Report for North Cumbria University Hospitals NHS Trust
Review into the Quality of Care & Treatment provided by
14 Hospital Trusts in England
RAPID RESPONSIVE REVIEW REPORT FOR RISK SUMMIT
June 2013
Contents
1.
Introduction
3
2.
Background to the Trust
7
3.
Key Lines of Enquiry
9
4.
Review findings
5.
10
Leadership and governance
15
Clinical and operational effectiveness
22
Patient experience
29
Workforce and safety
33
Conclusions and action plan
Appendices
49
48
Appendix I:
SHMI and HSMR definitions
49
Appendix II:
Interviews held
51
Appendix III: Observations undertaken
52
Appendix IV: Information available to the RRR panel
59
Appendix V: Agenda for unannounced visit
58
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1. Introduction
This section of the report provides background to the review process and details of the key stages of the review.
Overview of review process
On 6 February 2013, the Prime Minister asked Professor Sir Bruce Keogh, NHS England Medical Director, to review the quality of the care and treatment being provided by
those hospital trusts in England that have been persistent outliers on mortality statistics. The 14 NHS trusts which fall within the scope of this review were selected on the
basis that they have been outliers for the last two consecutive years on either the Summary Hospital-level Mortality Indicator (SHMI) or the Hospital Standardised Mortality
Ratio (HSMR). Definitions of SHMI and HSMR are included at Appendix I.
These two measures are intended to be used in the context of this review as a ‘smoke alarm’ for identifying potential problems affecting the quality of patient care and
treatment at the trusts which warrant further review. It was intended that these measures should not be reviewed in isolation and no judgements were made at the start of the
review about the actual quality of care being provided to patients at the trusts.
Key principles of the review
The review process applied to all 14 NHS trusts was designed to embed the following principles:
1)
Patient and public participation – these individuals have a key role and worked in partnership with clinicians on the reviewing panel. The panel sought the views of the
patients in each of the hospitals, and this will be reflected in the reports. The panel sought the views of the patients in each of the hospitals and also considered
independent feedback from stakeholders, related to the Trust that had been received through the Keogh review website. These themes have been reflected in the reports.
2) Listening to the views of staff – staff were supported to provide frank and honest opinions about the quality of care provided to hospital patients.
3) Openness and transparency – all possible information and intelligence relating to the review and individual investigations will be publicly available.
4) Cooperation between organisations – each review was built around strong cooperation between different organisations that make up the health system, placing the
interest of patients first at all times.
Terms of reference of the review
The review process was designed by a team of clinicians and other key stakeholders identified by NHS England, based on the NHS National Quality Board guidance on rapid
responsive reviews and risk summits. The process was designed to:


Determine whether there are any sustained failings in the quality of care and treatment being provided to patients at these Trusts.
Identify:
3
i.
ii.
iii.
Whether existing action by these Trusts to improve quality is adequate and whether any additional steps should be taken.
Any additional external support that should be made available to these Trusts to help them improve.
Any areas that may require regulatory action in order to protect patients.
The review follows a three stage process:

Stage 1 – Information gathering and analysis
This stage used information and data held across the NHS and other public bodies to prepare analysis in relation to clinical quality and outcomes as well as patient and staff
views and feedback. The indicators for each trust were compared to appropriate benchmarks to identify any outliers for further investigation in the rapid responsive review
stage as Key Lines of Enquiry (KLOEs). The data pack for each trust reviewed is published at http://www.nhs.uk/NHSEngland/bruce-keogh-review/Documents/trust-datapacks/data-pack-northcumbria.pdf.

Stage 2 – Rapid Responsive Review (RRR)
A team of experienced clinicians, patients, managers and regulators (see Appendix II for panel composition), following training, visited each of the 14 hospitals and observed
the hospital in action. This involved walking the wards and interviewing patients, trainees, staff and the senior executive team. This report contains the findings from this
stage of the review.

Stage 3 – Risk summit.
This brought together a separate group of experts from across health organisations, including the regulatory bodies. They considered the report from the RRR, alongside
other hard and soft intelligence, in order to make judgements about the quality of care being provided and agreed any necessary actions, including offers of support to the
hospitals concerned. A report following each Risk summit is publically available.
