Furness General Hospital is one of three locations providing care as part of University Hospitals of Morecambe Bay NHS Foundation Trust. It provides a full range of hospital services including emergency care, critical care, a comprehensive range of elective and non-elective general medicine (including elderly care) and surgery, an oncology unit, a neonatal unit, children and young people’s services, maternity services and a range of outpatient and diagnostic imaging services.

University Hospitals of Morecambe Bay NHS Foundation Trust provides services for around 360,000 people across North Lancashire and South Cumbria with over 700 beds. In total, Furness General Hospital has 239 beds.

We inspected University Hospitals of Morecambe Bay NHS Foundation Trust as part of our comprehensive inspection programme in February 2014. Following our inspection in February 2014 we rated the Furness General Hospital as ‘Requires Improvement’ overall. We judged the hospital as ‘Inadequate’ for safe, ‘Requires Improvement’ for responsive and well led and ‘good’ for effective and caring. CQC was specifically concerned about nursing staffing shortfalls, particularly in the critical care and high dependency units as well as medical wards in this hospital. Patient records, including risk assessments and care planning documentation were not always accurately and comprehensively completed. We also found the trust’s governance and management systems were inconsistently applied across services and the quality of performance management information required improvement.

We carried out this inspection to see whether the hospital had made improvements since our last inspection. We carried out an announced inspection of Furness General Hospital between 14 and 17 July 2015.

Overall we rated Furness General Hospital as ‘Requires Improvement’. We have judged the service as ‘good’ for caring, and ‘requires improvement' for safe, effective, responsive and well-led care.

Our key findings were as follows:

Cleanliness and infection control

• The trust had infection prevention and control policies in place which were accessible to staff.
• We observed good practices in relation to hand hygiene and ‘bare below the elbow’ guidance and the appropriate use of personal protective equipment, such as gloves and aprons, while delivering care.
• ‘I am clean’ stickers were used to inform staff at a glance that equipment or furniture had been cleaned and was ready for use.
• Overall, patients received care in a clean, hygienic and suitably maintained environment. Staff were aware of and applied infection prevention and control guidelines.
• In surgical services,. between April 2014 and February 2015, there had been seven avoidable cases in the surgical and critical care division at Furness General Hospital. On one ward there had been three cases in two months. This had resulted in additional information regarding control of this infection and hand hygiene being provided to all staff during the safety huddles.

• According to the submitted and verified intensive care national audit and research centre data (ICNARC), the unit performed as well and sometimes better than similar units for unit acquired methicillin-resistant staphylococcus aureus (MRSA) and clostridium difficile infection rates.

Nurse staffing

• Care and treatment were delivered by committed and caring staff who worked hard to provide patients with good services.
• The trust had actively recruited nursing staff from overseas to try to improve staffing levels. However, vacancy rates remained high and shortfalls were covered by bank and agency staff. Senior staff said that they tried to use the same bank and agency staff to ensure that they had the required skills to work on the ward. Agency staff were given an induction before commencing work on the wards.
• Nurses recruited from overseas were supernumerary while they awaited registration with the Nursing and Midwifery Council. However, in surgical services there was a lack of clarity about their role and responsibilities.
• Staffing establishments had improved since the last inspection however on some wards nurse staffing remained a challenge, particularly within medicine. A review of staffing within medicine showed that the skill mix did not always fall in line with the trust’s ‘red rules’ initiative. The principles 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.

Medical staffing

• Medical treatment was delivered by skilled and committed medical staff.
• The trust had identified areas where medical staff shortages presented risk to patient care and treatment and were working hard to recruit and retain consultants.
• Recruitment of consultants was a challenge particularly in Emergency and urgent care services, and respiratory and gastroenterology.
• In surgical services, 21% of medical staff posts were vacant in May 2015. This had resulted in increased locum medical cover with the highest use being in the urology speciality where 55% of medical cover was by agency staff in May 2015.
• There were ongoing vacancies within the radiology service. Managers said they were actively recruiting and had introduced the use of extended roles for advanced practitioners to help manage the case load. The service leads felt there had been some improvements in staffing but the recruitment of experienced radiology staff remained a challenge.
• There was a sufficient number of medical staff to support outpatient services. The majority of clinics were covered by specialist consultants and their medical teams.

