Source · CQC inspection

West Cumberland Hospital

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

Five CQC key questions
Safe
Requires Improvement
Effective
Requires Improvement
Caring
Good
Responsive
Requires Improvement
Well-led
Requires Improvement

Earlier inspection findings

pre-2024 framework · 29 must-do 43 should-do

Must-do actions (29)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 29
Must do
Safe
The trust must improve levels of mandatory training for medical and nursing staff.
Regulation: Regulation 18 (Staffing)
⚠ Neither nursing nor medical staff were meeting mandatory training requirements with low compliance against the trust standard of 95%. Compliance with training in immediate life support was particularly low. In the emergency department we were not assured that staff had undergone appropriate life support, paediatric life support and trauma life …
Must-do action 2 of 29
Must do
Safe
The trust must ensure toys and storage solutions were cleaned thoroughly and in line with IPC guidance
Regulation: Regulation 12 (Safe care and treatment)
⚠ Although the department was generally clean, we found toys were heavily soiled, there were dead insects inside an equipment cabinet and cleaning products were not stored securely. Staff were observed to not always follow hand hygiene processes.
Must-do action 3 of 29
Must do
Safe
The trust must improve the safety aspects of the designated mental health room
Regulation: Regulation 12 (Safe care and treatment)
⚠ In the emergency department during our initial inspection, the room used to accommodate patients with mental health conditions was not fit for purpose. There were ligature points and unsuitable furniture. However, after our inspection, the department took action quickly to make the room safer for patients. A second room which …
Must-do action 4 of 29
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.
Regulation: Regulation 17 (Good governance)
⚠ Seniormanagers told us that it was not always possible to measure the median time from arrival to treatment accurately, as medical staff did not always write the time that they saw a patient on the paper copy of the patient record form. This meant that the data later input to …
Must-do action 5 of 29
Must do
Safe
The trust must ensure medical cover overnight is qualified to at least level ST4 with ALS training
Regulation: Regulation 18 (Staffing)
⚠ The trust was not meeting the Royal College of Emergency Medicine (RCEM) standard that overnight cover should be provided by medical staff trained to a minimum of specialist trainee year four with advanced life support training. The department could not guarantee that staff providing overnight cover were trained to this …
Must-do action 6 of 29
Must do
Safe
The trust must improve identification and management of patients with time critical conditions such as sepsis, DKA and stroke.
Regulation: Regulation 12 (Safe care and treatment)
⚠ We were not assured that the emergency department identified and responded quickly enough to deteriorating patients or patients with a number of conditions including sepsis, diabeticketoacidosis (DKA) and stroke. There had been a number of serious incidents in the department related to these conditions and delays in treatment. The trust …
Must-do action 7 of 29
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.
Regulation: Regulation 18 (Staffing)
⚠ Compliance with training in immediate life support was particularly low. We were not assured that staff had undergone appropriate life support, paediatric life support and trauma life support training as per Royal College of Emergency Medicine (RCEM) guidance.
Must-do action 8 of 29
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.
Regulation: Regulation 18 (Staffing)
⚠ The department had not undergone a recent assessment of nurse staffing levels to ensure that there were sufficient suitably qualified staff deployed to meet the needs of patients. Staffing levels were based on the experience of the matron rather than on a formal nurse staffing assessment tool. From our observations …
Must-do action 9 of 29
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.
Regulation: Regulation 12 (Safe care and treatment)
⚠ In the emergency department controlled drugs were not checked and disposed of in line with trust policies. Medicines such as fluids with different strengths, for example like glucose, that could easily get mixed up, were stored together and were not stored securely in a locked cupboard. We also found that …
Must-do action 10 of 29
Must do
Effective
The trust must continue work to improve patient outcomes where the department failed to meet RCEM audit standards.
Regulation: Regulation 17 (Good governance)
⚠ The emergency department had not taken part in all Royal College of Emergency Medicine (RCEM) audits since 2015/2016. Of those they took part in, they had not met all of the standards and in the Consultant, sign off audit, they had not met any standards.
Must-do action 11 of 29
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.
Regulation: Regulation 12 (Safe care and treatment)
⚠ Flow through the emergency department remained a challenge within the trust. Moving patients to beds on wards did not happen quickly and meant patients had long waits in the department from decision to admit to actual admission on a ward. The number of patients waiting more than four hours from …
Must-do action 12 of 29
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.
Regulation: Regulation 17 (Good governance)
⚠ Senior departmental managers presented to us as less than confident about the staffing makeup of the department.
Must-do action 13 of 29
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.
