Inspectors say Cumbria Hospitals have improved but need to improve further

A report just published by the Care Quality Commission (CQC) has highlighted many improvements at North Cumbria’s hospitals, with many more services being rated "good" but more needing to be done and the overall rating still of "Requires Improvement".

More details at the Cumbria Crack site at

http://www.cumbriacrack.com/2015/09/08/cqc-report-highlights-improvements-at-north-cumbria-hospitals/

The report follows the Chief Inspector of Hospitals visit to the Cumberland Infirmary in Carlisle and West Cumberland Hospital in Whitehaven which took place from 31 March to 2 April 2015.

Overall, North Cumbria University Hospitals NHS Trust has been rated by the CQC as ‘requires improvement’. However, this year’s inspection saw many more services being rated as ‘good’.

As with last year’s inspection, every single service across both hospitals was rated as ‘good’ for providing a caring service to patients. The CQC saw ‘services being delivered by caring and compassionate staff. They witnessed staff treating patients with dignity and respect, with care planned and delivered in a way that took into account the wishes of patients.

Following the Trust’s 2014 inspection, critical care was rated overall as ‘good’ across both hospital sites. The service has maintained that rating this year with further improvements noted and has been joined by surgery and services for children and young people which have all been rated as ‘good’ across both the Cumberland Infirmary and West Cumberland Hospital.

Last year, the CQC found that outpatient services at both hospital sites were rated as ‘inadequate’ under the safe domain, largely due to issues around the timely supply of up-to-date medical records to outpatient clinics. Over the past 12 months, the Trust has carried out a significant amount of work in order to improve outpatient services including the opening of a new Contact Centre, which along with other improvements, has resulted in more ‘good’ ratings for the service. The inspection team noted that performance had improved by over 20% with 95% of patient records now available for appointments. It was also noted that with a clearer plan and vision for the service, staff were very positive and feel supported.

In surgery, the inspection team found ‘a number of improvements to the service’ which is now rated as ‘good’ overall. Good patient outcomes were demonstrated through patient reported outcomes measures (PROMs) data which showed the percentage of patients with improved outcomes following groin hernia, hip replacement, knee replacement and varicose vein procedures was either similar to or better than the England average. It was also found that the average length of stay for planned and emergency surgical admissions was better than the England average across all specialities.

In services for children and young people, it was noted that the service has improved since the last inspection in both hospitals with a ‘visible children centred culture within the service.’ The team found ‘staff were motivated and offered care that was kind, sensitive and supportive.’

The report acknowledges that the Trust has sustained the improvement in its mortality rates and says it is ‘evident the leadership team were committed to service improvement for the benefit of patients and were keen to include staff in the improvement journey.’

The Trust received one rating of ‘inadequate’ for the safety and responsiveness of medical care at West Cumberland Hospital as a result of the ongoing issues with regard to recruitment of medical staff and the high number of vacant consultant posts.

The CQC has outlined a series of recommendations which must be made to further improve services and the urgent actions required by the health system in order to agree and implement a clear clinical strategy which will help the Trust address the longstanding challenges which it has been unable to solve alone. The Trust will remain in special measures with the NHS Trust Development Authority and will continue to work closely with buddy trust Northumbria Healthcare NHS Foundation Trust and as part of the newly formed Success Regime which aims to accelerate the scale and pace of improvements needed across the entire health economy.

Ann Farrar, chief executive of North Cumbria University Hospitals NHS Trust said: “We wholeheartedly welcome this CQC report and recommendations. All of our staff have put a huge amount of work in over the past year to make improvements to our services and today I would like them to celebrate the successes we can clearly see within the report.

“I am immensely proud of our teams who have once again been recognised by the CQC for the care and compassion they show our patients every day in what can be very challenging circumstances.

“I am delighted to see more services being rated as ‘good’ at both hospital sites and it is fantastic to see such significant improvements in outpatients and surgery. I stated last year that improvements relating to outpatients were within the gift of the Trust to deliver and I would like to pay tribute to the teams who have worked so hard to implement and drive forward change.

“Critical care has not only maintained their ‘good’ rating but further improvements were also noted and children and young peoples’ services were very determined to receive a ‘good’ rating this year so I am thrilled that their hard work has paid off.

