We initially inspected the West Cumberland Hospital in May 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, particularly medical staff, in most areas of the hospital. Patient's told us that they often had to wait for basic tests or medical assessments. 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 West Cumberland Hospital.

Because of the substantial amounts of improvement needed following our inspection in March we returned to the West Cumberland Hospital 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 80 people and visited nine wards. We spoke with patients all of whom told us that their basic care needs were being met. They told us:

"The care here is unbelievable, The Consultant was excellent, everything was fully explained to me. I have never been as well looked after and would be happy to come back to West Cumberland Hospital if I needed an operation."

"I came in just for tests and was admitted straight away, staff are excellent and the Consultant was very proactive."

"Staff are marvellous but there is not enough of them day or night."

"Excellent care, very obliging staff."

Many of the staff we spoke with said that although 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 within 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. However medical cover at the West Cumberland Hospital was provided predominantly by locums. Staff told us:

"It's going well, lots to do, lots to change."

"They [the Trust] have been recruiting but it's going to be October before we see any new staff."

"There's light at the end of the tunnel."

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 two of the 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.

This unnanounced inspection focused on the provision of care within the surgical division of West Cumberland Hospital. We spoke with 21 patients on the day of our visit. They said:

"The nurses are brilliant...they explain what they are doing and are very reassuring".

"The nurses are busy at times...can be run off their feet...but they manage to look after me all right ...and they are fine in the main".

"They clean the ward really well...under beds and the bed itself...sheets are changed frequently".

"The treatment and care has been wonderful...from the staff who make the tea right up to the consultant...they work as a team and tell me how I am progressing...couldn't be better".

"I was given the chance to make up my mind...told the options and the outcomes in a very open way. I felt I was in control of my treatment".

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 did not seek the views of people using this service as part of this inspection.

Patients we spoke to were mostly very positive about their experience of care and treatment. Most patients said they had their care needs met and had been treated respectfully. A typical comment received was “There has been no waiting for care, treatment generally has been very good and staff are very caring.”

A relative said “We have been very happy with care in this hospital, we have experienced two hospitals out of the area and this is by far the best for care, and staff treating you right”.

The trust undertakes a patient satisfaction survey and between October 2010 and March 2011 this demonstrated a high level of patient satisfaction with regards to dignity and privacy. The data also shows that there has been an improvement in results compared with 2010 for all wards in the hospital.

Patients we spoke to felt well informed on their diagnosis, treatment and prognosis. All patients interviewed said staff were good at explaining treatments and let them know what they were about to do prior to carrying it out.

Overall patients are satisfied with the meals, the menu choice and the standard of the food on offer. They felt they were given the right amount of help and that staff were supportive and considerate.

Patients and relatives were mostly very complimentary about their experience of mealtimes stating:

“The food is good and improved since my last stay.”

“My special diet is catered for, food is hot and good, and choice is also very good. Amount eaten always recorded.”

“Staff check I have enough to eat and drink. I’ve never missed a meal and there’s always plenty of choice.”

These findings are supported by the trust’s inpatient Catering satisfaction survey for the hospital which had a 81% overall satisfaction rating, (Oct 10-Jan 11), This had been an improvement on the previous year.

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 guidelines and procedures 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.