Source · CQC inspection
Cumberland Infirmary
Provider North Cumbria University Hospitals NHS Trust
Type NHS Healthcare Organisation
Region North West
Last inspected 17 Jul 2018
Overall rating: Requires Improvement View full CQC report
Domain ratings
Safe
Requires Improvement
Effective
Requires Improvement
Caring
Good
Responsive
Requires Improvement
Well-led
Requires Improvement
Earlier inspection findings
Must-do actions (55)
Must-do action 1 of 55
Must do
Safe
The trust must improve levels of mandatory training for medical and nursing staff.
Must-do action 2 of 55
Must do
Safe
The trust must ensure toys and storage solutions were cleaned thoroughly and in line with IPC guidance
Must-do action 3 of 55
Must do
Safe
The trust must improve the safety aspects of the designated mental health room
Must-do action 4 of 55
Must do
Well-led
The trust must ensure patient interactions such as initial assessment, time to treatment and decision to admit are recorded accurately on the electronic administrations system and robust validation carried out.
Must-do action 5 of 55
Must do
Safe
The trust must ensure medical cover overnight is qualified to at least level ST4 with ALS training
Must-do action 6 of 55
Must do
Safe
The trust must improve identification and management of patients with time critical conditions such as sepsis, DKA and stroke.
Must-do action 7 of 55
Must do
Safe
The trust must ensure sufficient staff are trained in APLS and ALS to ensure the department has the necessary cover 24 hours a day, seven days a week.
Must-do action 8 of 55
Must do
Safe
The trust must review nurse staffing numbers using a recognised process to ensure sufficient qualified and experienced staff are deployed to meet the needs of patients.
Must-do action 9 of 55
Must do
Safe
The trust must ensure practice around the management and disposal of controlled drugs is in line with trust policy and ensure the dispensing and administration of all drugs is carried out by staff in line with trust policy.
Must-do action 10 of 55
Must do
Effective
The trust must continue work to improve patient outcomes where the department failed to meet RCEM audit standards.
Must-do action 11 of 55
Must do
Responsive
The trust must continue work with other wards and departments to make sure patients are moved to a ward as quickly as possible once a decision to admit has been made.
Must-do action 12 of 55
Must do
Well-led
The trust must ensure senior staff are fully aware of the staffing position of the department including vacancies and number of staff employed and on duty.
Must-do action 13 of 55
Must do
Well-led
The trust must ensure there is a department vision and strategy in place to ensure sustainability in the future and provide staff with information about the future direction of the department.
Must-do action 14 of 55
Must do
Well-led
The trust must ensure that the senior management of the trust are fully sighted on the challenges faced by frontline staff in the department.
Must-do action 15 of 55
Must do
Safe
The trust must ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed across all divisional wards. Specifically, registered nurses to ensure safe staffing levels are maintained;
Must-do action 16 of 55
Must do
Safe
The trust must ensure electronic systems which monitor acuity and staffing numbers are updated in a timely manner;
Must-do action 17 of 55
Must do
Safe
The trust must ensure patients assessed as requiring one to one support are provided with the appropriate provision of care;
Must-do action 18 of 55
Must do
Safe
The trust must ensure safeguarding training levels are delivered in accordance with intercollegiate guidance;
Must-do action 19 of 55
Must do
Safe
The trust must ensure mandatory training targets are met by the target date;
Must-do action 20 of 55
Must do
Safe
The trust must ensure there are appropriate numbers of qualified staff on the ward to improve second signatory and witness administration of intravenous medicines and controlled drug procedures;
Must-do action 21 of 55
Must do
Safe
The trust must ensure intravenous fluids are secured as per the trust's medicines policy;
Must-do action 22 of 55
Must do
Safe
The trust must ensure prescriptions comply with the trust prescribing policies;
Must-do action 23 of 55
Must do
Safe
The trust must ensure staff record minimum and maximum temperatures for medicines refrigerators;and,
Must-do action 24 of 55
Must do
Well-led
The trust must ensure actions are implemented following audit findings.
