The Royal Lancaster Infirmary 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, the Royal Lancaster Infirmary has 426 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 Royal Lancaster Infirmary as ‘Requires Improvement’ overall. We judged the hospital as ‘Requires improvement’ for safe, effective, responsive and well led and ‘good’ for caring. CQC was specifically concerned about staffing levels particularly in medical services (Ward 39) but also in other clinical areas such as the surgical wards, radiology, dermatology and paediatrics, where there was a shortage of specialist staff. 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 Royal Lancaster Infirmary on 15 July 2015. In addition an unannounced inspection was carried out between 4pm and 7:30pm on 29 July 2015. As part of the unannounced visit we looked at the care provided on Ward 39 and the acute surgical assessment unit.

Overall we rated Royal Lancaster Infirmary as ‘Requires Improvement’. We have judged the hospital as ‘good’ for caring. We found that services were provided by dedicated, caring staff and patients were treated with dignity and respect. However improvements were needed to ensure that services were safe, effective, well led and responsive to people’s needs.

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. ‘Bare below the elbow’ guidance was followed and personal protective equipment, such as gloves and aprons, was used appropriately 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.
• Patients received care in a clean, hygienic and suitably maintained environment. Staff were aware of and applied infection prevention and control guidelines.
• However, in the emergency department ,we saw some dusty equipment and shelving. We also found that inside a cupboard containing medical supplies was dirty. Some cubicle floors were dirty and there was debris on the floors. We inspected six mattresses and noted that four of them had holes in the covers and there was evidence of staining on the inside and onto the foam mattress itself. We later observed staff conducting a full audit of the mattresses.
• Between December 2014 and June 2015 there had been one case of MRSA in medical care services. There had been six cases of Clostridium difficile (C.diff) reported in the medical division in the same period. Four of these were avoidable. Meetings had taken place regarding these incidents that included looking at lessons learnt.
• Between April 2014 and February 2015 there had been three avoidable cases of C.diff in the surgical and critical care division at Royal Lancaster Infirmary. There had been no learning from these events that had resulted in additional measures to prevent infection.

• According to the submitted and verified intensive care national audit and research centre data (ICNARC), the critical care 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.
• Although we found staffing levels were adequate at the time of our inspection, there was no flexibility in numbers to cope with increased capacity and demand, or short-notice sickness and absence.
• The trust had actively recruited nursing staff from overseas to try to improve staffing levels. However, there were still staffing shortfalls that were covered by bank and agency staff. Senior staff said 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. Ward 39 in particular, remained a concern. Senior staff felt that the staffing establishment on the ward was unsustainable for the number of beds (50 beds) as they had been asked to reduce the number of clinical support workers. They were unsure how the new staffing figures for clinical support workers had been decided as they had not been involved in the review.
• A review of staffing over a one month period showed that the skill mix on ward 39 did not always fall in line with the trust’s ‘red rules’ initiative. 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.

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.
• There had been an increase in the number of cardiology consultants from two to six. These consultants worked across the trust on a six week rotation basis. This had improved patient care and facilitated earlier discharges. It had also reduced the angiogram waiting list from 18 months to three weeks. However, there was a lack of consultants in some specialist services such as respiratory and gastroenterology.
• Over the past 6 months the locum cover had been as high as 51.5% in some areas. The specialities that had high use of locum cover included elderly care, diabetes, dermatology and rheumatology services.
• 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. However, staff said paediatric clinics were frequently cancelled with less than six weeks’ notice due to the consultant rota and lack of junior and middle grade doctors.
• Anaesthetic cover was provided by an ST3 (specialist registrar year 3) or above, who was resident on call and provided cover for ITU and the obstetric epidural service; this was supported by a non-resident consultant intensivist. It was acknowledged that this fell short of national guidelines. However, there was no evidence to suggest there were any serious incidents or complaints relating to delays in obtaining an anaesthetist.

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 either weekly or monthly and were attended by representatives from 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.
• Patient records included an assessment of patients’ nutritional requirements based on the malnutrition universal screening tool (MUST).
• However, in medical care services, people were not always supported appropriately with their nutritional needs. For example, a patient on ward 39 required feeding via a gastro-enteric tube. There was a clear plan in place which outlined what the food and fluid intake should be for this patient including specified volumes and times for delivery. On checking the daily fluid monitoring chart the daily intake recorded did not match the amount stated on the plan for three days.
• 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, particularly in medical care services.
• 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 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 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 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.
• The provider must ensure that the Five Steps to Safer Surgery (World Health Organisation) safety checklist is consistently followed and fully embedded in obstetric theatre practice.
• The provider must ensure that all staff comply with hand hygiene requirements.
• Ensure referral to treatment times in surgical specialities improve

In addition the trust should:

In urgent and emergency services:

• Ensure all areas in the emergency department are clean and free from dust and debris and that mattresses are fit for purpose..
• 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 that call bells are easily accessible for patients so they can call for help when required.
• 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 improve 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 there are systems in place to identify themes from incidents and near miss events to promote safe care.
• Ensure all theatres are completing audits to monitor compliance with the 5 steps to safer surgery process.
• Ensure all staff understand the process for raising safeguarding referrals in the absence of the safeguarding lead.
• Reduce and improve readmission 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.
• Continue to engage staff and encourage team working to develop and improve the culture within the theatre department.

