care and treatment safely and to an appropriate standard. The trust had an effective system to regularly assess and monitor the quality of service that people received.

This unannounced inspection focused on the provision of emergency care within the Accident and Emergency (A&E) department. We spoke with ten patients and a number of carers who had used the A&E department both on the day of our visit and the day before. People said:

"Staff were helpful and polite".

"I am very happy with the care I received".

"I was seen very quickly".

"Spot on".

"I have no complaints".

"Straight in, straight through".

All the people we spoke with were positive about their experience and the way they were treated whilst in the A&E department.

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

We have not asked for the views of people within this review

Patients who were interviewed on the day expressed that they were satisfied with care and treatment given to them during their stay at the Cumberland Infirmary.

They told us that staff respected their views and that they were always helpful, polite and explain everything to them. Patients also told us that they felt that their care needs were being met and that staff responded quickly to their needs.

Patients told us that they were generally satisfied with the care given in meeting their nutritional needs. They also told us that the food choices, availability, presentation and special diets were of a good quality. All patients spoken to felt the choice of menu was good, and most of the meals they received were appetising and hot.

The hospital’s own patient satisfaction survey shows within their dignity and privacy data all wards included in the survey between January and March 2011 scored a 100% satisfaction score with a large proportion of inpatients expressing satisfaction with care, treatment, privacy, dignity, information and treatment with respect.

There were two complaints received by the trust in relation to outcome 1 between April 2010 – March 2011 but there were no complaints received regarding outcome 5 for the same period. Two positive comments were reported through NHS Choices between June and December 2010 about the care received.

The hospital provided several reports which demonstrate they seek and monitor patient satisfaction on a regular basis, this work is across all inpatient areas. The patient satisfaction surveys demonstrate a high level of satisfaction with care, treatment, privacy, dignity, information and treatment with respect in the months of January and March 2011. The results also support high levels of satisfaction with menus, meal choice and dietary requirements.

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

• 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; the trust had developed a comprehensive improvement plan in response.
• There was a large number of maternity guidelines 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.