Must-do action 25 of 55
Must do
Safe
The trust must ensure compliance with the completion of the WHO surgical safety checklist for every patient;
Must-do action 26 of 55
Must do
Safe
The trust must ensure consistent practice and compliance across wards with trust policies regarding the management of medicines;
Must-do action 27 of 55
Must do
Safe
The trust must ensure mandatory training compliance rates meet trust targets;
Must-do action 28 of 55
Must do
Safe
The trust must ensure safeguarding training compliance rates meet trust targets and are delivered in accordance with ‘Adult Safeguarding Levels and Competencies for Healthcare.
Must-do action 29 of 55
Must do
Safe
The trust must ensure safeguarding level three training meet the standards recommended by Royal Collage of Paediatrics and Child Health intercollegiate document, which states: “Training, education and learning opportunities should be multi-disciplinary and inter-agency, and delivered internally and externally. It should include personal reflection and scenario-based discussion, drawing on case studies, serious case reviews, lessons from research and audit, as well as communicating with children about what is happening. This should be appropriate to the speciality and roles of the participants.”
Must-do action 30 of 55
Must do
Safe
Improve mandatory training compliance levels for both qualified nursing and medical staff.
Must-do action 31 of 55
Must do
Safe
Improve safety in the designated mental health room.
Must-do action 32 of 55
Must do
Well-led
Ensure patient interactions such as initial assessment, time to treatment and decision to admit are recorded accurately on the electronic administrations system and robust validation is carried out.
Must-do action 33 of 55
Must do
Safe
Ensure medical cover overnight is always provided by a doctor of ST4 level or above, who is trained in advanced life support (ALS) and advanced paediatric life support (APLS).
Must-do action 34 of 55
Must do
Safe
Ensure sufficient staff are trained in ALS and APLS to ensure the department has the necessary cover 24 hours a day, seven days a week.
Must-do action 35 of 55
Must do
Safe
Improve identification and management of patients with time-critical conditions such as sepsis, diabetic ketoacidosis (DKA), and stroke.
Must-do action 36 of 55
Must do
Safe
Review nurse staffing numbers using a recognised process to ensure sufficient qualified and experienced staff are deployed to meet the needs of patients.
Must-do action 37 of 55
Must do
Safe
Ensure practice around the management and disposal of controlled drugs is in line with trust policy and ensure the dispensing and administration of all drugs is carried out by staff in line with trust policy.
Must-do action 38 of 55
Must do
Effective
Continue work to improve patient outcomes where the department failed to meet Royal College of Emergency Medicine (RCEM) audit standards.
Must-do action 39 of 55
Must do
Responsive
Continue work with other wards and departments to make sure patients are moved to a ward as quickly as possible once a decision to admit has been made.
Must-do action 40 of 55
Must do
Well-led
Ensure senior staff are fully aware of the staffing position of the department including vacancies and number of staff employed and on duty.
Must-do action 41 of 55
Must do
Well-led
Ensure there is a department vision and strategy and provide staff with information about the future direction of the department.
Must-do action 42 of 55
Must do
Well-led
Ensure that the senior management of the trust are fully-sighted on the challenges faced by front-line staff in the department.
Must-do action 43 of 55
Must do
Safe
Ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed across all divisional wards. Specifically, registered nurses and physicians to ensure safe staffing levels are maintained;
Must-do action 44 of 55
Must do
Safe
Ensure electronic systems which monitor acuity and staffing numbers are updated in a timely manner;
Must-do action 45 of 55
Must do
Safe
Ensure patients assessed as requiring one to one support are provided with the appropriate provision of care;
Must-do action 46 of 55
Must do
Safe
Ensure safeguarding training levels are delivered in accordance with intercollegiate guidance;
Must-do action 47 of 55
Must do
Safe
Ensure mandatory training targets are met by the target date;
Must-do action 48 of 55
Must do
Safe
Ensure there are appropriate numbers of qualified staff on the ward to improve second signatory and witness administration of intravenous medicines and controlled drug procedures;
Must-do action 49 of 55
Must do
Safe
Ensure prescriptions comply with the trust prescribing policies;
Must-do action 50 of 55
Must do
Safe
Ensure staff record minimum and maximum temperatures for medicines refrigerators;and,
Must-do action 51 of 55
Must do
Well-led
Ensure actions are implemented following audit findings.
