Westmorland General Hospital is one of three locations providing care as part of University Hospitals of Morecambe Bay NHS Foundation Trust. The hospital provides elective surgical services, a midwifery led maternity service and outpatient and diagnostic services including pathology, radiology and endoscopy, and allied health services such as physiotherapy, occupational therapy, dietetics and pharmacy services. The hospital does not provide Accident & Emergency services, critical care or services for children and young people. However the hospital does hold paediatric clinics in the outpatients department.

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, Westmorland General Hospital has 43 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 Westmorland General Hospital as ‘good’ overall. We judged the hospital as ‘good’ for safe, effective, caring, and responsive. Surgery and maternity were rated as ‘good’, however outpatients and diagnostic imaging was rated as ‘requires improvement’. This was because of long waiting time appointments in some departments and difficulties in securing case notes and test results for patient appointments.

At this inspection, we rated Westmorland General Hospital as ‘good’. We have judged the service as ‘good’ for safe, effective, caring, responsive and well-led care. Surgery, maternity and outpatient and diagnostic imaging were rated as ‘good’.

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.
• Patients received care in a clean, hygienic and suitably maintained environment. Staff were aware of and applied infection prevention and control guidelines.
• Between April 2014 and February 2015 there had been no cases of Clostridium Difficile in the surgical division at Westmorland General Hospital.

Nurse staffing

• Care and treatment were delivered by committed and caring staff who worked hard to provide patients with good services.
• The nursing staff vacancy rate was 18.8 whole time posts in May 2015. There had been no use of agency staff as staff had been made available from the elective orthopaedic unit which had been closed for two months.
• The nursing staff ratios were calculated separately in each area to determine safe staffing levels dependent on the activity for the day.
• Numbers of staff on duty met with the NICE guidelines “Safe staffing for nursing in adult inpatient wards in acute hospitals” in the ratio of one nurse to eight patients. This was maintained with clinical support workers providing additional assistance.
• The service met the national benchmark for midwifery staffing set out in the Royal College of Obstetricians and Gynaecologists (RCOG/RCM) guidance (Safer Childbirth: Minimum Standards for the Organisation and Delivery of Care in Labour) with a ratio of 1 midwife to 25 births compared to the RCOG recommendation of 1 midwife to 28 births.

Medical staffing

• The number of medical staff employed to work solely at Westmorland General Hospital was 4.4 doctors. There was a vacancy of 1.4 doctors and recruitment was underway.
• Consultants completed operations for their speciality at this hospital at booked session times. If there were low numbers of permanent staff in that speciality, for example urology, then locum medical doctors would carry out the procedures.
• There was a resident medical officer who was on-

  call at all times, including nights and weekends. They visited the inpatient wards every morning, midday and evening seven days per week and were available to visit during the night if required.

• In maternity services, there were two consultant led antenatal clinics per week.
• There were vacancies for radiologists. The trust was actively recruiting for these posts and had introduced the use of extended roles for advanced practitioners to help manage caseloads.

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 at the other trust sites and were attended by representatives from all teams within the relevant divisions from this hospital. 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..

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 in outpatients.

In addition the trust should:

In surgical services:

• Ensure that there are systems and process in place to for staff to be made aware of any learning and change of practice from audit programmes.

• Review written consent being obtained on the day of surgery.
• Ensure that the 5 steps to safer surgery process is audited to monitor that it is being used appropriately, particularly in surgical care.

In maternity and gynaecology services:

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

• Ensure that a practical test of the child and infant abduction policy is completed every 12 months in line with trust policy.
• Ensure safeguarding records always record outcomes of meetings with social workers.
• Ensure that staff act in accordance with the requirements of the Mental Capacity Act 2005 and associated codes of practice.

In outpatients and diagnostic imaging:

• Ensure that staff act in accordance with the requirements of the Mental Capacity Act 2005 and associated codes of practice.