Methods of Investigation
The three day announced RRR visit took place on Tuesday 7, Wednesday 8 and Thursday 9 May and an out of hours unannounced site visit on the evening of Thursday 16
May and morning of Friday 17 May. A variety of methods were used to investigate the Key Lines of Enquiry (KLoEs) to enable the panel to analyse evidence from multiple
sources and follow up any trends present in the Trust’s data.
The visit included the following methods of investigation:

Interviews
Ten interviews took place with key members of the Board and other staff during the announced site visits on 7, 8 and 9 May 2013. See Appendix II for details of the
interviews undertaken.

Observations
Ward observations enable the panel to see a ward undergo its day to day operations. It allows the panel to talk to current patients, and their families if the observations are
scheduled during visiting hours. They allowed the panel to speak with a range of staff, observe the ward environment and review patient notes, staff rotas and training
records and enabled the panel to analyse any observed handover processes within wards, to ensure that the staff that are coming on duty are appropriately briefed on
patients.
4
Observations took place in 11 areas of the Cumberland Infirmary and 9 areas of West Cumberland Hospital during the announced site visit on 7, 8 and 9
May, and in 8 areas of the Cumberland Infirmary and 9 areas of West Cumberland Hospital the unannounced site visit on the evening of 16 and morning
of 17 May.. See Appendix III for details of the observations undertaken.

Focus groups
Focus groups provided an opportunity to talk to staff groups individually, and for each staff group to discuss what they feel is the contributing factor to the Trust’s high mortality
scores and to provide an opportunity to explore further the key lines of enquiry and other issues raised by the staff groups. It also enabled staff to speak up if they feel there is
a barrier that is preventing them from providing quality care to patients. A staff focus group, which was open to staff at all levels, was held at each site: Cumberland Infirmary
in Carlisle and West Cumberland Hospital in Whitehaven.
As well as these focus groups, there were four drop-in sessions held across the two sites. These sessions provided both patients and staff with an opportunity to speak oneon-one with panel members. The attendance at both focus groups and the drop-in sessions was good.
The panel would like to thank all those who attended the focus groups and were open and balanced with the sharing of their experiences and their perceptions of the quality
of care and treatment at the Trust.

Listening events
Public listening events give the public an opportunity to share their personal experiences with the hospital, and to voice their opinion on what they feel works well or needs
improving at the Trust.
Listening events for the public and patients were held on the evening of 7 May at The Crowne and Mitre Hotel in Carlisle and on the evening of 8 May at the Civic Hall in
Whitehaven. The listening events were attended by approximately 100 members of the public, patients and members of the Trust staff.
The panel would like to thank all those who attended the listening event and were open with sharing their experiences and balanced in their perceptions of the quality of care
and treatment at the Trust.

Data review
A number of documents were provided to the panellists during and after the site visit. Whilst the documents were not reviewed in detail, they were available to the panellists
to influence/verify findings as considered appropriate by the panellists. See Appendix V for details of the documents available to the panel.

Unannounced site visit
The unannounced site visit took place on the evening of Thursday 16 May and the morning of Friday 17 May 2013. This visit focused observations in areas identified from the
announced site visit, see Appendix VI.
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Next steps
This report has been produced by Gill Harris, Panel Chair, with the full support and input of panel members. It has been shared with the Trust for a factual accuracy check.
This report was issued to attendees at the risk summit, which focussed on supporting Cumbria University Hospitals NHS Trust (“the Trust”) in addressing the actions identified
to improve the quality of care and treatment.
Following the risk summit the agreed action plan will be published alongside this report on the Keogh review website. A report summarising the findings and actions arising
from the 14 investigations will also be published.
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2. Background to the Trust
Context
The Trust was created in 2001 following the merger of Carlisle Hospitals NHS Trust and West Cumberland NHS Trust. It is based primarily over two acute medical sites;
Cumberland Infirmary at Carlisle and the West Cumberland Hospital at Whitehaven. In February 2011, the Trust Board concluded that the best option to secure high quality
and safe services for the people of North Cumbria was to merge with another NHS trust. In January 2012, Northumbria Healthcare NHS Foundation Trust was named as the
preferred bidder. Currently, the Trust is in a period of detailed negotiations around the financial arrangements surrounding the acquisition with Northumbria, local health commissioners and
NHS North of England (the strategic health authority).The Trust’s main commissioners are Cumbria CCG. Should the acquisition be successful, the dissolution of North Cumbria
University Hospitals is estimated to be October 2013.