Must-do action 52 of 55
Must do
Safe
Ensure compliance with the completion of the WHO surgical safety checklist for every patient;
Must-do action 53 of 55
Must do
Safe
Ensure consistent practice and compliance across wards with trust policies regarding the management of medicines;
Must-do action 54 of 55
Must do
Safe
Ensure mandatory training compliance rates meet trust targets.
Must-do action 55 of 55
Must do
Safe
Ensure safeguarding training compliance rates meet trust targets and are delivered in accordance with ‘Adult Safeguarding Levels and Competencies for Healthcare, Intercollegiate guidance (2016)’.
Should-do actions (78)
Should-do action 1 of 78
Should do
Safe
The trust should ensure safeguarding children level three training meets intercollegiate standards
Should-do action 2 of 78
Should do
Safe
The trust should improve staff awareness of the importance of infection prevention and control
Should-do action 3 of 78
Should do
Responsive
The trust should pursue plans to improve the paediatric waiting area
Should-do action 4 of 78
Should do
Safe
The trust should improve department assurance that staff are correctly recording NEWS and vital signs via robust clinical audit
Should-do action 5 of 78
Should do
Responsive
The trust should continue work to improve ambulance handover times
Should-do action 6 of 78
Should do
Well-led
The trust should ensure regular robust record keeping audits take place to identify areas for improvement and action taken.
Should-do action 7 of 78
Should do
Safe
The trust should monitor ambient temperature in the medicines room to ensure medication is stored at its optimum temperature.
Should-do action 8 of 78
Should do
Safe
The trust should ensure fluids are stored safely and securely to minimise the risk of errors.
Should-do action 9 of 78
Should do
Caring
The trust should ensure patients are suitable hydrated whilst waiting in the department.
Should-do action 10 of 78
Should do
Effective
The trust should ensure pain scores are reassessed and recorded
Should-do action 11 of 78
Should do
Effective
The trust should work towards improving the unplanned reattendance within seven days rate.
Should-do action 12 of 78
Should do
Well-led
The trust should ensure all staff have undergone a recent appraisal and that appraisals are of a high standard.
Should-do action 13 of 78
Should do
Caring
The trust should consider how a private space can be made available for families to spend time with a deceased relative.
Should-do action 14 of 78
Should do
Well-led
The trust should ensure staff are aware of the clear lines of management escalation in the department.
Should-do action 15 of 78
Should do
Responsive
The trust should consider how to manage patients who have long waits on trolleys in the department to ensure the risk of pressure damage is minimised and work with wards and departments to reduce the number of patients waiting more than four hours from decision to admit, to admission on a ward.
Should-do action 16 of 78
Should do
Responsive
The trust should work towards meeting the 95% four hour waiting target.
Should-do action 17 of 78
Should do
Well-led
The trust should ensure the risk register for the department accurately reflects all the risks faced by the department.
Should-do action 18 of 78
Should do
Well-led
The trust should consider developing a trust wide strategy to improve the perception of staff about the trust so more than 23% of staff would recommend the trust as a place to work.