“Although we know there is undoubtedly still a lot of work to be done, our staff, patients and members of the public should take confidence and reassurance from today’s report and the significant amount of progress which has continued to be made thanks to the unwavering commitment and hard work from our staff.

“The support and counsel of our buddy trust Northumbria Healthcare continues to be invaluable and we are pleased to see acknowledgement from the CQC that a clear path for the future is now required.

“The CQC has also clearly recognised that the deep-rooted problems faced by our hospitals, in particular the ongoing fragility of services at West Cumberland, require NHS system-wide solutions and a clear clinical strategy to be agreed with urgency. We hope the newly formed Success Regime for the health economy in North Cumbria will now give the extra focus and pace urgently required so that we can develop services which are of the highest possible quality for our patients for many years to come.”

Jim Mackey, chief executive of Northumbria Healthcare NHS Foundation Trust, said: “This CQC report shows further real progress being made by North Cumbria and demonstrates that the positive actions taken, those which have been within the gift of the Trust to deliver, have further enhanced patient care, experience and, most importantly, outcomes.

“It is very encouraging to see more services across both hospitals being rated as ‘good’ and the significant improvements which have been made in areas such as outpatients and surgery. This progress is testament to the hard work of staff and the care and compassion they show everyday to patients.

“We remain fully committed to working with North Cumbria and welcome the CQC’s urgent recommendation that a safe and sustainable clinical strategy is implemented and also that a clear path for the long-term future is agreed so that Northumbria can continue to support the Trust to further improve both patient and staff experience.

But he added:

“It is hugely disappointing that many of the deep-rooted and system-wide problems at North Cumbria, which the CQC highlighted 12 months ago, have still failed to be addressed, despite the Trust outlining its preferred clinical options for the future. With the support of the Success Regime, system leaders must now act urgently, for the benefit of patients and staff, so that there are no further delays in agreeing the clinical way forward to create services which are sustainable in the long term for North Cumbria.”

David Rogers, Medical Director at NHS Cumbria Clinical Commissioning Group said: “We’re pleased to see an overall improvement from the previous inspection – especially around the availability of records for outpatient appointments, surgical services and the care of children and young people.

“It’s also encouraging to see the Trust has maintained its good rating around caring and critical care. This reflects the hard work of all the staff at the Trust.

“However, we note the ongoing significant concerns about acute medical staffing, particularly around the West Cumberland Hospital in Whitehaven and there is still a lot of work to do around the access targets.”

Lyn Simpson, Delivery and Development Director North, NHS TDA said: “NHS TDA is pleased that so much progress has been made by North Cumbria University Hospitals NHS Trust. The Trust is to be congratulated on its good report for patient care.

“However, there remain ongoing concerns about the provision of care, for example, with regard to delays and in respect of the need for greater numbers in the clinical workforce. These continue to be addressed. Through the Board and within the Trust, we remain vigilant and continue to give focus and attention on these and other matters raised by CQC.

“The support that all partners in the health and care community continue to demonstrate for the Trust, and the assistance in place from the Success Regime, should ensure further progress towards an exit from special measures.”

Tim Rideout, director of commissioning operations for NHS England Cumbria and the North East, said: “We welcome this report from the CQC and the recognition that North Cumbria University Hospitals NHS Trust has made some significant improvements.

“As part of the North Cumbria success regime initiative, we are working with partners to address the challenges highlighted in the CQC report to ensure patients receive safe, high-quality hospital services.”


Summary of CQC findings for North Cumbria University Hospitals NHS Trust:
The Chief Inspector of Hospitals (CIOH) CQC report for North Cumbria gives an overall rating of ‘requires improvement’ – this is one of four possible ratings which range from ‘excellent’, ‘good’, ‘requires improvement’ or ‘inadequate’ which are explained below:

• Outstanding – the service is performing exceptionally well.
• Good – the service is performing well and meeting CQC expectations
• Requires improvement – the service isn’t performing as well as it should and the CQC has told the service how it must improve
• Inadequate – the service is performing badly and the CQC has taken enforcement action against the provider of the service

SAFE

 The CQC acknowledges the positive work being undertaken by North Cumbria to improve patient safety, including that the Trust has been actively recruiting medical and nursing staff although there are still vacancies. The Trust is committed to securing additional doctors as a priority the CQC saw evidence of on-going recruitment.

