Cumberland Infirmary

⚠ We heard from staff at all levels, that board members were not always visible within the organisation, particularly at the West Cumberlands site. Board meetings were predominantly held at the Carlisle site. There were weekly executive meetings, we were told that during these meetings strategy was discussed, developed, and challenged. …

⚠ The director of infection prevention and control (DIPC) did not attend board meetings. They also did not line manage the IPC team. We were not assured how accountability for IPC within the trust was managed robustly. There was no non-executive director with the responsibility for IPC. The draft IPC strategy …

⚠ Overall, underpinning strategy and plans were not in place across the organisation. Strategic plans were still a long list of ideas and were not yet actionable project with timescales and deliverables.

⚠ We did not have confidence that cultural issues were taken with the appropriate level of seriousness in the trust and were not assured that cultural issues could be fully addressed in an environment where lived experiences were undermined. The results showed a deterioration in the key indicators of staff morale …

⚠ The latest WRES/WDES action plan covered a wider range of initiatives which were rated and updated quarterly. Whilst the action plan indicated some executive team involvement in the plan, executives sponsorship of the plan was not obvious and where actions were not on track these were often awaiting executive team …

⚠ Reports to board and committees were being developed, but they lacked measurables and standardisation. There were no regular performance reports or dashboards and committees relied on reports mostly of narrative. There was a risk that key issues were absent from reporting mechanisms to board.

⚠ There was no accountability framework for care groups to monitor performance on action plans or mitigating risk.

⚠ The trust did not follow NHS England guidance on the investigation of cases referred to the health and safety investigation branch (HSIB). Rather than conducting their own review of the incident following the early learning from an initial 72-hour report they waited for the return of the HSIB report.

⚠ We reviewed 6 SJRs and found that they lacked explicit judgments around the standards of care given. The records provided were incomplete, for example they had no time of death or date of completion of the review or the author. The documentation did not contain reasons for carrying out an …

⚠ There was a backlog of assessments against NICE guidance. The organisation did not have full assurance that they were compliant with evidence-based guidance.

⚠ The board assurance framework (BAF) was linked to the trust strategic objectives and contained 11 risks reflected in the corporate risk register (CRR). However, the BAF constituted a long list of actions which were not tracked. Actions were not measurable and the BAF did not reflect risk appetite within the …

⚠ Performance on complaints was variable across care groups, with an average performance of 70% of all responses being sent within 30 days for the core services we inspected. We reviewed 6 complaints and in all cases the responses were poorly written, contained medical jargon and often did not address the …

⚠ We were told during inspection that despite ketone testing machines being available with in the medical care division, staff continued to use machines allocated to other departments within the hospital. Insulin chart guidelines state that should a patient’s blood glucose readings be 15mmol or over, a ketone test must be …

⚠ During the inspection we observed storage doors left open on most wards we inspected. Doors had digi-locks in place; however, most doors were either left propped open or unlocked. Storage rooms contained consumables for the wards including, sharps, venflons, intravenous fluids (IV), meal replacements drinks and dietary supplements. We also …

⚠ However, due to the recent influx of newly qualified staff within the trust, we were not always assured that staff had the relevant experience or right skills and knowledge to meet the needs of all patients. Particularly due to the ongoing need for staff to be redeployed within the trust …

⚠ During inspection we observed the clean utility room temperature on one of the wards we visited was out of range. Staff had recorded the room temperature as 26 degrees and had reported this on the trust’s electronic recording system to alert pharmacy and estates staff. The clean utility contained controlled …

⚠ There were also shortfalls identified in the most recent oxygen prescribing audit completed in November 2022 where only 35% of a sample of 36 patients based on the acute medical unit had completed oxygen prescribing documentation within their records.

