Source · CQC inspection

West Cumberland Hospital

Provider North Cumbria Integrated Care NHS Foundation Trust Type NHS Healthcare Organisation Region North West Last inspected 20 Nov 2023

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

Good

Earlier inspection findings

pre-2024 framework · 18 must-do 3 should-do

Must-do actions (18)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 18

Must do

Safe

The trust must ensure care and treatment is provided in a safe way for patients, including assessing the risks to the health and safety of service users of receiving the care or treatment and doing all that is reasonably practicable to mitigate any such risks.Regulation12(1)(a)(b).

Regulation: Regulation12(1)(a)(b).

⚠ Staff completed and updated risk assessments for each patient; however not all risks were removed or minimised. Some staff told us that visibility in some of the side rooms on specific wards was poor and it was necessary to ensure patients deemed a high risk of falls were not allocated …

Must-do action 2 of 18

Must do

Safe

The trust must ensure that persons providing care or treatment to service users have the qualifications, competence, skills and experience to do so safely.Regulation12(1)(2)(c).

Regulation: Regulation12(1)(2)(c).

⚠ Due to national shortages of nursing and support staff the service did not always have enough nursing and support staff to keep patients safe. All wards inspected had vacancies for qualified nurses and healthcare assistants. Staff in the areas we inspected told us they were often short of qualified nursing …

Must-do action 3 of 18

Must do

Safe

The trust must ensure that all medicines are stored in accordance with temperature thresholds to ensure efficacy of medication is not impacted upon.Regulation12(1)(2)(g).

Regulation: Regulation12(1)(2)(g).

Must-do action 4 of 18

Must do

Safe

The trust must ensure the timely administration and accurate recording of all medications, including oxygen, prescribed to patients under its care.Regulation(1)(2)(c)(g).

Regulation: Regulation(1)(2)(c)(g).

⚠ Staff did not always follow systems and processes to prescribe and administer medicines safely. During the inspection we had concerns with treatment provided to patients experiencing alcohol withdrawal, as this was not done so in-line with the trust policy. Data provided by the trust highlighted that staff did not always …

Must-do action 5 of 18

Must do

Safe

The trust must ensure storeroom doors are not left open or unlocked and accessible to patients or members of the public.Regulation12(1)(2)(b).

Regulation: Regulation12(1)(2)(b).

⚠ 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 …

Must-do action 6 of 18

Must do

Responsive

The trust must ensure that the medical care service is responsive in terms of access and flow, which should include specific admission criteria for each ward based within the medical care core service.Regulation17(1)(2)(a)(b).

Regulation: Regulation17(1)(2)(a)(b).

⚠ 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 …

Must-do action 7 of 18

Must do

Safe

The service must ensure that the assessment of risk, preventing, detecting, and controlling the spread of, infections, including those that are healthcare associated is managed in line with national guidance. This includes, but is not limited to, cleaning substances subject to COSHH regulations are stored securely.Regulation15(1)(2)(h).

Regulation: Regulation15(1)(2)(h).

⚠ 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 …

Must-do action 8 of 18

Must do

Safe

The trust must ensure that systems and processes are in place to accurately review and categorise patient safety incidents logged by frontline staff.Regulation17(2)(a)(b).

Regulation: Regulation17(2)(a)(b).

⚠ 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. As a …

Must-do action 9 of 18

Must do

Safe

The trust must ensure that all patient records are stored securely across the medical division to adhere to patient confidentiality and general data protection regulation (GDPR) guidelines.Regulation17(1)(2)(c).

Regulation: Regulation17(1)(2)(c).

⚠ 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 …

Must-do action 10 of 18

Must do

Safe

The trust must ensure that all staff complete mandatory training to comply with targets for completion set by the trust.Regulation12(1)(2)(c).

Regulation: Regulation12(1)(2)(c).

⚠ 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 …

Must-do action 11 of 18

Must do

Safe

The trust must ensure that mandatory training including resuscitation, infection prevention and control and safeguarding meet the trust target for all staff.Regulation12(1)(2)(c).

Regulation: Regulation12(1)(2)(c).

⚠ 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 …

Must-do action 12 of 18

Must do

Safe

The trust must ensure that all premises and equipment used by patients are clean, secure, suitable for the purpose for which they are being used for and properly maintained.Regulation15(1)(a)(e).

Regulation: Regulation15(1)(a)(e).

⚠ 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 …

Must-do action 13 of 18

Must do

Safe

The trust must ensure that patient risk assessment are completed and updated so that staff can identify and act upon patients at risk of deterioration.Regulation12(1)(2)(a)(b).

Regulation: Regulation12(1)(2)(a)(b).

⚠ 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 …

Must-do action 14 of 18

Must do

Safe

The trust must ensure that enough suitably, qualified, competence nursing staff are deployed.Regulation18(1)(2)(a).

Regulation: Regulation18(1)(2)(a).

⚠ The service did not always have enough nursing and support staff to keep patients safe. Senior staff told us their usual staffing was down by 1 or 2 members of staff. We saw there were gaps in the roster. Nursing vacancy rates were around 8%.

Must-do action 15 of 18

Must do

Effective

The trust must improve the quality and accuracy of record keeping ensuring clinical records are contemporaneous, detailed, signed and clearly show the care and treatment patients receive and when they have received it.Regulation17(1)(2)(c)(d).

Regulation: Regulation17(1)(2)(c)(d).

⚠ 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.

Must-do action 16 of 18

Must do

Effective

The trust must ensure all patients receive pain relief in a timely manner in line with RCEM guidelines.Regulation12(1)(2)(a)(b).

Regulation: Regulation12(1)(2)(a)(b).

⚠ 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 …

Must-do action 17 of 18

Must do

Safe

The trust must ensure that controlled drugs and other medications should be stored correctly and securely.Regulation12(1)(2)(g).

Regulation: Regulation12(1)(2)(g).

⚠ 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 …

Must-do action 18 of 18

Must do

Effective

The trust must ensure that when a patient lacks mental capacity to make an informed decision, or give consent, staff must act in accordance with the requirements of the Mental Capacity Act 2005 and associated code of practice.Regulation13(1)(2)(3)(4)(d).

Regulation: Regulation13(1)(2)(3)(4)(d).

⚠ 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. We observed that this was not always applied in practice. Staff did not …

Should-do actions (3)

Recommended improvements to enhance service quality.

Should-do action 1 of 3

Should do

Safe

The service should ensure that there is consistent oversight of consumable items on all wards to ensure expired items are appropriately removed from circulation.Regulation15(2).

Regulation: Regulation15(2).

Should-do action 2 of 3

Should do

Effective

The trust should continue to monitor its use of blanket restrictions on wards where patients may be inadvertently deprived of their liberty.Regulation13(5).

Regulation: Regulation13(5).

Should-do action 3 of 3

Should do

Effective

The trust should ensure that its alcohol withdrawal policy is reviewed and updated accordingly in a timely manner.Regulation17(2)(b).

Regulation: Regulation17(2)(b).