The Trust has been selected for the review as a result of its HSMR results for 2011 and 2012. In both years, its HSMR was statistically above the expected level. It was
during this time that the Trust Board decided to be acquired because it determined that this was the best way forward to secure long term sustainability and improve quality.
The Trust serves a population of 340,000 people. This is a rural community spread over a large geographical area. Deprivation levels are relatively low, as is ethnic diversity.
However, homelessness and youth drinking is significantly more common in North Cumbria than in the rest of England. Over 65s constitute a larger proportion of the
population than the national average.
Key messages from the Trust data pack
The Trust data pack identified a number of key areas of concern that were used to inform the Key Lines of Enquiry; these are outlined below:
Mortality
The Trust has an overall SHMI of 110 for the last 12 months (Dec 11 – Nov 12), which has only fallen slightly since 2009/10. This indicates that the number of actual deaths is
higher than the expected level. From August 2012, there has been an upward trend in SHMI. Specialty-level analysis of SHMI results highlight some key diagnostic groups
within General Medicine which have higher than expected SHMI, including pneumonia (excluding that caused by tuberculosis or sexually transmitted disease) and congestive
heart failure (non-hypertensive).
The Trust’s HSMR for the past 12 months (Jan 12 – Dec 12) is 116. There are significant variations since 2007/08 with an overall increase in the annual HSMR from 106 to
114 in 2011/12. Specialty-level analysis of HSMR results indicate that the following areas have higher than expected HSMR: pneumonia, congestive heart failure (nonhypertensive), urinary tract infections, acute cerebrovascular disease and gastrointestinal haemorrhage.
The key lines of enquiry for the RRR targeted the panel’s observations and interviews to review the identified specialties in the Trust with higher mortality indicators.
Patient Experience
The data pack considers nine measures as a proxy for patient experience. Of the nine measures reviewed, there were three which are rated ‘red’, specifically results from the
cancer survey, patient voice comments, and complaints about clinical aspects of care. A particular area of concern from the cancer survey was support of people with cancer.
Of 61 individual comments from patients and public as part of the Patient Voice, 21 were negative (34%). Key themes in these comments were the poor complaints
procedure, poor reputation locally, low staff morale linked to poor staff attitudes, lack of professionalism amongst staff, and poor arrangement of appointments.
Key lines of enquiry were included in the review to focus on how the Trust engaged with stakeholders including patients, and how the Trust delivered on its duty of candour.
Safety and Workforce
7
The panel considered nine measures as proxies for patient safety. Of these, the Trust was rated ‘red’ in four; these were rate of serious harm from
patient incidents, harm for all four Safety Thermometer indicators (pressure ulcers, falls, urinary tract infections and venous-thromboembolism), pressure
ulcers, and clinical negligence scheme payments.
th
The Trust is ranked 7 worst for C. difficile recorded deaths over a three year period (out of 141 non-specialist trusts); a potential indicator of infection control concerns at the
Trust.
A review of the workforce data identified that 16 of the 19 proxy indicators were rated ‘red’. Notably, the Trust’s staff engagement, as measured by the annual NHS Staff
Survey, is in the bottom fifth of all acute trusts for both 2011 and 2012.
Key lines of enquiry were included in the review focusing on the Trust’s workforce strategy and staff engagement.
Clinical and Operational Effectiveness
The Trust is an outlier for a number of indicators of clinical effectiveness, including the proportion of women receiving ante-natal steroids, percentage of diabetes patients
receiving a foot risk assessment during their hospital stay and post-operative mortality for bowel cancer. The Trust performs more favourably in relation to measures of
operational efficiency; crude readmission rates and length of stay are better than the national average.
The Trust is not currently meeting its target of seeing 95% of A&E patients within four hours, with 92.1% being seen within four hours in Q4 2012/13. The Trust also breached
its referral to treatment (RTT) target for admitted patients, with only 82.4% of patients receiving treatment within 18 weeks of being referred in March 2013, compared to a
target of 90%.
Key lines of enquiry were included in the review focusing on the monitoring of clinical and operational effectiveness, including mortality data.
Leadership and Governance
There have been significant changes in the management at the Trust over the past five years. Within the current Board, the Chairman, Chief Executive, Director of
Transformation and Director of Finance roles are interim positions, whilst the Director of Nursing position is an ‘acting’ role. The interim CEO joined the Trust in September
2012 and together with the Director of Transformation is seconded from Northumbria Healthcare NHS Foundation Trust, which is currently the preferred bidder to acquire the
Trust.