Should-do action 19 of 78
Should do
Safe
The trust should continue to proactively recruit nursing and medical staff;
Should-do action 20 of 78
Should do
Safe
The trust should ensure staff are given time to complete all necessary mandatory training modules and an accurate record kept;
Should-do action 21 of 78
Should do
Well-led
The trust should ensure all staff can access development opportunities in line with organisational/staff appraisal objectives protecting/negotiating study time where required;
Should-do action 22 of 78
Should do
Safe
The trust should ensure best practice guidelines for medicines related documentation is reinforced to all prescribers;
Should-do action 23 of 78
Should do
Responsive
The trust should ensure minimal patient moves after 10pm;
Should-do action 24 of 78
Should do
Safe
The trust should continue to progress patient harm reduction initiatives;
Should-do action 25 of 78
Should do
Well-led
The trust should ensure the risk register is current and reflects actual risks with corresponding accurate risk rating;
Should-do action 26 of 78
Should do
Well-led
The trust should ensure all staff are aware of the divisional risk register and the associated risks;
Should-do action 27 of 78
Should do
Well-led
The trust should ensure all actions and reviews of risk ratings are documented;
Should-do action 28 of 78
Should do
Well-led
The trust should ensure ward governance files are maintained and up-to-date;
Should-do action 29 of 78
Should do
Well-led
The trust should revisit medical rota management processes for junior doctors;
Should-do action 30 of 78
Should do
Well-led
The trust should revisit modes of communications with staff;
Should-do action 31 of 78
Should do
Well-led
The trust should ensure staff involved in change management projects are fully informed of the aims and objectives of the proposal and these are implemented and concluded in appropriate time frames;
Should-do action 32 of 78
Should do
Well-led
The trust should ensure divisional leads and trust leaders promote their visibility when visiting wards and clinical areas.
Should-do action 33 of 78
Should do
Safe
The trust should ensure measures are put in place to support units where pending staffing departures will temporarily increase vulnerability;
Should-do action 34 of 78
Should do
Caring
The trust should ensure food satisfaction standards are maintained;
Should-do action 35 of 78
Should do
Well-led
The trust should ensure quality of appraisals is improved and maintained.
Should-do action 36 of 78
Should do
Responsive
The trust should ensure continued improvement in compliance with the overall referral to treatment time (RTT) for admitted pathways target for surgery and particularly for trauma and orthopaedics and ophthalmology surgical specialities;
Should-do action 37 of 78
Should do
Responsive
The trust should ensure patient information leaflets are available in different languages and formats and staff are aware how to access.
Should-do action 38 of 78
Should do
Well-led
The trust should look to develop a formal strategy for the future of maternity services.
Should-do action 39 of 78
Should do
Effective
The trust should ensure all out of date maternity guidelines and procedures are reviewed and updated.
Should-do action 40 of 78
Should do
Safe
The trust should work to ensure mandatory training rates to include safeguarding level three meet the trust target of 95%.
Should-do action 41 of 78
Should do
Safe
The trust should work towards all women receiving one to one care in labour
Should-do action 42 of 78
Should do
Safe
The trust should review the management of drugs in the community and ensure there are consistent practices across all community midwifery teams
Should-do action 43 of 78
Should do
Effective
The trust should ensure all accessible procedures and guidelines (paper and electronic) have been appropriately reviewed, include current evidence-based guidance, and are in date.
Should-do action 44 of 78
Should do
Safe
Ensure safeguarding children level3 training meets intercollegiate standards.
Should-do action 45 of 78
Should do
Safe
Improve department assurance that staff are correctly recording NEWS and vital signs via robust clinical audit.
Should-do action 46 of 78
Should do
Responsive
Continue work to improve ambulance handover times.
Should-do action 47 of 78
Should do
Effective
Ensure pain scores are reassessed and recorded at suitable intervals.
Should-do action 48 of 78
Should do
Well-led
Ensure that staff appraisals are of a high standard.
Should-do action 49 of 78
Should do
Well-led
Ensure regular, robust record-keeping audits take place to identify areas for improvement and action taken.
Should-do action 50 of 78
Should do
Safe
Monitor medicines fridge temperatures daily to ensure that medicines are safely stored.
