Source · CQC inspection

Royal Lancaster Infirmary

Provider University Hospitals of Morecambe Bay NHS Foundation Trust Type NHS Healthcare Organisation Region North West Last inspected 30 Jan 2026

Overall rating: Good  View full CQC report

Domain ratings

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

Current CQC assessment

Single Assessment Framework

From 2024 CQC rates services through ongoing assessments rather than comprehensive inspections.

Good Assessed 30 January 2026
The service is performing well and meeting our expectations.
The University Hospitals of Morecambe Bay NHS Foundation Trust (UHMBT) provides hospital servicesacross the Morecambe Bay area - an area covering a thousand square miles in south Cumbria andnorth Lancashire. It operates from three main hospitals - Furness General Hospital in Barrow, the RoyalLancaster Infirmary and Westmorland General Hospital in Kendal.The Royal Lancaster Infirmary has a range of general hospital services, with an emergency department,critical/coronary care unit and various consultant-led services. It provides a range of planned careincluding outpatients, diagnostics, therapies, day case and inpatient surgery.We carried out an unannounced …

Ratings by service

Maternity
Good
May 2025
Maternity
Good
May 2025
Urgent and emergency services
Requires Improvement
May 2025
Urgent and emergency services
Requires Improvement
May 2025

Regulatory breaches & enforcement

Current-framework "must do" equivalent

Breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, stated verbatim in the CQC assessment.

Breaches identified (8)

Breach Overall
At our last inspection we identified breaches in two regulations.
· 30 Jan 2026
Breach Overall
At this inspection we identified one regulatory breach.
· 30 Jan 2026
Breach Caring
The service was previously in breach of the legal regulations in relation to dignity and respect, safe care and treatment and premises and equipment.
Regulation: Regulation 10 (Dignity and respect) · 30 Jan 2026
Breach Safe
The service was in breach of the legal regulations relating to safe care and treatment relating to medicines management in maternity care.
Regulation: Regulation 12 (Safe care and treatment) · 30 Jan 2026
Breach Overall
The service was previously in breach of the legal regulations and improvements were found at this assessment.
· 30 Jan 2026
Breach Overall
Improvements were found at this assessment, but the service remains in breach of regulation.
· 30 Jan 2026
Breach Safe
The service was in breach of the legal regulations relating to safe care and treatment relating to medicines management, safe staffing and good governance.
Regulation: Regulation 12 (Safe care and treatment) · 30 Jan 2026
Breach Safe
The service was still in breach of the legal regulation in relation to safe care and treatment and staffing.
Regulation: Regulation 12 (Safe care and treatment) · 30 Jan 2026

