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Westmorland General Hospital

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
Good
Effective
Good
Caring
Good
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.
Westmorland General Hospital is a part of the University Hospitals of Morecambe Bay NHS Foundation Trust.It has an urgent treatment centre and a midwifery-led maternity unit and provides elective surgery and out -patient services.We visited Westmorland General Hospital as part of our unannounced inspection of maternity services on 15 and 16 July 2025.This assessment looked at the maternity service at Helme Chase based at Westmorland General Hospital which is part of the University Hospitals Morecambe Bay Trust. We conducted this unannounced assessment on 15 and 16 July 2025 as a …

Ratings by service

Maternity
Good
May 2025

Earlier inspection findings

pre-2024 framework · 56 must-do 33 should-do

Must-do actions (56)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 56
Must do
Well-led
The trust must ensure that governance processes are robust and effective
Regulation: Regulation 17(1)
⚠ Trust governance processes were not robust or always effective.
Must-do action 2 of 56
Must do
Well-led
The trust must ensure that risks in the organisation are correctly identified and appropriate mitigations put in place in a timely way
Regulation: Regulation 17(1)(2)(b)
⚠ Risks were not always identified correctly with appropriate mitigations put in place.
Must-do action 3 of 56
Must do
Safe
The trust must ensure that incidents are identified, graded appropriately to reflect the level of harm and that they are acted upon and investigated in a timely way.
Regulation: Regulation 12(1)(2)(b)
⚠ Although harm grading guidance was available, we were not assured that all incidents were graded appropriately to reflect the level of harm.
Must-do action 4 of 56
Must do
Responsive
The trust must improve on the timeliness of responses to complaints.
Regulation: Regulation 16(1)(2)
⚠ The timeframes for a response were not timely and the examples reviewed had taken between six and 12 months to complete.
Must-do action 5 of 56
Must do
Well-led
The trust must continue to make improvements in the culture of the organisation, especially within maternity and trauma and orthopaedics, to enable staff to be supported to perform their duties effectively.
Regulation: Regulation 18(1)(2)(a)
⚠ In the core services we inspected, we found that the culture was varied. In some services some staff felt respected, supported and valued, although this was not universal. There were some services where the culture was poor and had remained so for some time.
Must-do action 6 of 56
Must do
Safe
The trust must ensure that further development and investment in pharmacy resources should be prioritised to make sure medicines reconciliation rates and antimicrobial stewardship are improved across the trust.
Regulation: Regulation 12(1)(2)(g)
⚠ Controlled drugs were not always stored, administered and recorded safely. The Trust process for the administration of medicines following Patient Group Directions (PGD’s) had been reviewed and updated but had not been implemented effectively in some locations. Poor performance in terms of medicines reconciliation rates for the whole trust; these …
Must-do action 7 of 56
Must do
Effective
The trust must ensure that stroke patients receive treatment in line with best practice guidance and in line with the trust’s stroke pathway so there are no delays to treatment.
Regulation: Regulation 12(1)(2)(i)
⚠ Patients identified for the stroke pathway did not always receive care and treatment in line with national guidance or trust policies.
Must-do action 8 of 56
Must do
Safe
The trust must ensure that risk assessments and mental capacity assessments are carried out for mental health patients in line with trust policy.
Regulation: Regulation 12(1)(2)(a)
⚠ Risk assessments were not always completed for women or for patients identified with mental health concerns.
Must-do action 9 of 56
Must do
Safe
The service must ensure that there is enough staff with the right qualifications, skills, training and experience to provide care and treatment, specifically in relation to medical staffing including taking into account national guidance for the care of children and specifically paediatric emergency medicine consultant cover – This in line with the Royal College of Paediatrics and Child Health “Facing the Future – standards for children and young people in emergency care settings”.
Regulation: Regulation 18(1)