Mortality rates

• The trust was highlighted as a ‘risk’ for the in-hospital mortality indicator - Cerebrovascular conditions in the CQC Intelligent monitoring report May 2015.
• Mortality and morbidity meetings were held weekly or monthly and were attended by representatives from all teams within the relevant divisions. As part of these meetings, attendees reviewed the notes for patients who had died in the hospital within the previous week. Any learning identified was shared and applied.

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 by the speech and language therapy team.
• The patient records we reviewed included an assessment of patients’ nutritional requirements based on the malnutrition universal screening tool (MUST).
• Where patients were identified as being at risk, there were fluid and food charts in place. However, the recording of fluid balance charts was inconsistent.
• Parents told us there was a good selection of food on the menu for children and young people. Children were also offered snacks and food was available as it was required.

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

Importantly, the trust must:

• Ensure that all premises used by the service provider are clean, secure, suitable for the purpose for which they are being used, properly used, properly maintained and appropriately located for the purpose for which they are being used. This is particularly in relation to services provided from critical care and outpatients.
• Ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed in order to meet the needs of the patients. This is particularly in relation to medical care, children and young people's services, and radiology, dermatology and allied health professionals.

• Ensure that staff receive appropriate support, training, supervision and appraisal to enable them to carry out the duties they are employed to perform, particularly in Accident and Emergency, medical and surgical services and Children and Young People's services.
• Ensure that staff understand and act in accordance with the requirements of the Mental Capacity Act 2005 and associated codes of practice.
• Ensure referral to treatment times in surgical specialities improve.
• Ensure that staff follow policies and procedures around managing medicines, including intravenous fluids particularly in children and young people's and critical care services.

• Ensure that risk registers clearly identify all risks within the division, the actions taken to mitigate those risks and demonstrate timely review, particularly in medical care.
• Maintain securely an accurate, complete and contemporaneous record in respect of each service user, including medical and nursing, and food and fluid charts, particularly in medical and surgical services.

In addition the trust should:

In urgent and emergency services:

• Take action to improve waiting times and ambulance handovers.
• Ensure action plans following CEM audits clearly state the steps required to secure improvement.
• Improve staff engagement, knowledge and awareness of the strategy for the service.

In medical care services:

• Ensure there are clear plans in place to reduce the number of falls occurring within the service.
• Improve the management of people with a stroke in line with national guidance.
• Consider improving arrangements for clinical supervision to ensure they are appropriate and support staff to effectively carry out their responsibilities, offer relevant development opportunities and enable staff to deliver care safely and to an appropriate standard.
• Take action to reduce the number of patients staying on medical wards that are not best suited to their needs and to reduce the number of moves between wards.

In surgical services:

• Ensure all staff understand the process for raising safeguarding referrals in the absence of the safeguarding lead.
• Reduce and improve re-admission rates.

• Ensure all procedures are performed in line with best practice guidance. Where practice deviates from the guidance, a clear risk assessment should be in place.

In critical care services:

• Ensure that there is timely access to medical care for patients out of hours and that any delays do not result in patient harm.
• Consider how it is going to improve performance in reducing the number of delayed and out of hours discharges of patients from critical care.
• Ensure that any delayed discharges from critical care do not result in a breach of the government’s single sex standard.
• Ensure that all entries in patient records are appropriately signed and dated.
• Consider the provision of a supernumerary clinical co-ordinator on duty 24/7.
• Consider how it intends to respond to the latest Health Building Notes guidance for critical care units in planning its vision and strategy for the service.

In maternity and gynaecology services:

• Ensure that the actions of the Kirkup recommendations are implemented within timescales and embedded across the trust.

• Ensure there are clear lines of responsibility and accountability at ward manager and matron level within maternity so that staff feel supported and barriers to communication and change are removed.

• Implement the recommendations of and monitor compliance with, the PHSO Report 'Midwifery supervision and regulation: recommendations for change' (2013) with regard to Trust/Midwifery Supervisory investigations, so that parent(s) receive a joint set of recommendations and a single timeframe resulting from the investigation.
• Ensure that the ‘Five steps to safer surgery’ (World Health Organisation) is embedded in obstetric theatre practice.
• Ensure that a physical test is carried out in line with trust policy to ensure that the infant abduction procedures work correctly and that staff understand how they work.