An inspection of Cumberland Infirmary performed by Care Quality Commission in March 2013 (report published in May 2013) has indicated concerns relating to a number of
outcomes, including people receiving safe and appropriate care that meets their needs and supports their rights, safe staffing levels and medical records.
Key lines of enquiry focused on the quality priorities of the Trust, and the use of information to improve services. A review of the Trust’s information also indicated that
significant cost savings were being made at the Trust, and therefore a key line of enquiry focusing on the impact of these savings on the quality of care provided was included
in the review.
Although the review team recognised that there was evidence of good decision making to enhance quality being made at CEO level, the impact of this has yet to fully filter
down into the wider organisation.
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3. Key Lines of Enquiry
The Key Lines of Enquiry (KLOEs) were drafted using the following key inputs:




The Trust data pack produced at Stage 1 and made publicly available;
The data submitted by the Trust;
Insights from the Trust’s lead Clinical Commissioning Group (CCG), Cumbria CCG; and
Review of the patient voice feedback received specific to the Trust prior to the site visit.
These were agreed by the panellists at the panel briefing session prior to the RRR site visit. The KLOEs identified for the Trust were the following:
Theme
Key Line of Enquiry
Governance and leadership
1. Can the Trust clearly articulate its governance process for assuring the quality of treatment and care?
2. How is the board using performance information to drive improvements?
3. How does the Trust use information locally?
Clinical and operational effectiveness
4. What governance arrangements does the Trust have to monitor and address clinical and operational performance
data at a senior level?
5. What processes does the Trust have in place to support monitoring mortality data and clinical effectiveness?
6. How does the Trust work with stakeholders on the QIPP agenda?
Patient experience
7. How does the Trust engage with stakeholders?
8. How is the board responding to the challenges relating to the duty of candour?
Workforce and safety
9. What are the key themes from staff engagement by the Trust?
10. Describe the Trust’s workforce strategy.
Trust-specific – CIPs quality impact
assessments
11. What is the Trust’s process to assess the impact of cost savings plans on quality of patient care and its workforce?
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4. Review findings
Introduction
The following section provides a detailed analysis of our findings based on the evidence we received in the Trust data pack, interviews, observations, staff focus groups and
patient listening events. From the data we have gathered we have identified six key areas the Trust must focus on to improve quality of care, patient safety and experience.
These are summarised in the key messages below and are set out in more detail in the following tables.
Whilst these findings highlight a number of serious concerns around the quality of care provided by the Trust, it is important to note that the review team met many caring staff
whilst at its hospitals. These staff are passionate, committed and want to do the best they can to care for their patients, albeit under frequently challenging circumstances. It is
also noted that the most recent change in Board leadership at Chief Executive and Chair level was having a demonstrable improvement on morale and the pace of change
within the organisation, although it is acknowledged that the pace needs to increase. The Chief Executive and Chair welcomed the review and were keen to learn of any
further improvements they could make to enhance the quality of the care they offer.
Key messages
1.
Inadequate governance, and pace and focus of change to improve overall safety and experience of patients
Positive changes have been made at the Trust over the past six months as a result of its relationship with Northumbria Healthcare NHS Foundation Trust as the preferred
bidder for acquisition (for example, the impact of newly appointed Board members, has been well received and they are seen to be driving change), however, the extent and
pace of change has been insufficient to rectify all weaknesses in governance. There are identified weaknesses in clinical leadership, (which are now being addressed), and
the poor quality of reporting does not yet fully support appropriate identification and prioritisation of risks to quality, nor would it likely support a robust review and challenge of
the Trust’s approach to quality. As reflected in the key messages below, governance failings are evident in a number of areas. There are concerns over the capacity and
capability of senior and middle management to deliver on the breadth and pace of change required and although some of these are now being covered by increased
partnership arrangements with Northumbria there is a requirement for further acceleration to enhance the pace of change. We witnessed at times a lack of attention to
compliance with internal procedures at a local level and an apparent acceptance of care which could put patients at risk.