⚠ Staff mostly followed infection control principles including the use of personal protective equipment (PPE). However, during the inspection we saw storage of some consumable items in large boxes which was not in-line with infection control guidance, as they had been placed on the floor within stock cupboards instead of designated …

⚠ We were not assured of senior management oversight of serious incidents reported within the trust. Although staff had been reporting incidents via the standard reporting channels, the trust informed us that they had identified discrepancies with the accurate grading of serious incidents involving patient falls since January 2023. The trust …

⚠ During the inspection there was a lack of consistency with the storage of patient records across most wards, these continued to not always be securely stored. On all wards we visited, notes trollies were mostly left unlocked and unattended, with patient notes stored underneath trollies and easily accessible to visitors. …

⚠ Not all nursing staff kept up to date with their mandatory training. Data provided by the trust highlighted shortfalls with basic life support training (between 50% and 83% compliance), immediate life support training (between 55% and 71% compliance) moving and handling level 2 training (between 71% and 83% compliance). Most …

⚠ Not all nursing staff received and kept up to date with their mandatory training. Shortfalls were found in 8 modules which included infection prevention & control L1, safeguarding children’s level 1-3, safeguarding adults L3, moving and handling L2, basic life support, immediate life support adults and paediatric. Not all medical …

⚠ Only 74% of medical staff had completed level three safeguarding children training. This was a concern and meant that not all medical staff may not recognise possible safeguarding concerns. We reviewed 2 children safeguarding record and found a clear timeline of history, appropriate referrals, and escalations in both set of …

⚠ Not all areas within the emergency department were clean. We observed that the triage room and clean utility to be dirty and cluttered. The clinical waste bin that was in the clean utility was overflowing and staff could not access the sink or handwashing facilities as boxes were stored directly …

⚠ Staff did not always complete risk assessments for each patient on admission, using a recognised tool, and reviewed this regularly, including after any incident. During our inspection, we saw that important risk assessments, such as venous thromboembolism (VTE), bedrails, falls risk, SSKIN (a resource pack to aid in the assessment …

⚠ The service did not always have enough nursing and support staff to keep patients safe. The number of nurses and healthcare assistants did not always match the planned numbers. Senior staff told us their usual staffing was down by 1 or 2 members of staff. We saw there were gaps …

⚠ Recordswere not always stored securely. We observed notes trollies that contained patient records were mostly left unlocked and unattended and accessible to unauthorised personnel. We also saw several computers left open with patients' details. This was not in line with trust policy and General Data Protection Regulations (GDPR).

⚠ Patient notes were not always comprehensive; however, all staff could access them easily. We were not assured of the quality of records produced and used by the department. During the inspection we were made aware of a vulnerable young person who was known to the paediatric emergency department (PED) and …

⚠ Staff did not always assess patients’ pain using a recognised tool and did not always give pain relief in line with individual needs and best practice. We saw in 15 patients records that no pain scores were recorded. Patients did not always receive pain relief soon after it was identified …

⚠ Controlled drugs were stored securely in all areas we looked at; however, we found on some occasions that controlled drug registers in the resuscitation department were not completed in line with trust policy. We found no oversight of controlled drug discrepancies in the main department with senior staff informing us …

⚠ Staff did not always gain consent from patients for their care and treatment in line with legislation and guidance. We observed on inspection one incident where staff did not follow best interest decision making for the patient. Staff did not always record consent in patients’ records.

⚠ Staff did not always complete, or arrange, psychosocial assessments and risk assessments for patients thought to be at risk of self-harm or suicide at triage.

⚠ Staff told us that they had raised concerns about the use of offensive language in meetings. Staff reported that the language used had been deemed as unacceptable, but this had not been followed up with meaningful action by the leadership team.

⚠ The most recent sepsis audit data highlighted that all wards had consistently recorded patient NEWS2 scores. However, the most recent sepsis audits completed by the trust highlighted some significant inconsistencies with overall standards, particularly regarding the completion of the sepsis screening tool where compliance ranged between 0% and 61% and …

⚠ However, staff in the areas we inspected told us they were often short of qualified nursing staff and healthcare assistants with the right skills and competency to care for patients with in the medicine speciality. Most wards we visited during inspection had high numbers of newly appointed internationally recruited nurses …

⚠ The service used systems and processes to prescribe, administer, record and store medicines. However, this was not always done in-line with trust policy.