Regulation: Regulation 17 (Good governance)
⚠ The department did not have a clear vision and strategy for the future of the department therefore staff were not clear about the future direction of the department.
Must-do action 14 of 29
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.
Regulation: Regulation 17 (Good governance)
⚠ Senior emergency department management were not always visible and there was some confusion among staff about who to escalate concerns to, above their line manager.
Must-do action 15 of 29
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;
Regulation: Regulation 18 (Staffing)
⚠ Registered nurse staffing shortfalls and registered nurse vacancies persisted on all divisional wards. Several registered nurse shifts remained unfilled despite escalation processes. Nursing staff sickness was also prevalent across wards with several wards having teams that were described as “burnt out”.
Must-do action 16 of 29
Must do
Safe
The trust must ensure electronic systems which monitor acuity and staffing numbers are updated in a timely manner;
Regulation: Regulation 17 (Good governance)
⚠ We saw that patient acuity was not regularly updated on the medical wards when patient complexity changed or updated following patient ward moves.
Must-do action 17 of 29
Must do
Safe
The trust must ensure patients assessed as requiring one to one support are provided with the appropriate provision of care;
Regulation: Regulation 12 (Safe care and treatment)
⚠ Wards also noted that despite having patients with complex needs including those requiring one to one support that additional staff support was not available.
Must-do action 18 of 29
Must do
Safe
The trust must ensure safeguarding training levels are delivered in accordance with intercollegiate guidance;
Regulation: Regulation 18 (Staffing)
⚠ We were not assured that safeguarding training was delivered in accordance with Adult Safeguarding Levels and Competencies for healthcare, Intercollegiate guidance (2016).
Must-do action 19 of 29
Must do
Safe
The trust must ensure mandatory training targets are met by the target date;
Regulation: Regulation 18 (Staffing)
⚠ The trust submitted data prior to inspection which showed the mandatory target for nursing staff was not met for majority of the 26 mandatory courses, with the worst 34% completion
Must-do action 20 of 29
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;
Regulation: Regulation 12 (Safe care and treatment)
⚠ There was difficulty gaining a second signature for intravenous medicines and controlled drugs. This was due to only having one nurse on a ward. This is not in line with trust policy or Nursing and Midwifery Council (NMC) code of practice.
Must-do action 21 of 29
Must do
Safe
The trust must ensure intravenous fluids are secured as per the trusts medicines policy;
Regulation: Regulation 12 (Safe care and treatment)
⚠ Intravenous fluids were not always secured as per the trust's medicines policy.
Must-do action 22 of 29
Must do
Safe
The trust must ensure prescriptions comply with the trust prescribing policies;
Regulation: Regulation 12 (Safe care and treatment)
⚠ In all of the charts we looked at we found prescriptions which did not comply with the trust prescribing policy.
Must-do action 23 of 29
Must do
Safe
The trust must ensure staff record minimum and maximum temperatures for medicines refrigerators;and,
Regulation: Regulation 12 (Safe care and treatment)
⚠ We could not be assured medicines requiring cold storage had been stored at the recommended temperature and were safe to use.
Must-do action 24 of 29
Must do
Well-led
The trust must ensure actions are implemented following audit findings.
Regulation: Regulation 17 (Good governance)
⚠ A prescription audit carried out in August 2017 identified some of the issues we found on inspection, but we could not see evidence of actions taken to improve this.
Must-do action 25 of 29
Must do
Safe
The trust must ensure compliance with the completion of the WHO surgical safety checklist for every patient;
Regulation: Regulation 12 (Safe care and treatment)
⚠ Audits of completion of the WHO surgical safety checklist showed completion of the checklist had been ‘poor’ and had not been completed for every patient;
Must-do action 26 of 29
Must do
Safe
The trust must ensure consistent practice and compliance across wards with trust policies regarding the management of medicines;
Regulation: Regulation 12 (Safe care and treatment)
⚠ We found inconsistent practice across wards regarding the management of medicines, maximum and minimum temperatures were not recorded on wards.
Must-do action 27 of 29
Must do
Safe
The trust must ensure mandatory training compliance rates meet trust targets;
Regulation: Regulation 18 (Staffing)
⚠ The 95% target was met for only three of the 27 mandatory training modules for which qualified nursing staff were eligible and for only one of the 27 mandatory training modules for which medical staff were eligible;
Must-do action 28 of 29
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.
Regulation: Regulation 18 (Staffing)
⚠ We were not assured that safeguarding training was delivered in accordance with ‘Adult Safeguarding Levels and Competencies for Healthcare, Intercollegiate guidance (2016)’;
Must-do action 29 of 29
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.”
Regulation: Regulation 18 (Staffing)
⚠ Safeguarding level three training did not meet the standards recommended by Royal Collage of Paediatrics and Child Health intercollegiate document. The trust had recently replaced the interactive face-to-face training with a four-hour online e-learning module. This meant medical and nursing staff did not have the opportunity to participate in scenario-based …