There is a high reliance on the success of the acquisition to bring about change that the organisation itself recognises is needed. However, this will not guarantee patient
safety in the interim or immediately post-acquisition and the Trust does require further support to help deliver this agenda. An urgent review of the Trust’s Corporate Risk
Register (CRR) and Board Assurance Framework (BAF) is required to provide the Board with a focus for risk management. The Trust also recognises more support from key
stakeholders in the wider healthcare system is required, including, the NHS Trust Development Authority (NTDA) and Cumbria Clinical Commissioning Group (CCG). The
requirement for more support from partner agencies including primary care was stressed by many interviewed. There is a need for a full, independent quality governance
review to ensure that current gaps are addressed without delay. This will facilitate appropriate prioritisation of timing on the Board agenda and support the new leadership
team in increasing the awareness of the organisation to the level of change required. The CEO has already recognised this and has commenced a period of consultation to
establish an appropriate middle management tier (General Managers, Matrons and operational managers) whose primary focus will be to support an enhanced clinical
management system.
2.
Slow and inadequate responses to serious incidents and a culture which does not support openness, transparency and learning
Documentary evidence provided demonstrates a slow response to serious incidents. Although senior management described improvement in the openness and ability of staff
to have honest discussions about incidents, and staff at Cumberland Infirmary confirmed that there had been some improvements in this area, the panel did not observe
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adequate embedded learning from incidents. Discussions with staff revealed that learning is still not adequately shared, and that there are deep set
cultural issues, such as apportionment of blame, which negatively impacts on learning. The recurrence of some types or categories of events, for
example, a second never event involving a retained guide wire also suggests that the organisation is slow to learn from serious incidents. Likewise a significant adverse event
occurring within obstetrics at Whitehaven did not appear to have resulted in disseminated learning within the department. This is something that the new CEO is aware of and
has been prioritising as evidenced within the ‘face to face’ meetings she is now having with staff to enhance communication and develop clear lines of accountability.
Historically, feedback at a local level has not been routinely provided to those reporting incidents, which could impact reporting. The Trust has now sought the support of and
is working in partnership with the CCG and the TDA to develop its serious incident investigations processes. This has commenced and the initial feedback demonstrates an
improving trend since the senior management changes have taken place. This needs to be supported by a change in culture around serious incidents and improved
communications. It has been noted following the immediate review undertaken in partnership with the CCG and Area Team that this culture is changing.
There are reduced resources to deal adequately with the current level of complaints (14 of the 23 complaints closed in March 2013 had been open for more than 30 days),
and at the listening events, members of the public highlighted a perceived lack of openness and poor communication by the Trust as a result.
3.
Staffing shortfalls and other workforce issues across staff groups which may be compromising patient safety
Staff at both Cumberland Infirmary and West Cumberland Hospital spoke about poor nurse and medical staffing, especially out of hours. This was evidenced through a review
of ward staff rotas and staffing audit charts whilst on-site, and by information provided which indicated low medical cover of some areas, for example, general and acute
medicine at West Cumberland Hospital, and an over-reliance on locum appointments. The panel was provided with the report on the most recent nursing review performed by
management. However, it was recognised that as this pre-dated the Francis Report it did not offer assurance that it had addressed fully the recommendations. The length of
time this review has taken has seriously impacted staff morale (it was commenced before the current senior team were in place and as a consequence of several leadership
changes within the organisation has been subject to multiple format changes. Given this the Trust needs to further review its skill mix in line with patient acuity, professional
judgement and ward geography, inclusion of ward managers within this review would improve morale and reflect best practice.
The high reliance on medical locums, particularly at the West Cumberland site, is a major concern. For example, the senior resident medical doctor (SpR) is virtually always a
locum. At mid grade level this is particularly acute within Obstetrics and Gynaecology at West Cumberland and at Consultant level within General Medicine at West
Cumberland. This has already been identified by the Trust as a risk and they are working with Northumbria Trust to help strengthen their recruitment processes and utilise the
flexibility of the FT model to fast track appointments. This should also have a positive impact on financial sustainability.
Staff reported that they have not had sufficient time to complete mandatory training; this is confirmed by the low mandatory training rates set out in information supplied by
management and also triangulated from the panel’s observation of training records. This means that staffing shortfalls may be having a compounding effect on risks to patient
safety and experience. Staff also feel that they have lost access to important face-to-face training, which they believe can be more effective than e-learning (for example in
relation to fire safety). Training in other staff groups such as estates and medical engineering is lacking (no-one is qualified to undertake revalidation) and staff on some wards
have reported no formal training on medical equipment. The Trust should urgently address these training shortfalls and reconsider its methods for the delivery of training.