⚠ Data provided by the trust highlighted that staff did not always complete medicines records accurately. The prescribing and administration audit contained findings from a random sample of ten medicines charts which had been selected from medical, surgical and community hospital ward settings. The most recent findings highlighted poor compliance with …

⚠ During the inspection we observed storage doors left open on most wards we inspected. Doors had digi-locks in place; however, we found that most doors were either left propped open or unlocked. Storage rooms contained consumables for the wards including, sharps, venflons and intravenous fluids (IV). We also found sluice …

⚠ During the inspection we found that not all wards on-site had a set patient criteria for admissions. Two of the wards we visited had been set-up as escalation wards during the COVID-19 pandemic and over time had been adapted to become general admission/medical wards. We noted that the patients on …

⚠ Staff mostly followed infection control principles including the use of personal protective equipment (PPE). However, during the inspection we saw storage of some consumable items in large boxes which was not in-line with infection control guidance, as they had been placed on the floor within stock cupboards instead of designated …

⚠ We were not assured of senior management oversight of serious incidents reported within the trust. Although staff had been reporting incidents via the standard reporting channels, the trust informed us that they had identified discrepancies with the accurate grading of serious incidents involving patient falls since January 2023. The trust …

⚠ During the inspection there was a lack of consistency with the storage of patient records and across most wards, these continued to not always be securely stored. On all wards we visited, notes trollies were mostly left unlocked and unattended, with patient notes stored underneath trollies and easily accessible to …

⚠ Not all nursing staff kept up to date with their mandatory training. Data provided by the trust highlighted showed the most significant shortfalls within basic life support training (lowest compliance rates between 50% and 81%), immediate life support training (lowest compliance rates between 43% to 72%) and moving and handling …

⚠ Not all medical staff had not kept up to date with their mandatory training. Data received from the trust showed shortfalls in all 14 modules. Overall compliance rates were 64% which was below the trust target. Compliance for the highest life support training had not been achieved. Data provided by …

⚠ Staff did not always follow infection control principles including the use of personal protective equipment (PPE). We saw staff did not always wash her hands before and after patient contact. We observed that mostly all oxygen ports within the ED and Paediatrics had green dot sticker but no dates available …

⚠ Staff did not always complete risk assessments for each patient on admission, using a recognised tool, and reviewed this regularly, including after any incident. During our inspection, we saw that important risk assessments, such as venous thromboembolism (VTE), bedrails, falls risk, SSKIN (a resource pack to aid in the assessment …

⚠ The service did not always have enough nursing and support staff to keep patients safe. The number of nurses and healthcare assistants did not always match the planned numbers. Senior staff told us their usual staffing was down by 1 or 2 members of staff. We saw there were gaps …

⚠ Patient notes were not always comprehensive; however, all staff could access them easily. We were not assured of the quality of records produced and used by the department. The department used a combination of electronic and paper documents to record care and treatment of patients.

⚠ Staff did not always assess patients’ pain using a recognised tool and did not always give pain relief in line with individual needs and best practice. Patients did not always receive pain relief soon after it was identified and when they needed it or request it. Staff prescribed but did …

⚠ Controlled drugs were stored securely, and stock checks were taking place. Audits on controlled drugs by the pharmacy were taking place however the frequency of this was not in line with trust policy with the last audit taking place in September 2022. We also found the audit did not relate …

⚠ Staff did not always demonstrate the correct skills to support patients who lacked capacity to make their own decisions or were experiencing mental ill health. They did not always use agreed personalised measures that limit patients' liberty. Staff understood how and when to assess whether a patient had the capacity …