In children and young people’s services:

• Ensure that there are clearly defined and formalised job plans in place for consultant paediatricians.
• Consider reviewing the investigation process of patient safety incidents with full consideration given to the reporting of the professional’s account of events and concerns.
• Ensure that there are measures in place to monitor the effectiveness of joint working within medical staff teams.

In end of life care services:

• Ensure there is a clear and accessible system in place to identify and monitor risks within end of life care services.
• Continue to take action to improve those areas identified by the NCDAH.
• Ensure all DNACPR forms are completed to the appropriate standard.

In outpatients and diagnostic imaging:

• Continue to build relationships and develop closer team working to develop a one trust culture.

Professor Sir Mike Richards

Chief Inspector of Hospitals

We visited the A&E department at Furness General Hospital as part of a review following an investigation into the emergency care pathway undertaken in 2012 under section 48 (1) (2) (a) of the Health and Social Care Act 2008 which enabled the CQC to look at the provision and commissioning of health care more widely beyond the 16 outcomes within the essential outcomes of quality and safety.

During the review we found that patients were not cared for in a clean, hygienic environment within the A&E department. Health and social care providers are required to follow the guidance laid out in the Department of Health's publication: The Code of Practice for health and adult social care on the prevention and control of infections and related guidance. This guidance forms part of outcome 8: cleanliness and infection control underpinned by Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

This report concerns the Furness General Hospital maternity unit.

Women we spoke with were all pleased with the level of care they had received.

One woman told us "I have no problems. I am happy with the service. I have been given lots of explanations and information. I have had no problems or concerns about lack of privacy or dignity."

As part of our inspection we spoke with local stakeholders such as the local councils Overview & Scrutiny Committee who have a duty to look more closely into public services outside their own organisation which includes local NHS hospitals. They said they had not received any concerns from the public about Furness General Hospital or the Royal Lancaster Infirmary maternity units in recent months. They told us they had regular meetings with senior staff at University Hospitals of Morecambe Bay Trust which kept them up to date with any changes in service provision at the trust.

We also spoke with the Local Involvement Networks (LINks) who had not received any issues or concerns from the public about the provision of maternity services at University Hospitals of Morecambe Bay.

We inspected Furness General Hospital (FGH) maternity unit to check compliance with a warning notice served in August 2011 and to follow up compliance actions from the last inspection report. We had issued a warning notice and compliance actions across FGH and Royal Lancaster Infirmary Hospital (RLI) maternity units. A separate report has been written for FGH. Although the previous report highlighted some different issues for each site there were common themes identified therefore it is beneficial to read this report in conjunction with the one for RLI.

The trust had made good progress in addressing our concerns contained in the warning notices and compliance actions from last year. It was evident that the trust was working with staff to develop a safe, women centred, evidence based maternity service. Good practice points were noted across both The Royal Lancaster and Furness General Hospital sites.

Clinical staff involved in the inspection gave us honest, helpful and well considered explanations. They were able to support their answers with robust examples and both written and verbal evidence. They demonstrated excellent skills in relationship building throughout the two days and were warm and welcoming.

Work is still ongoing, which is to be expected, around cultural change, staffing levels and data management systems but significant progress has been made to address these.

This unannounced inspection along with a second one at the Royal Lancaster Infirmary (RLI) on the 13 August 2012 focussed on the accident and emergency department including the medical assessment unit (MAU).

During our visit to Furness General Hospital (FGH) we spoke with six people using the service and three of those had come into hospital via the A&E department. The people we spoke with were complimentary about the care they had received from staff in A&E.

Another person told us “They (A&E staff) have been wonderful” and “the nurses have infinite patience” and “the food is very good.”

Another said “I can’t fault anything.”

As part of our inspection we spoke with stakeholders such as the local council’s Overview & Scrutiny Committee who have a duty to look more closely into public services outside their own organisation, which includes local NHS hospitals. They said they had not received any concerns from the public about the accident and emergency departments in recent months. They told us they had regular meetings with senior staff at University Hospitals of Morecambe Bay Trust which kept them up to date with any changes in service provision at the trust. They were fully aware of the issues in the past that had led us to issue a warning notice.

We also spoke with the Local Involvement Networks (LINks) who had also not recently received any issues or concerns from the public about the emergency departments.

We inspected FGH to check compliance with a warning notice served in February 2012 and to follow up compliance actions from the last inspection report. We had issued warning notices and compliance actions across FGH and RLI for the provision of emergency care.