Should-do action 51 of 78
Should do
Responsive
Consider how to manage patients who have long waits on trolleys in the department, to ensure the risk of pressure damage is minimised, and work with wards and departments to reduce the number of patients waiting more than four hours from a decision to admit to admission to a ward.
Should-do action 52 of 78
Should do
Responsive
Work towards meeting the 95% four hour waiting target.
Should-do action 53 of 78
Should do
Well-led
Ensure the risk register for the ED accurately reflects each of the risks faced by the department.
Should-do action 54 of 78
Should do
Safe
Continue to proactively recruit nursing and medical staff;
Should-do action 55 of 78
Should do
Safe
Ensure staff are given time to complete all necessary mandatory training modules and an accurate record kept;
Should-do action 56 of 78
Should do
Well-led
Ensure all staff can access development opportunities in line with organisational/staff appraisal objectives protecting/negotiating study time where required;
Should-do action 57 of 78
Should do
Safe
Ensure best practice guidelines for medicines related documentation is reinforced to all prescribers;
Should-do action 58 of 78
Should do
Responsive
Ensure minimal patient moves after 10pm;
Should-do action 59 of 78
Should do
Safe
Continue to progress patient harm reduction initiatives;
Should-do action 60 of 78
Should do
Well-led
Ensure the risk register is current and reflects actual risks with corresponding accurate risk rating;
Should-do action 61 of 78
Should do
Well-led
Ensure all staff are aware of the divisional risk register and the associated risks;
Should-do action 62 of 78
Should do
Well-led
Ensure all actions and reviews of risk ratings are documented;
Should-do action 63 of 78
Should do
Well-led
Revisit medical rota management processes for junior doctors;
Should-do action 64 of 78
Should do
Well-led
Revisit modes of communications with staff;
Should-do action 65 of 78
Should do
Well-led
Ensure staff involved in change management projects are fully informed of the aims and objectives of the proposal and these are implemented and concluded in appropriate time frames;
Should-do action 66 of 78
Should do
Well-led
Ensure divisional leads and trust leaders promote their visibility when visiting wards and clinical areas.
Should-do action 67 of 78
Should do
Safe
Ensure measures are put in place to support units where pending staffing departures will temporarily increase vulnerability;
Should-do action 68 of 78
Should do
Well-led
Ensure quality of appraisals is improved and maintained.
Should-do action 69 of 78
Should do
Safe
Ensure the continuing cover of the anaesthetic rota at West Cumberland Hospital to deliver the care model through the recruitment and retention of sufficient numbers of appropriately skilled staff;
Should-do action 70 of 78
Should do
Responsive
Ensure continued improvement in compliance with the overall referral to treatment time (RTT) for admitted pathways target for surgery and particularly for trauma and orthopaedics and ophthalmology surgical specialities;
Should-do action 71 of 78
Should do
Responsive
Ensure patient information leaflets are available in different languages and formats and staff are aware how to access them.
Should-do action 72 of 78
Should do
Safe
Ensure mandatory training rates for all staff meet the trust target of 95%.
Should-do action 73 of 78
Should do
Safe
Ensure regular cleaning audits are carried out and results are displayed.
Should-do action 74 of 78
Should do
Safe
Ensure systems and processes for the storage of medicines are standardised following best practice and adhered to across all sites and throughout the community teams.
Should-do action 75 of 78
Should do
Safe
Comply with Health and Safety Executive best practice guidance to reduce the risk of legionella in the birthing pool.
Should-do action 76 of 78
Should do
Well-led
Ensure regular audits are undertaken within the Birthing Centre in line with maternity service audits and results displayed and shared with all staff.
Should-do action 77 of 78
Should do
Well-led
Ensure a formal audit and records of themes regarding transfers to the consultant led units and record risk assessments and decisions made for all transfers.
Should-do action 78 of 78
Should do
Effective
All accessible policies and guidelines have been appropriately reviewed, include current evidence-based guidance, and are in date.