The following was also noted:

• The Trust has a comprehensive process for investigating serious incidents and the standard of investigation reports reviewed was good
• The midwife to birth ratio was 1 to 25 at Cumberland Infirmary and 1 to 24 at West Cumberland Hospital – better than the England average of 1 to 28. 100% of patients had one to one care from a midwife during labour
• The Trust has a comprehensive mandatory training programme in place and annual appraisal process to support staff development

The CQC also highlighted a number of areas for further improvement in relation to safety, notably:

• Improve the number of substantive medical posts – there was not always enough medical staff (particularly in medicine at West Cumberland Hospital where there are ‘chronic’ shortages) to provide timely treatment and review of patients.
• Improve nurse staffing levels, particularly in medicine at West Cumberland Hospital where there are high nurse vacancy rates
• Improve the rate of incident reporting – currently at the lower end of performance for a Trust of this size

At West Cumberland Hospital, the CQC rated the medicine service as inadequate under the safe and responsive domains, largely due to the acute medical staffing problems highlighted above.

EFFECTIVE

The CQC acknowledged that the Trust has continued to improve its mortality rates and both the HSMR and SHMI mortality indicators remain within the expected range. It was noted that the Trust is working well in understanding the mortality data in order to improve outcomes and reduce avoidable mortality.
At the last inspection, compliance with the use of National Institute of Clinical Excellence (NICE) guidance for the delivery of care and treatment for patients was an area of concern. This year, it was found there had been significant improvement in the use of national guidance as well as the use of clinical audit. This meant there was better evidence that care and treatment was delivered in accordance with best practice guidance.
Patient outcomes for elective surgery and heart attacks are in line or better than the England average, however there is still work for the Trust to do to secure further improvement in outcomes for patients that had suffered a stroke, patients with diabetes and patients who suffered a fractured neck of femur (hip fracture).

CARING

The Trust maintained a rating of ‘good’ across all services at both hospitals, demonstrating that compassion, kindness, dignity and respect are all embedded within the Trust’s everyday values.
The CQC acknowledged that services were delivered by caring and compassionate staff and staff treated patients with dignity and respect. Care was planned and delivered in a way that took into account the wishes of patients. Staff were mindful of patient’s individual fears and anxieties and offered appropriate emotional and psychological support to patients who were anxious or worried.

RESPONSIVE

The CQC recognised some good initiatives to meet the needs of patients whose circumstances or illness made them vulnerable such as the adults’ hospital passport and the Butterfly scheme for dementia patients. An improvement in the timeliness of complaint responses and shared learning from complaints with staff was also noted.
However, as the Trust has openly reported, meeting national performance standards remains a challenge with the CQC reporting the following:

• The Trust remained under pressure from the numbers of emergency admissions through its A&E departments
• Emergency admissions affected the number of available beds particularly in medicine. Patients were often placed on wards and areas that were not best suited to their needs
• Although the Trust had systems in place to make sure that patients placed in areas away from the relevant specialist area were seen regularly by an appropriate doctor, patients often experienced a number of moves from ward to ward
• Operations were cancelled if inpatient beds were not available
• There were occasions when patients were in hospital longer than they needed to be, often due to patients waiting for care packages in the community or places in long-term care
• The Trust was consistently failing to achieve the majority of access targets

The CQC also stated that services were planned to meet the needs of the local population, however the Trust was aware that for the longer term, changes would be required to the configuration of a number of core services particularly at West Cumberland Hospital.

WELL-LED

The CQC acknowledges the continued progress and changes taking place in culture to develop a well-led organisation, notably:

• The leadership team were visible and accessible and were regular visitors to the wards and departments – the ‘walkabouts’ were seen as positive by the staff
• It was evident that the leadership team were committed to service improvement for the benefit of patients and were keen to include staff in the improvement journey.
• The nursing, midwifery and AHP strategy launched in December 2014. All the nursing staff spoken to were aware of the strategy and could talk about the impact this might have on them in the future
• It was evident that the Trust had made good improvements to its governance and risk management systems since the last inspection
• Staff were more positive about the senior team and the support given by their line managers
• Information relating to core objectives and performance targets were visibly displayed in all of the areas. Staff at all levels now understood the purpose of the performance boards and felt they could directly contribute to the setting of specific ward-based objectives
• There were examples of very positive cultures in some wards and departments. Staff worked well together as a team for the benefit of patients and were proud of the work they did
• Communication with and the inclusion of staff continued to improve with regular briefings issued to staff and opportunities to share their views at team meetings and engagement events
• Nursing staff were positive about the accessibility of the senior team and the impact made by the director of nursing & midwifery