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 coordinator on duty 24/7.

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 service:

• 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 professional’s account of events and concerns.
• Ensure there is sufficient and appropriate access to oxygen points on the neonatal unit in line with BAPM standards.

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 improve closer team working to develop a one trust culture.

Professor Sir Mike RichardsChief Inspector of Hospitals

Professor Sir Mike Richards

Chief Inspector of Hospitals

We visited the Trust in order to assess their progress against two warning notices we issued regarding staffing on ward 39. At this inspection we found that the Trust had failed to comply with the warning notices served. We are currently considering what further action to take and this report is published in the interim.

On the 5th of February 2014 we will be undertaking a detailed wave 2 inspection of the Trust and will use any further information that we gather from across the Trust to feed into our decisions about the action we will take. We have also written to the Trust to ask them for detailed assurances about how they will immediately rectify the issues of staffing levels on ward 39.

This inspection report has been generated to amend two areas of non compliance from an inspection of maternity services which was undertaken in July 2011. At that time CQC found that Furness General Hospital maternity unit was non compliant for outcomes 8 cleanliness and infection control and 10 safety and suitability of premises. The Royal Lancaster Infirmary was found to be compliant in both these outcomes. We inspected Furness General Hospital (FGH) and the Royal Lancaster Infirmary maternity units on 13 and 14 August 2012. At that inspection the two areas of non compliance at FGH were reviewed and FGH was found to be compliant. See the CQC website www.cqc.org.uk for the relevant inspection reports.

We carried out this inspection as a desk top based review for this service on the 01 March 2013 using information gathered to assess if the service had achieved full compliance with outcome 5 Meeting Nutritional Needs. We did not visit the service. The evidence we had gathered from different sources indicated that the service was now compliant with outcome 5 which we had found to be non compliant. Our inspection of April 2011 found that that whilst tools were in place to ensure nutritional risk assessment and recording nutrition and hydration the effectiveness of these and the standards of individual practices on the wards was not always of a consistently good standard. As a result people were not always being well supported individually to have adequate nutrition and hydration. People using the service could not be confident that they would be supported to eat their meals according to their ability and to maintain their dignity and independence or that their nutritional intake would be monitored.

Recent evidence received from a number of different sources indicated there were now systems in place for gathering, recording and evaluating information about the quality of nutritional support and that staff were receiving relevant training. People who used the service were being supported at mealtimes and their nutritional needs were being assessed and the information identified by these assessments was being acted upon.

This unannounced inspection along with a second one at Furness General Hospital on the 14 August 2012 focussed on the accident and emergency departments including the medical assessment unit (MAU), the clinical decision unit (CDU), ward 6 male medical short stay, ward 5 female medical short stay and ward 3 a general medical ward at the Royal Lancaster Infirmary (RLI). We made general observations of the environment and the day to day activities that were going on around us

We spoke with six people who used the service at RLI. We also spoke with one person on ward 35 (orthopaedic) who had been admitted through the accident and emergency department (A&E). They told us that they had arrived in A&E on a Friday at quarter to midnight. By 3am they said they had been admitted onto ward 35 and had surgery the following morning. They said that the staff had been “great” and had “delivered good care”. The people we spoke with were positive about the treatment, care and support they had received.

One person told us, “everybody has been so good” and that “the doctor talked me through it and the nurses told me why I was coming to this ward.”

Another told us,” “I can’t express how good they have been with me everywhere I have been and so nice with it....they put me at ease and have a sense of humour.”

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 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.

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

We inspected Royal Lancaster Infirmary (RLI) to check compliance with two warning notices served in February 2012 and to follow up compliance actions from the last inspection report. We had issued warning notices and compliance actions across RLI and Furness General Hospital (FGH) for the provision of accident and emergency care. A separate report has been written for FGH. Although the previous reports highlighted some different issues for each site there were common themes identified so it is beneficial to read this report in conjunction with the one for FGH.

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 Royal Lancaster Infirmary (RLI) site from 6 February to 9 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.

We focused during our visit upon the experiences of the people using the accident and emergency department at Royal Lancaster Hospital and on getting their opinions on the care and support they had received. We talked with patients and their relatives as well as nursing and support staff, trust management staff and paramedics. We made general observations of the environment and general activities and what was going on generally during our visit.

The main focus of our contact with people and the questions we asked focused upon patient safety, the staffing levels and the capacity of the department to function under pressure. We also wanted to see if people had access to staff who could make prompt diagnosis and provide treatment.