⚠ There was not always sufficient staff with the right qualifications, skills, training and experience to provide care and treatment for children in the urgent and emergency departments.
Must-do action 10 of 56
Must do
Effective
The service must ensure that audit information (including national audits) is submitted, up to date, accurate and properly analysed and reviewed by people with the appropriate skills and competence to understand its significance. When required, results should be escalated, and appropriate actions taken to improve.
Regulation: Regulation 17(1)(2)(a)
⚠ The trust did not always submit information for audits, including national audits, and not all services were included in the audit programme.
Must-do action 11 of 56
Must do
Safe
The trust must ensure that controlled drugs are safely prescribed, administered, recorded and stored and that registers are correctly and fully completed. The trust must ensure there is a system in place to assess and monitor formal competencies for nursing staff to administer medicines under patient group directions.
Regulation: Regulation 12(1)(2)(g)
⚠ Controlled drugs were not always stored, administered and recorded safely. The Trust process for the administration of medicines following Patient Group Directions (PGD’s) had been reviewed and updated but had not been implemented effectively in some locations.
Must-do action 12 of 56
Must do
Responsive
The trust must ensure that robust action plans to improve and manage the flow of patients through the emergency department are put in place, taking into account known factors contributing to the hindrance of flow through the department and mitigating the ongoing risks and issues identified in the department.
Regulation: Regulation 17(1)(2)(b)
⚠ The trust did not always manage the flow of patients, in the urgent and emergency care department with patient spending long period waiting for an in-patient bed.
Must-do action 13 of 56
Must do
Safe
The department must ensure that the corridor escalation plan is adhered to and that incidents are appropriately recorded when the plan dictates.
Regulation: Regulation 12(1)(2)(a)(b)(d)
⚠ The escalation plan for caring for patients in the corridor was not always adhered to.
Must-do action 14 of 56
Must do
Caring
The service must ensure that privacy and dignity of patients is maintained, particularly when patients are in non-designated cubicle areas.
Regulation: Regulation 10(1)(2)(a)
⚠ The trust did not always maintain patients’ privacy and dignity, specifically when needing to be cared for in a corridor in the urgent and emergency department.
Must-do action 15 of 56
Must do
Effective
The trust must ensure that patients’ pain is effectively managed including that pain scores are re-assessed within 60 minutes as per trust policy.
Regulation: Regulation 12(1)(2)(a)(b)
⚠ The trust did not always manage patient pain effectively including reassessing pain scores in line with trust policy.
Must-do action 16 of 56
Must do
Effective
The trust must improve the multidisciplinary working and culture between the department and specialities and speciality teams to maximise patient care and outcomes.
Regulation: Regulation 12(1)(2)(i); Regulation 17(1)(2)(a)
⚠ There was not always effective multidisciplinary working in the trust to benefit patient care, treatment and outcomes.
Must-do action 17 of 56
Must do
Well-led
The department must ensure that all known risks are singularly identified on the risk register and that risks are supported by robust action plans that can reduce or mitigate the risks. They must also ensure that these action plans are regularly reviewed to ensure effectiveness and action plans amended where progress cannot be achieved.
Regulation: Regulation 17(1)(2)(b)
⚠ Risks were not always identified correctly with appropriate mitigations put in place.
Must-do action 18 of 56
Must do
Well-led
The trust must implement an effective risk and governance system for the whole stroke pathway.
Regulation: Regulation 17(1)(2)(a)(b)
⚠ The trust did not have an effective risk and governance system for the whole stroke pathway.
Must-do action 19 of 56
Must do
Safe
The trust must operate an effective clinical escalation system to ensure stroke care and treatment is assessed and implemented in a timely way.
Regulation: Regulation 12(1)(2)(a)(b)
⚠ The trust did not operate an effective clinical escalation system to ensure stroke care and treatment was assessed and implemented in a timely way.
Must-do action 20 of 56
Must do
Effective