A separate report has been written for RLI. Although the previous reports highlighted some different issues for each site there were common themes identified across both so it is beneficial to read this report in conjunction with the one for RLI.

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 conducted an on site investigation into the emergency pathway at Furness General Hospital (FGH) on 20th February 2012 under the powers of section 48, Health and Social Care Act 2008. The remit of this investigation was to review the urgent care pathway. An investigation differs from a responsive compliance review in that it normally necessitates a much wider and deeper look at a range of concerns potentially across all locations within a single provider such as an NHS hospital. During the investigation the team identified a number of concerns that demonstrated a breech in the regulations.

The investigation team collected feedback from a wide number of people living in the local

area who had used the services provided by the trust. This will be reported in more detail in the investigation report which is due to be published in July.

People reported varying experiences when they received treatment and care at the hospital.

Our rating of services stayed the same. We rated them as good because:

• Patients received care and treatment from staff who were caring, compassionate, respectful and maintained their dignity.
• Both medical and nursing staff told us the emergency department had an open supportive culture and staff felt leaders were open, helpful and listened to their concerns.
• When things went wrong, staff felt able to report them and discuss them and were confident they would receive the support they needed.
• The flow of the emergency department was well managed and there were robust systems in place to monitor deteriorating patients waiting for assessment and treatment in the department.
• There were paediatric nurses embedded in the emergency department and there were clear pathways for paediatric patients to wards and medical staff to the department.
• Learning from complaints was embedded and there were systems in place to ensure feedback was given to staff.
• Risks were identified on the risk register and reviewed regularly.
• Staff were kept up to date with governance concerns via meetings and newsletters.
• The trust had systems to identify capacity and demand issues. This was reviewed regularly, and concerns escalated and managed by the team.
• The trust had introduced an updated version of the National Early Warning Score (NEWS2) to measure whether a patient’s condition was improving, stable or deteriorating indicating when a patient may require a higher level of care. We saw that when a patient’s score increased staff had taken the appropriate action to escalate.
• The care group leadership team were visible and approachable, and managers had good oversight of their areas. Staff said they were well supported to do their job and felt comfortable sharing any concerns with their immediate line manager.
• Staff told us there had been a marked improvement in the culture of the organisation and that the behavioural standards had made a positive difference.
• Registered nurse staffing levels had improved since our last inspection and were good on the medical wards we visited. On the day of inspection, we found that actual registered nurse staffing levels met planned levels on most wards.
• There was good multidisciplinary team working and staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
• The service managed flow through the hospital well and there were no extra capacity beds open at the time of our inspection. Plans were in place to further improve flow with the reconfiguration of the acute medical unit.
• The service took account of patients’ individual needs. Arrangements were in place to support the needs of patients living with dementia or with a learning disability.
• 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.

However:

• We were not assured about the quality of care patients received because the trust had not performed well against Royal College of Emergency Medicine (RCEM) standards.
• The department was not meeting national performance standards for patients being admitted or discharged within four hours, or moved to a ward within 12 hours of a decision to admit being made. The four-hour target performance in every month from September 2017 to August 2018 had not been met.
• There were no rooms suitable to manage patients suffering from a deterioration in mental health within the ED. We had concerns about patients self-harming despite the department having ligature cutters for staff.
• Patients experienced delays at handover and there had been a high number of black breaches.
• Staff within the emergency department were not meeting mandatory training standards including safeguarding vulnerable adults and children. Additionally, staff had not undergone additional training to ensure they had the additional skills and competencies to look after children and not all staff had undergone an annual appraisal within the last 12 months.
• There was no designated room meeting the PLAN standard to ensure patients living with a mental health condition were in a safe and suitable environment within the emergency department. The trust had no plans to create a room that met PLAN standards.
• Patients living with a mental health condition, waiting for beds at psychiatric facilities sometimes waited significantly longer than 12 hours in the department.
• Five specialties were below the England average for RTT rates (percentage within 18 weeks) for admitted pathways within surgery.
• The department was failing to meet performance targets. They failed to meet the standard for inpatients waiting more than 12 hours from the decision to admit until being admitted in nine out of 12 months.
• The department only had one resuscitation room, although there were plans to rectify this and building work had started to increase the number of resuscitation rooms at the time of our inspection.