Professor Sir Mike Richards

Chief Inspector of Hospitals

In July 2011 we inspected The University Hospitals of Morecambe Bay NHS Foundation Trust in relation to concerns that were raised around Maternity Services. Following that inspection The Royal Lancaster Infirmary (RLI) and Furness General Hospital (FGH) were found to be non compliant in outcomes 1,8,10,13,16 and 21 and we served a warning notice and set compliance actions.

In July 2012 we re visited RLI and FGH to check compliance with the warning notice and to follow up compliance actions from the 2011 inspection. In 2011 we did not find any areas of non compliance specific to the Westmorland General Hospital (WGH) maternity service other than those that were shared across all three sites around the escalation of risk and medical teams not working effectively. The governance work that was completed to achieve compliance across RLI and FGH had a positive impact on the service at WGH.

Helme Chase maternity unit in Westmorland General hospital provides a midwifery led service.

The way the reports were generated in 2011 meant that it looked like Westmorland General Hospital was non compliant. This report has been generated to make sure this hospital site contains the correct information. We did not make a visit to WGH at this time but used the information that we had previously gathered in July 2011 and August 2012. For a full picture of the maternity services please refer to the reports generated for RLI and FGH published in September 2012.

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

• Staff were well supported to improve quality and continuously develop. Staff were encouraged to contribute and work collaboratively to provide innovative ways to deliver more joined up care.
• Consent practices were strong, and patient focussed including the accommodation of individual needs. People who use services were involved in the development of tools and support to aid informed consent.
• Staff morale was high. Teams supported each other well and we saw examples of good teamwork. We saw staff from different professions working well together and staff told us they were proud of their work.
• Infection control measures were effective. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection.
• Patient records across the trust were of a good standard, up to date, legible and accessible.
• Feedback for the service was good and there were very few complaints. The culture was very person-centred and promoted kindness and dignity. People’s needs, and preferences were respected. The emotional needs of patients were in the forefront of the minds of staff and they worked with patients to develop better ways to encompass these.
• There were escalation policies, guidance and care pathways for deteriorating patients. Staff completed and updated risk assessments for each patient. They kept clear records and asked for support when necessary.
• Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
• Staff involved patients and those close to them in decisions about their care and treatment. Patients confirmed that staff treated them well and with kindness, providing emotional support to minimise their distress.
• The service provided care and treatment based on national guidance and evidence of its effectiveness. Staff used the World Health Organisation (WHO) surgical safety checklist, ‘Five Steps to Safer Surgery’. National and local safety standards for invasive procedures incorporated the contents of the WHO surgical safety checklist.
• Managers checked to make sure staff followed guidance, monitored the effectiveness of care and treatment and used the findings to improve them. They compared local results with those of other services to learn from them.

However:

• Staff were not up to date with mandatory training and other important training such as safeguarding vulnerable adults and children. Safeguarding processes were not robust. Additionally, staff had not undergone regular appraisals and did not feel competent to manage some of the patients who attended the department. As a result, we had concerns about the safety of the department.
• The department did not have a suitable safe place for patients living with a mental health condition.
• Some patients experienced delays in receiving some test results and often experienced delays being transported to other care settings; transport delays were outside of the influence of the trust. This was a potential risk to patients.
• The UTC did not have embedded governance systems in place and had only recently introduced clinical audit as a way of assuring quality. Patient outcomes had not been monitored and managed in a robust way.
• The UTC had undergone a series of changes. As a result, governance and leadership processes were not fully embedded in the department. Therefore, at the time of the inspection, despite there being plans in place for the department, we were not assured the department was able to demonstrate that it was well led.
• Not all staff were not up to date with mandatory training and other important training such as safeguarding vulnerable adults and children. Safeguarding processes were not always robust in UTC. Additionally, staff had not undergone regular appraisals and did not feel competent to manage some of the patients who attended the department. As a result, we had concerns about the safety of the department.