The trust must implement an effective system to ensure that all clinical staff have the knowledge, competence, skills and experience to care for and provide treatment to patients presenting with symptoms of stroke.
Regulation: Regulation 18(1)(2)(a)
⚠ The didn't have an effective system to ensure that all clinical staff had the knowledge, competence, skills and experience to care for and provide treatment to patients presenting with symptoms of stroke.
Must-do action 21 of 56
Must do
Responsive
The trust must continue to monitor and take appropriate actions to improve average length of patient stay for patients having trauma and orthopaedics surgery.
Regulation: Regulation 12(1)
⚠ The length of stay for patients receiving care for trauma and orthopaedics was longer than the national average.
Must-do action 22 of 56
Must do
Responsive
The trust must continue to monitor and take action to improve referral to treatment waiting time performance in line with national standards.
Regulation: Regulation 12(1)
⚠ The service performed worse than national standards for waiting times from referral to treatment.
Must-do action 23 of 56
Must do
Effective
The service must ensure staff have access to up-to-date and evidence-based guidelines and policies.
Regulation: Regulation 12(1)
⚠ Current policies were not always available for staff to access during care and treatment of patients.
Must-do action 24 of 56
Must do
Safe
The service must ensure all women assessed as at risk of having sepsis receive care and treatment in line with national guidance and requirements.
Regulation: Regulation 12(1)
⚠ Women receiving maternity care, who were assessed as at risk of sepsis, did not always receive care and treatment in line with national guidance.
Must-do action 25 of 56
Must do
Well-led
The service must continue to develop a vision and strategy through engagement with staff, focused on sustainability and aligned to local plans within the wider health economy.
Regulation: Regulation 17(1)(2)(a)(e)
⚠ Although the trust had an overall vision and strategies, not all services had their own vision and strategy.
Must-do action 26 of 56
Must do
Well-led
The trust must ensure they establish and operate effective governance processes and systems, with robust action plans to monitor and improve the safety and quality of services and mitigate risks to women and families using the service.
Regulation: Regulation 17(1)(2)(a)(b)
⚠ Trust governance processes were not robust or always effective. Risks were not always identified correctly with appropriate mitigations put in place.
Must-do action 27 of 56
Must do
Safe
The trust must ensure that staff in the service adhere to trust infection prevention and control policy in the use of personal protective equipment and maintain patient and staff safety through social distancing at all times and in all areas.
Regulation: Regulation 12(1)(2)(h)
⚠ Staff did not always adhere to trust and national infection prevention and control guidance with regards to social distancing and wearing of personal protective equipment in urgent and emergency services.
Must-do action 28 of 56
Must do
Effective
The service must ensure they participate in clinical audit to demonstrate the effectiveness of care and treatment.
Regulation: Regulation 17(1)
⚠ The trust did not always submit information for audits, including national audits, and not all services were included in the audit programme.
Must-do action 29 of 56
Must do
Responsive
The service must ensure that care is provided in line with national performance standards for waiting times from referral to treatment and arrangements to admit, treat and discharge patients.
Regulation: Regulation 12(1)(2)(i)
⚠ The trust did not always manage the flow of patients, in the urgent and emergency care department with patient spending long period waiting for an in-patient bed.
Must-do action 30 of 56
Must do
Responsive
The trust must ensure that, patients with mental health concerns are seen in a timely way
Regulation: Regulation 12(1)(2)(i)
⚠ Risk assessments were not always completed for women or for patients identified with mental health concerns.
Must-do action 31 of 56
Must do
Effective
The trust must ensure pain is assessed in line with clinical standards, administered in a timely way and recorded in patient notes.
Regulation: Regulation 12(1)(2)(i)
⚠ The trust did not always manage patient pain effectively including reassessing pain scores in line with trust policy.
Must-do action 32 of 56
Must do
Safe
The trust must ensure all patients are clinically assessed and National Early Warning Scores are documented for all patients.