People using the department confirmed that they were given information about their conditions and treatment and generally kept informed about what was happening. If they were having to wait for admission they reported that they were told why this was the case. One person told us they did not mind the wait for a bed because they had been seen and attended to quickly when they came in. People using the department told us that staff were "polite" and also "helpful". People confirmed that staff explained to them what was going to happen next with treatment and procedures and about future appointments at outpatients clinics.

One person told us, " I have seen the doctor and he has told me what the plan is and that I need to stay overnight". They were satisfied with how they had been treated and supported by doctors and nursing staff. Although they and other patients commented that the department was "way too small" and also that "the nurses never stop". Another patient waiting for a bed told us they had no complaints about their care in the department and felt that staff "do a good job".

We talked with people who were waiting to be seen using the triage system and people confirmed that they were given target times by which they could expect to be seen. A triage system is a process for sorting injured people into groups based on their need for or likely benefit from immediate medical treatment. Triage is used in hospital emergency departments when limited medical resources must be allocated.

We visited three wards on the day of our visit, Ward 23, which is the stroke unit, and orthopaedic wards 35 and 36. We focused in particular aspects of people’s experience of discharge planning. We talked with patients, their relatives and staff and people expressed a range of views indicating that experiences were not consistent across the three wards.

Patients on all three wards did make positive comments about the care and support they received but especially on the stroke unit where one person told us that the best thing was “the support I have been given, the back up has been marvellous”.

A patient on ward 35 told us they were “not very happy with accident and emergency” but said the doctors and nurses were "brilliant in here".

The majority of people we talked to understood, their care and treatment although sometimes they were not kept up to date about what was happening. One patient told us despite having been assessed by a doctor no one had really told them what they could or could not do after the hip operation. But they and their relative both told us that when it got to the “rehab assessment stage then we had good explanations from nurses, the physiotherapists and occupational therapists. Need to close the quotes

Overall people were positive about their care and general experience whilst patients in the hospital and this was evident comments made during our conversations with them, including

“I am very satisfied with my care, I have no complaints and the back up has been marvellous”.

“I have been very impressed with the nurses and their tolerance and patience with people with dementia or other behavioural problems, it was very good.”

“Physiotherapy is good and they come every day”.

Less positively a smaller number of people had negative experiences, telling us, “Some nurses are rather flippant”.

We did find that patients on the orthopaedic wards commented on how busy the staff were and how this had affected them.

“The nurses are very good but sometimes you have to wait for attention because they are so busy”.

“I was taken to the toilet but was often left for long periods of time because staff are too busy to take me off again”

Some people had negative things to say and this was noticeable particularly about food across all the wards we visited.

One told us, “the food is not very good and I’m not eating so well but of course that might be because of what I’ve gone through”.

Another said “The soup is very good but the rest of the food is atrocious”.

Another said “I did not like anything that was on the menu and nothing else was offered “

“Food not as good as it should be”.

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

• The rating for caring and responsive went down from our previous inspection in 2016. Caring went down from outstanding to good and responsive went down from good to requires improvement.
• Within ED, we lacked assurance that the process for communicating when a patient required isolation was robust. Staff outside of the department and visitors may not be aware when precautions were required.
• We found some gaps in the checking of emergency equipment in the four resuscitation trollies we looked at within the ED.
• When the ED 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 patient’s privacy and dignity was compromised while they waited and received treatment in the ED.
• All specialties were below the England average for RTT rates (percentage within 18 weeks) for admitted pathways.
• The process for managing patient flow in the emergency department was not robust, especially for patients waiting in corridors on trolleys and in wheelchairs.
• The emergency department was failing to meet performance targets. They failed to meet the standard in patients waiting more than 12 hours from the decision to admit until being admitted and four-hour target performance in every month from September 2017 to August 2018.
• The mental health facilities in the emergency department did not meet the PLAN standard and mental health patients waited a long time for admission to the local mental health trust. However, the delays in patients being admitted by the local mental health trust were not under the control of UHMB.
• No testing was initiated at triage which meant patients waited longer than necessary in the emergency department to be assessed by medical staff.
• There were systems in place for leaning from complaints, however, from speaking with staff we were only provided with limited examples.

However:

• The trust had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.
• Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
• The trust had systems and processes in place to ensure that the needs of local people were considered when planning the service delivery.
• Managers at all levels in the trust had the right skills and abilities to run a service providing high-quality sustainable care.
• 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.
• Whilst we could not be provided with mandatory training data by site and staff group. The data we were provided with and saw on site showed that compliance was at or just below the trust target of 95%. This was an improvement from the last inspection.
• There was a focus on training and development within the department to provide staff with the skills to care for unwell patients.
• We saw examples of good multidisciplinary team working and staff demonstrated a good understanding of mental capacity and deprivation of liberty safeguards.