The CQC also highlighted a number of areas for further improvement in relation to creating a well-led organisation, notably:

• The CQC acknowledged the efforts of the Trust to clearly articulate a clinical strategy and its preferred options for the future of safe and sustainable services, however, these are yet to be agreed as part of the necessary system wide transformation required in North Cumbria. This lack of an agreed system wide strategy has impacted on the quality of care provided at West Cumberland Hospital and the Trust’s leadership team has been unable to address this issue in the absence of a clear system-wide strategic framework. Staff understood that change was inevitable but were anxious as to the impact of the changes, particularly at West Cumberland Hospital
• Prior to the inspection, a significant number of staff contacted the CQC highlighting their concerns. Many of the concerns could and should have been addressed directly with mangers and indicates further work is required to encourage and enable staff to raise concerns
• There were examples where morale was low, this was a particular issue in services that struggled to maintain appropriate staffing levels

Surgery

• There had been a number of improvements in the service and the overall rating was ‘good’
• Staffing levels and skill mix was sufficient to meet patients’ needs
• Patients received care in safe, clean and suitably maintained premises
• There were systems in place for the escalation of patients whose condition was deteriorating
• Patient care was supported with the right equipment
• Medicines were stored and administered appropriately
• Patient safety was monitored and incidents were investigated to assist learning and improve care
• The theatre teams were undertaking ‘five steps to safer surgery’ procedures and audit records indicated a high level of compliance
• Treatment followed national clinical guidelines and staff used care pathways effectively
• The majority of patients had a positive outcome following their care and treatment
• There was effective teamwork and visible leadership within the surgical services – the majority of staff were positive about the culture and support available

Critical care

• Maintained ‘good’ rating achieved last year with further improvements noted
• The previous inspection had identified improvements required in the submission of data to the Intensive Care National Audit and Research Centre (ICNARC). At this inspection, the units consistently collected and submitted ICNARC data for validation
• There were robust systems and processes in place for reporting incidents and there was evidence that learning from incidents was shared and evaluated
• Patients and those close to them were positive about the care and treatment provided by the team

Services for children and young people

• There have been improvements to reduce the risk of avoidable patient harm
• Resuscitation equipment had been improved and was regularly checked and available for use
• Incident reporting was better managed and learning from incidents was shared
• Child safeguarding was well managed and supported by staff training
• Nurse staffing levels had improved
• Care and treatment was delivered in accordance with NICE guidance and readmission rates were now within national averages
• There was a visible child-centred culture within the service
• Staff were motivated and offered care that was kind, sensitive and supportive
• Cross site working was providing good opportunities for the sharing of information and good practice

Outpatients and diagnostic imaging

• In the 2014 inspection, elements of this service were found to be inadequate, notably the availability of patient records when attending for a consultation. As a result of targeted work, there has been a significant improvement with 98% at WCH 95% at CIC of patients records now available for appointments
• The introduction of a team to support had provided the infrastructure to deliver this important element of the service
• Staff were very positive regarding this major improvement and the impact it was having on performance and patient experience
• The introduction of the Contact Centre was beginning to address appointment delays
• The storage of patient records had significantly improved at West Cumberland Hospital with off-site storage also in place

Key areas of focus for the Trust
Safe staffing
Medical staff
The Trust has been very open about the challenges faced in recruiting more permanent doctors to work in North Cumbria and the current, but entirely necessary, over-reliance on locum staff to keep services running and ensure safe and effective care for patients at all times.
The rising cost of locums is an indication of the seriousness of this issue, particularly in acute medicine at West Cumberland Hospital where we many extra locum doctors have been employed to keep services running. Recruitment efforts are focussed on attracting a more permanent workforce to Cumbria, which remains one of the core challenges faced by the local health and social care economy.
The Trust has had some success in appointment more permanent consultants over the past two years with 40 consultants joining in 2013 and 48 in 2014. However sadly this is not happening at the scale and pace required and the wider clinical strategy must address this problem in the long-term.
Recruitment continues to be a key focus for the Trust, with upcoming activity including:

• Continuing with the Trust’s highly promoted recruitment campaign, ‘Looking for a fresh start’
• A Memorandum of Understanding was signed in March 2015 between the Trust and the University of Central Lancashire (UCLan) to develop future educational opportunities in West Cumbria linked to undergraduate medicine – with recruitment launching October 2015
• Delivery of the medical workforce strategy
• NHS Providers ‘Find your place in the North East and Cumbria’ campaign to promote the area as a place to live and train to establish our future workforce

Nursing staff
The nursing, midwifery and AHP strategy launched in December 2014 and is continuously being embedded into the Trust in order to provide a clear vision and focus for nurses, midwives and allied health professionals.
The senior nursing team continues to closely monitor nurse staffing levels on a daily basis and in recent weeks 44 registered nurses have been appointed, 34 of which are student nurses who will qualify in September 2015. In addition, the first cohort of cadet nurses at Carlisle College for the Cumberland Infirmary will start in September 2015 and a second cohort will begin at Lakes College for West Cumberland Hospital.
The Trust is also currently looking at further investment in healthcare assistants who are a vital part of delivering compassionate care to our patients. This work will include supporting the transformation of healthcare assistants and working with organisations who have successfully developed the band 4 assistant practitioner roles.
Safe services
The Trust is continuing to work with partners to deliver the clinical strategy as part of the ‘Together for a healthier future’ work. The programme board includes senior colleagues from health and care organisations across North Cumbria, NHS England and Healthwatch Cumbria who are working together to ensure that people receive high quality, safe and sustainable health services for the future. Creating robust services will also provide a more attractive working environment for prospective clinicians.
The Trust has continued to focus on sustaining models of care for high risk and emergency pathways which has resulted in much better outcomes for patients and a clear reduction in the Trust’s mortality rates which are now within expected range.
Further high risk pathways have been introduced in 2015 for high risk cardiology, upper GI and respiratory patients. This means a small number of patients are being transferred from West Cumberland Hospital to the Cumberland Infirmary in order to benefit from urgent specialist care by a dedicated consultant.
The Trust is now focussing on the stroke pathway in order to improve the quality of stroke services for patients across North Cumbria which the CQC has also recommended.
Another area of focus is to increase surgical activity at West Cumberland Hospital when the new hospital opens in October 2015 offering a surgical floor with seven operating theatres. Some specialities have already seen an increase over the past year such as breast surgery (6.5% increase from 2013/14 to 2014/15) and thyroid surgery (9.7% increase from 2013/14 to 2014/15).
Plans are now being put in place to offer more services to patients at West Cumberland Hospital between October 2015 and January 2016 in the following specialities:

• Breast
• Vascular
• General surgery
• Gynaecology
• Orthopaedics
• ENT
• Orthodontics
• Urology

Following the publication of the CCG commissioned independent maternity review of Cumbria and North Lancashire, a project team has now been established with includes some external and independent experts. The team are now actively looking at the feasibility of the recommendations and their work will include a programme of engagement activity to ensure the views of local women as users and future users of the services, and their families, are sought.
Further work will be strongly linked to the Success Regime of which North Cumbria is one of the three health economies to be included. The new national initiative has been introduced to help the most challenged health economies. A programme director with significant experience and leadership skills will be appointed to drive the process forward.

Responsive services

The Trust is committed to improving its performance against the core national standards such as the 95% four hour emergency standard, 18 week referral to treatment, cancer pathway and diagnostic standards.
Monthly action plans are produced for all areas and the Trust continues to actively work to improve patient flow throughout both hospital sites.
Following the declaration of an internal major incident in March 2015 due to the level of emergency admissions the Trust was experiencing and significant difficulty in ‘patient flow’ and moving patients through the system, an internal review was carried out setting out key priority actions such as:

• Implementing a ‘home to assess’ model to enhance early discharge
• Developing a clear whole system frailty pathway and whole system approach to workforce issues
• A system-wide choice policy, owned by the whole economy, shared with patients on entry to the healthcare system which sets out clear expectations
• A system-wide escalation plan which is used, understood and actioned by all members of the economy
• 7 day working should be agreed as a whole system health and social care offer to prevent bottlenecks and individual organisation disengagement
• Joint training packages on discharge planning across the system to benefit flow