Regulation: Regulation 12(1)(2)(i)
⚠ It was not clear if national early warning scores were always assessed and used to identify any signs of deterioration as they were not always documented in patient records.
Must-do action 33 of 56
Must do
Safe
The trust must ensure all relevant staff have completed Paediatric Advanced Life Support when supporting paediatric provision in the emergency department.
Regulation: Regulation 12(1)(2)(i)
⚠ Not all staff supporting children had completed paediatric advanced life support training.
Must-do action 34 of 56
Must do
Safe
The trust must review the service’s paediatric staffing provision, including the environment they wait in and the paediatric nursing and medical cover in line with The Royal College of Paediatrics and Child Health (RCPCH) Standards for Children and Young People in Emergency settings (2012)
Regulation: Regulation 18(1)
⚠ There was not always sufficient staff with the right qualifications, skills, training and experience to provide care and treatment for children in the urgent and emergency departments.
Must-do action 35 of 56
Must do
Safe
The trust must take action to improve safeguarding adults and safeguarding children level three training rates for doctors and nurses.
Regulation: Regulation 18(1)
⚠ Not all staff, at the trust, had completed safeguarding level three training.
Must-do action 36 of 56
Must do
Well-led
The trust must implement an effective risk and governance system for the whole stroke pathway.
Regulation: Regulation 17(1)(2)(a)(b)
⚠ The trust did not have an effective risk and governance system for the whole stroke pathway.
Must-do action 37 of 56
Must do
Safe
The trust must operate an effective clinical escalation system to ensure stroke care and treatment is assessed and implemented in a timely way.
Regulation: Regulation 12(1)(2)(a)(b)
⚠ The trust did not operate an effective clinical escalation system to ensure stroke care and treatment was assessed and implemented in a timely way.
Must-do action 38 of 56
Must do
Effective
The trust must implement an effective system to ensure that all clinical staff have the knowledge, competence, skills and experience to care for and provide treatment to patients presenting with symptoms of stroke.
Regulation: Regulation 18(2)(a)
⚠ The didn't have an effective system to ensure that all clinical staff had the knowledge, competence, skills and experience to care for and provide treatment to patients presenting with symptoms of stroke.
Must-do action 39 of 56
Must do
Responsive
The trust must take actions to improve average length of patient stay for patients having trauma and orthopaedics surgery.
Regulation: Regulation 12(1)
⚠ The length of stay for patients receiving care for trauma and orthopaedics was longer than the national average.
Must-do action 40 of 56
Must do
Responsive
The trust must take actions to improve referral to treatment waiting time performance in line with national standards.
Regulation: Regualtion 12(1)
⚠ The service performed worse than national standards for waiting times from referral to treatment.
Must-do action 41 of 56
Must do
Safe
The service must ensure there are sufficient maternity staff with the right qualifications, skills, training and experience to keep women safe from avoidable harm and to provide the right care and treatment.
Regulation: Regulation 18(1)(2)(a)
⚠ There was not always sufficient staff with the right qualifications, skills, training and experience to care for women in maternity services.
Must-do action 42 of 56
Must do
Safe
The service must ensure medical staff complete all required safeguarding level 3 training.
Regulation: Regulation 18(1)(2)(a)
⚠ Not all staff, at the trust, had completed safeguarding level three training.
Must-do action 43 of 56
Must do
Safe
The service must ensure risk assessments are completed and are actions taken to minimise any risks identified
Regulation: Regulation 12(1)(2)(a)(b)
⚠ Risk assessments were not always completed for women or for patients identified with mental health concerns.
Must-do action 44 of 56
Must do
Safe
The service must ensure all women assessed as at risk of having sepsis receive care and treatment in line with national guidance and requirements.
Regulation: regulation 12(1)
⚠ Women receiving maternity care, who were assessed as at risk of sepsis, did not always receive care and treatment in line with national guidance.
Must-do action 45 of 56
Must do
Well-led
The service must ensure appropriate systems are used for maintaining accurate, complete and contemporaneous records for service users
Regulation: Regulation 17(1)(2)(c)