4.
Lack of support for staff and effective, honest communication from middle and senior management level
Senior and middle management need to drive openness and support. Whilst there is evidence that this is being introduced by the new CEO, discussions with staff and patient
stories suggest that they do not feel supported, and in many cases provided evidence of feeling intimidated and bullied; nor do they seem to be receiving effective
communication. Evidence suggests that staff who were favoured are treated as elite, whilst on the other hand there were three allegations of potential racism.
During the review, there was evidence of excellent staff communication around moving trauma, vascular and elective orthopaedics.
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Several members of staff expressed fear about speaking openly about issues or being seen talking to the Keogh review team by their line managers.
Nurses confirmed that they are struggling to escalate acute staffing shortfalls – a number of staff reported that they were directed by the middlemanagement team to find staff themselves to close the gaps, but this meant that more time was taken away from patient care. The introduction of a ‘bench’ of staff to be
accessed by wards and departments who require urgent access was noted as good practice, but staff expressed that in some areas these had ‘been swallowed up’. The CEO
had ‘unblocked’ nursing vacancies since her appointment, but the full impact of this had not yet been felt due to delays in appropriate staff applying and recruitment processes
(i.e. CRB check).
Communication between all levels of staff should be improved and the Trust should explore other opportunities in this regard.
Although staff recognise the potential benefits of the impending acquisition by Northumbria, the panel members detected some scepticism around it delivering the changes
required and recognising the “good” in North Cumbria, and it will be extremely important not to let staff feel disengaged and disempowered in the process. Due consideration
should be given to different models and ways of working to deliver the breadth and pace of change required, whether the Northumbria way or an alternative. A number of staff
and patients sought assurance that acquisition would not compromise the service provided by the Newcastle teaching hospitals for tertiary level care.
5.
Failure in governance to ensure adequate maintenance of the estate and equipment
Governance processes have failed to identify significant shortcomings in the assessment and maintenance of the estate and equipment. Despite requests, no evidence could
be provided to show that ventilation systems in theatres had been inspected, audited, and risk assessed; no action plans were available to show mitigating actions.
Specifically, the Trust failed to respond to a report that its ultra-clean ventilation (UCV) theatres at the Whitehaven site were not meeting relevant standards, and could not
provide evidence that other operating theatres had been adequately tested. Validation and verification reports for recent years were requested but were not available and
without these no assurance can be provided of the environmental compliance for these areas. An urgent external review of the estates department is required to ascertain
their competence and capability, and ensure that medical equipment maintenance is appropriately prioritised and undertaken. There was no evidence that this issue had been
escalated for inclusion on the corporate risk register and did not feature in the BAF.
There was limited assurance provided in respect of water management by the estates department; any external review should incorporate a specific review into the current
arrangements. The Trust would benefit from a full statutory compliance review and this is strongly advised.
The panel members saw medical equipment that was labelled as being beyond its servicing date on several wards at Cumberland Infirmary, and concerns that service
stickers are put on equipment throughout the Trust when servicing has not taken place were raised by a small number of staff and estates engineers. The extent of these
issues needs to be investigated by the Trust. There are concerns that over 1,000 maintenance requests were outstanding and a list of prioritised backlog maintenance was
requested by the panel. Senior staff in theatres at Cumberland Infirmary and West Cumberland Hospital were unaware of the planned preventative maintenance programme
for theatres. The panel were told of ongoing issues in trying to contact the estates department when equipment fails in theatre. The review team noted the medical equipment
register and whilst this appeared comprehensive, there appeared to be a lack of risk based maintenance, a significant number of devices classified as high risk were outside
their normally prescribed maintenance periods. Accordingly, the external review of estates should include a review of medical device management to ensure compliance with
relevant Medical Device Directive (MDD) standards.
Whilst the panel were informed that there is a deep cleaning team in place, including a rapid response team it was acknowledged within the estates team that this was not
time-tabled as a rolling programme. There was both ingrained dirt and dust on surfaces in the wards visited at the Whitehaven site. Hydrogen Peroxide Vapour (HPV) Fogging
(a common method of deep cleaning) was not being used in a structured and coordinated way. Whilst we acknowledge that there is currently a redevelopment programme
underway at the site, there are compromised surfaces which could negatively impact on the prevention and control of infection.