Earlier inspection findings

pre-2024 framework · 10 must-do 11 should-do

Must-do actions (10)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 10
Must do
Responsive
The trust must operate an effective complaints procedure which includes providing timely responses and updates to complainants.
Regulation: Regulation 16(2)
⚠ From our inspection findings and our ongoing monitoring of the trust, we found evidence that there could be significant timelapses in responding to concerns to individual complaints.
Must-do action 2 of 10
Must do
Effective
The trust must ensure that mandatory training completion rates are in line with trust targets.
Regulation: Regulation 18
⚠ Staff did not all have training in key skills. The service provided mandatory training in key skills to all staff but the targets for completion rates had not been met for some training courses.
Must-do action 3 of 10
Must do
Safe
The service must ensure that there is a clear protocol for identifying women for prioritisation of induction of labour and that it is recorded in the care records.
Regulation: Regulation 12
⚠ There was no documented process or prioritisation of order for women needing induction of labour. Individual risk assessments were recorded in the records of women waiting for induction, but staff could not articulate which induction was a priority.
Must-do action 4 of 10
Must do
Safe
The service must ensure women receiving maternity care, who are assessed as at risk of sepsis, have their care and treatment recorded in line with national guidance.
Regulation: Regulation 12
⚠ Audits showed that staff did not always adhere to the policy and were not achieving 100% in most of the 15 benchmark standards.
Must-do action 5 of 10
Must do
Safe
The service must ensure that there is a clear protocol for identifying women for prioritisation of induction of labour and that it is recorded in the care records.
Regulation: Regulation 12
⚠ There was no documented process or prioritisation of order for women needing induction of labour. Individual risk assessments were recorded in the records of women waiting for induction, but staff could not articulate which induction was a priority.
Must-do action 6 of 10
Must do
Safe
The service must ensure women receiving maternity care, who are assessed as at risk of sepsis, have their care and treatment recorded in line with national guidance.
Regulation: Regulation 12
⚠ Data provided for April 2023 showed staff at the South Lake Birth Centre (SLBC) did not always adhere to the policy and audits showed they were not achieving the 100% in most of the 15 benchmark standards.
Must-do action 7 of 10
Must do
Safe
The service must ensure they remove equipment when out of service.
Regulation: Regulation 15
⚠ One resuscitation trolly in antenatal clinic had a last recorded check on 8 August 2022 when the checkbook was full. A new checkbook had been ordered 8 December 2022 but had not been replaced. We escalated this immediately and was told the equipment was out of use. We asked that …
Must-do action 8 of 10
Must do
Safe
The service must ensure medical staff are compliant with their mandatory training including safeguarding level 3.
⚠ Medical staff mandatory training including safeguarding compliance had not improved since our last inspection and staff did not know or understood the service’s vision and values, or how to apply them in their work. Medical staff (Drs), with the exception of New Born Life Support (Face to face), were failing …
Must-do action 9 of 10
Must do
Effective
The service must ensure staff follow the most current evidence-based care and treatment for fetal monitoring, post-partum haemorrhage and shoulder dystocia proformas.
Regulation: Regulation 12
⚠ Guidance for CTG’s for reduced fetal movements in the perinatal period was not always followed. We noted a senior clinician had instructed auscultation of the fetal heart rather than CTG as per national guidelines. Emergency protocols for staff to follow in clinical areas were not always updated following policy review. …
Must-do action 10 of 10
Must do
Safe
The service must ensure hand gel expiry dates are compliant and the environment is visibly clean with cleaning schedules appropriately completed.
Regulation: Regulation 12
⚠ Hand hygiene gel did not always have expiry dates on the bottle and some handwritten dates added were out of date. On the birthing unit we noted a shower head had limescale which posed an infection risk in a birthing room. When reviewing the theatres undertaking maternity procedures, we escalated …

Should-do actions (11)

Recommended improvements to enhance service quality.

Should-do action 1 of 11
Should do
Well-led
The trust should consider continuing to pursue plans for development and investment in pharmacy workforce, to make sure medicines reconciliation rates and antimicrobial stewardship improves across the trust.
Should-do action 2 of 11
Should do
Safe
The trust should ensure that the plans to redesign the department are progressed in a timely way so that the bereavement suite can be reopened and oversight of patients waiting to be triaged can be always maintained.
Regulation: Regulation 15
Should-do action 3 of 11
Should do
Safe
The service should consider employing a housekeeper for the ward area.
Should-do action 4 of 11
Should do
Well-led
The service should consider the improvement of internet connectivity in the department.
Should-do action 5 of 11
Should do
Well-led
The trust should continue to pursue plans for development and investment in pharmacy workforce to support continued improvement in medicines optimisation, medicines reconciliation rates and antimicrobial stewardship.
Should-do action 6 of 11
Should do
Effective
The trust should ensure that all nurse appraisals are completed in a timely manner.
Should-do action 7 of 11
Should do
Effective
The service should ensure staff complete mandatory training in accordance with the relevant schedule.
Should-do action 8 of 11
Should do
Safe
The service should ensure there are sufficient blood pressure monitoring equipment.
Regulation: Regulation 15
Should-do action 9 of 11
Should do
Safe
The service should continue to monitor and review antimicrobial stewardship and prescribing in sepsis.
Regulation: Regulation 12
Should-do action 10 of 11
Should do
Safe
The service should continue to ensure staff complete VTE risk assessments at appropriate times throughout pregnancy and following birth.
Regulation: Regulation 12
Should-do action 11 of 11
Should do
Well-led
The service should continue to develop a long term vision and strategy through engagement with staff, focused on sustainability and aligned to local plans within the wider health economy.
Regulation: Regulation 17

Location details

CQC ID: RTX02
Local authority: Lancashire
Region: North West

Inspection report

Type: Location
Date: 23 August 2023
Rating: Requires Improvement
Actions: 10 must-do 11 should-do
AI-extracted 3 Jun 2026