⚠ It was not always clear if national early warning scores were always assessed and used to identify any signs of deterioration as they were not always documented in patient records.
Must-do action 46 of 56
Must do
Effective
The service must ensure staff have access to up-to-date and evidence-based guidelines and policies.
Regulation: Regulation 12(1)
⚠ Current policies were not always available for staff to access during care and treatment of patients.
Must-do action 47 of 56
Must do
Well-led
The service must continue to develop a vision and strategy through engagement with staff, focused on sustainability and aligned to local plans within the wider health economy.
Regulation: Regulation 17(1)(2)(a)(e)
⚠ Although the trust had an overall vision and strategies, not all services had their own vision and strategy.
Must-do action 48 of 56
Must do
Well-led
The trust must ensure they establish and operate effective governance processes and systems, with robust action plans to monitor and improve the safety and quality of services and mitigate risks to women and families using the service.
Regulation: Regulation 17(1)(2)(a)(b)
⚠ Trust governance processes were not robust or always effective. Risks were not always identified correctly with appropriate mitigations put in place.
Must-do action 49 of 56
Must do
Safe
The service must ensure staff assess the risks to women during and after birth in order to identify women at risk of deterioration.
Regulation: Regulation 12(1)(2)(a)
⚠ It was not always clear if all risks to women in labour were assessed, including when risk levels changed from low to high, with a need to escalate care safely.
Must-do action 50 of 56
Must do
Safe
The service must ensure that women presenting in labour have immediate access to suitable qualified and skilled midwifery staff.
Regulation: Regulation 18(1)
⚠ There was not always sufficient staff with the right qualifications, skills, training and experience to care for women in maternity services.
Must-do action 51 of 56
Must do
Safe
The service must ensure staff assess and mitigate the risks to women’s health and safety in an emergency situation either during home birth or at the unit. They must ensure appropriate escalation and transfer takes place.
Regulation: Regulation 12(1)(2)(a)(b)
⚠ It was not always clear if all risks to women in labour were assessed, including when risk levels changed from low to high, with a need to escalate care safely.
Must-do action 52 of 56
Must do
Effective
The service must ensure staff have access to up-to-date and evidence-based guidelines and policies.
Regulation: Regulation 12(1)
⚠ Current policies were not always available for staff to access during care and treatment of patients.
Must-do action 53 of 56
Must do
Safe
The service must ensure all equipment is properly maintained and that staff do not use equipment that is not safe nor used for its intended purpose. Specifically, they should not use a domestic bath to support water birth. All staff should be aware of the birthing pool emergency evacuation process and have access to the required equipment at all times.
Regulation: Regulation 12(1)(d)(e)
⚠ The design, maintenance and use of facilities, premises and equipment were not managed well to keep people safe.
Must-do action 54 of 56
Must do
Well-led
The service must continue to develop a vision and strategy through engagement with staff, focused on sustainability and aligned to local plans within the wider health economy.
Regulation: Regulation 17(1)(2)(a)(e)
⚠ Although the trust had an overall vision and strategies, not all services had their own vision and strategy.
Must-do action 55 of 56
Must do
Well-led
The trust must ensure they establish and operate effective governance processes and systems, with robust action plans to monitor and improve the safety and quality of services and mitigate risks to women and families using the service.
Regulation: Regulation 17(1)(2)(a)(b)
⚠ Trust governance processes were not robust or always effective. Risks were not always identified correctly with appropriate mitigations put in place.
Must-do action 56 of 56
Must do
Safe
The service must ensure they deploy sufficient suitably competent and experienced staff and ensure all staff receive appropriate skills and drills training and professional development to enable them to maintain competency given the low numbers of deliveries.
Regulation: Regulation 18(1)(2)(a)
⚠ There was not always sufficient staff with the right qualifications, skills, training and experience to care for women in maternity services.