Should-do actions (43)

Recommended improvements to enhance service quality.

Should-do action 1 of 43
Should do
Safe
The trust should ensure safeguarding children level three training meets intercollegiate standards
Should-do action 2 of 43
Should do
Safe
The trust should improve staff awareness of the importance of infection prevention and control
Should-do action 3 of 43
Should do
Responsive
The trust should pursue plans to improve the paediatric waiting area
Should-do action 4 of 43
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 43
Should do
Responsive
The trust should continue work to improve ambulance handover times
Should-do action 6 of 43
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 43
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 43
Should do
Safe
The trust should ensure fluids are stored safely and securely to minimise the risk of errors.
Should-do action 9 of 43
Should do
Caring
The trust should ensure patients are suitable hydrated whilst waiting in the department.
Should-do action 10 of 43
Should do
Effective
The trust should ensure pain scores are reassessed and recorded
Should-do action 11 of 43
Should do
Effective
The trust should work towards improving the unplanned reattendance within seven days rate.
Should-do action 12 of 43
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 43
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 43
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 43
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 43
Should do
Responsive
The trust should work towards meeting the 95% four hour waiting target.
Should-do action 17 of 43
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 43
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 43
Should do
Safe
The trust should continue to proactively recruit nursing and medical staff;
Should-do action 20 of 43
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 43
Should do
Effective
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 43
Should do
Safe
The trust should ensure best practice guidelines for medicines related documentation is reinforced to all prescribers;
Should-do action 23 of 43
Should do
Responsive
The trust should ensure minimal patient moves after 10pm;
Should-do action 24 of 43
Should do
Safe
The trust should continue to progress patient harm reduction initiatives;
Should-do action 25 of 43
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 43
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 43
Should do
Well-led
The trust should ensure all actions and reviews of risk ratings are documented;
Should-do action 28 of 43
Should do
Well-led
The trust should ensure ward governance files are maintained and up-to-date;
Should-do action 29 of 43
Should do
Well-led
The trust should revisit medical rota management processes for junior doctors;
Should-do action 30 of 43
Should do
Well-led
The trust should revisit modes of communications with staff;
Should-do action 31 of 43
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;and,
Should-do action 32 of 43
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 43
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 43
Should do
Caring
The trust should ensure food satisfaction standards are maintained;and,
Should-do action 35 of 43
Should do
Well-led
The trust should ensure quality of appraisals is improved and maintained.
Should-do action 36 of 43
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 43
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 43
Should do
Well-led
The trust should look to develop a formal strategy for the future of maternity services.
Should-do action 39 of 43
Should do
Effective
The trust should ensure all out of date maternity guidelines and procedures are reviewed and updated.
Should-do action 40 of 43
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 43
Should do
Safe
The trust should work towards all women receiving one to one care in labour
Should-do action 42 of 43
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 43
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.

Location details

CQC ID: RNLBX
Local authority: Cumberland
Region: North West

Inspection report

Type: Inspection report
Date: 17 July 2018
Rating: Requires improvement
Actions: 29 must-do 43 should-do
AI-extracted 3 Jun 2026