Should-do actions (33)

Recommended improvements to enhance service quality.

Should-do action 1 of 33
Should do
Safe
The trust should ensure that Patient Group Directions oversight should be strengthened to ensure sure appropriate and timely review and implementation.
Should-do action 2 of 33
Should do
Safe
The trust should ensure that the uptake of medicines management e-learning be prioritised to help improve medicines safety.
Should-do action 3 of 33
Should do
Safe
The trust should ensure that Electronic Prescribing and Medicines Administration (EPMA) auditing be strengthened to proactively identify prescribing and administration errors.
Should-do action 4 of 33
Should do
Safe
The trust should ensure that all staff follow infection control principles, including the use of personal protective equipment (PPE) at all times and receive refresher training in this where deemed necessary.
Should-do action 5 of 33
Should do
Safe
The trust should consider whether they can build a separate paediatric treatment area to meet best practice guidelines.
Should-do action 6 of 33
Should do
Safe
The trust should consider whether the triage service in the walk-in waiting area can be improved so that the triage nurse can observe patients in the waiting area more easily.
Should-do action 7 of 33
Should do
Safe
The trust should consider ensuring that there is a doctor or consultant at all safety huddles so that clinical information is not omitted from being shared with nursing staff.
Should-do action 8 of 33
Should do
Safe
The trust should ensure that patients waiting in corridors have formal assessments of skin integrity and pressure sores risk, if prompted by the Safe and seen document.
Should-do action 9 of 33
Should do
Well-led
The trust should consider giving emergency department managers access to view incidents that are graded no harm or low harm, in order that there is complete oversight of incidents in the department to ensure that they have been graded correctly or may meet the criteria for a serious incident.
Should-do action 10 of 33
Should do
Well-led
The trust should consider completing the urgent and emergency care plans that have been delayed so that these can feed into the medicine care group strategy.
Should-do action 11 of 33
Should do
Safe
The trust should take appropriate actions to improve staff mandatory training, including safeguarding training in line with trust compliance targets.
Should-do action 12 of 33
Should do
Effective
The trust should take appropriate actions to improve staff appraisal completion in line with trust compliance targets.
Should-do action 13 of 33
Should do
Safe
The service should consider implementing a policy and schedule for changing the keypad code at ward entrances to maintain security.
Should-do action 14 of 33
Should do
Safe
The service should ensure the policy for cleaning of the birthing pool is ratified and implemented to control the risk of spread of infection.
Should-do action 15 of 33
Should do
Well-led
The service should ensure that recommendations from external incident investigations are fully considered and appropriate, robust action plans put in place.
Should-do action 16 of 33
Should do
Effective
The service should act to improve the assessment of women’s pain in light of their clinical condition and ensure all women receive pain relief in a timely manner.
Should-do action 17 of 33
Should do
Responsive
The service should continue to act to ensure women received continuity of care in line with national recommendations and targets.
Should-do action 18 of 33
Should do
Safe
The trust should consider what actions the service can take to improve safeguarding adults and safeguarding children level three training rates for doctors and nurses.
Should-do action 19 of 33
Should do
Well-led
The trust should ensure senior leaders of the department have oversight of paediatric activity and performance in the ED.
Should-do action 20 of 33
Should do
Safe
The trust should ensure that wards are secured to maintain patient safety.
Should-do action 21 of 33
Should do
Safe
The trust should ensure that fire doors are maintained and used correctly.
Should-do action 22 of 33
Should do
Safe
The trust should ensure that systems and processes are established and operated effectively to identify, assess, monitor, escalate and take mitigating actions, particularly in relation to the safest storage of medicine and the checking of emergency resuscitation equipment.
Should-do action 23 of 33
Should do
Safe
The trust should ensure patient records are stored securely.
Should-do action 24 of 33
Should do
Safe
The service should act to improve the quality of safety information shared in situation, background, assessment and recommendation (SBAR) handover.
Should-do action 25 of 33
Should do
Safe
The service should ensure the policy for cleaning of the birthing pool is ratified and implemented to control the risk of spread of infection.
Should-do action 26 of 33
Should do
Effective
The service should act to improve the assessment of women’s pain in light of their clinical condition.
Should-do action 27 of 33
Should do
Responsive
The service should progress actions to enable improved access within the birth centre, in context of the physical environment.
Should-do action 28 of 33
Should do
Well-led
The service should implement effective use of the whiteboard communications system on the birth centre.
Should-do action 29 of 33
Should do
Caring
The trust should ensure that visible information about requesting a chaperone is available to patients attending the centre.
Should-do action 30 of 33
Should do
Caring
The trust should ensure that privacy and confidentiality is maintained for patients when sharing personal information.
Should-do action 31 of 33
Should do
Safe
The service should consider protected time to allow for the completion of mandatory training.
Should-do action 32 of 33
Should do
Safe
The service should ensure staff clean the birthing pool in line with the policy for cleaning of the birthing pool, which should be reviewed, ratified and implemented to control the risk of spread of infection.
Should-do action 33 of 33
Should do
Well-led
The service should work to engage the workforce and increase visibility of the executive team.

Location details

CQC ID: RTXBW
Local authority: Westmorland and Furness
Region: North West

Inspection report

Type: Location
Date: 20 August 2021
Rating: Requires Improvement
Actions: 56 must-do 33 should-do
AI-extracted 3 Jun 2026

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