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The review panel were not assured in respect of the Trust's decontamination practice. Whilst there was some evidence of acceptable practice in
endoscopy, the validation and verification documentation in respect of the endoscopy AER’s were not provided, prior reports were also requested but
were not forthcoming. The copies of the accreditation certifications for the SSD were requested and were not forthcoming, as were the validation documentation for the
sterilisers and the surgical instrument washer disinfectors, these were not provided.
The Trust must undertake an urgent review of its compliance status for the SSD and endoscopy, and set this against the CFPP 01- 01 and CFPP 01 -06 standards
respectively, the Director of Infection Prevention and Control (DIPC) should be fully engaged in this process.
The governance and assurance arrangements for decontamination should be reviewed, these should form an integral part of the infection control committee agenda in the
future.
Immediate action to address non-compliant theatres, including temporary closure, was taken by the Trust during the review and the review team asked that the Trust urgently
gain assurance of the safety of all other theatres. It is recommended that a further review is performed by a specialist decontamination expert, and that a formal, annual deepclean programme is implemented. An independent review of estates, including equipment maintenance, needs to be performed to identify the significant gaps in this area.
The Trust has taken action pending further investigations into these areas. Furthermore, in the detailed findings reference has been made to information requests which had
not been received. The Trust has provided the panel via email a number of documents which were received late in the day and have not yet therefore been reviewed by the
expert advising the panel.
6.
Significant weaknesses in infection control practices
Improvements to the governance and implementation of infection control have recently been made or are planned, for example, the Chief Executive has taken on the role of
Chair of the Infection Control Committee and there had been a recent change in DIPC. Cleaning products are under review. However, governance improvements have not yet
had the chance to demonstrate a full impact regarding the poor practices observed whilst at both hospitals (in addition to those relating to maintenance mentioned above).
These included weaknesses in content, knowledge and compliance of the antibiotic prescribing policy, cluttered wards which would be difficult to keep clean at both sites,
medical staff who were not bare below the elbows and junior doctors unfamiliar with Aseptic Non Touch Technique (ANTT) training, unreliable hand hygiene audit results
which were not understood by staff, and beds which are too proximate in wards at the Carlisle site, especially the stroke unit Elm A. There is a need to further review the
antibiotic prescribing guidelines to minimise the risks of further cases of C. difficile and to ensure that there is clinical agreement to, and compliance with these guidelines.
A review of infection control practices, including a further review of the antibiotic policy, should be undertaken and a more multi-disciplinary approach needs to be adopted
with more involvement from estates and buy-in from all staff across the Trust. The Trust needs to urgently declutter its wards. Whilst on-site the review team recommended to
management that all drug storage should be fully secured as we found examples of unlocked drug fridges. Additionally, the review team found drug fridges that contained
food and drink. Security of drugs needs to be audited frequently in line with latest national guidance.
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The following definitions are used for the rating of recommendations in this review:
Rating
Definition
Urgent
The Trust should take immediate action to respond to these recommendations and
ensure improvement in the quality of care
High
The Trust should develop a response and action plan for these recommendations to
ensure improvement in the quality of care
Medium
The Trust should implement these recommendations to ensure ongoing improvement
in the quality of care
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Leadership and governance
Overview
The three KLOEs in the area of leadership and governance were focussed on the governance processes for assuring the quality of treatment and care, including the use of
performance information to drive improvements and the Trust’s use of information locally. They were based on the template KLOEs for governance and leadership and
tailored to the Trust.
The panel sought to address the effectiveness of governance and leadership through reviewing documentation supporting key governance processes, interviews with key
senior managers. We also spoke to staff in different settings and observed conditions in clinical areas to understand whether improvements in governance reported by
management were having an impact in clinical areas and whether staff were benefiting from effective leadership.
Detailed findings
The governance process for assuring the quality of treatment and care
KLOE 1: Can the Trust clearly articulate its governance process for assuring the quality of treatment and care?
Good practice identified
A new interim Chief Executive, Ann Farrar, was seconded in September 2012 from Northumbria Healthcare NHS Foundation Trust where she is Chief Operating Officer.
Staff at both sites acknowledged the relatively high visibility of the interim Chief Executive and the positive impact she is making. Staff at a focus group noted the significant
personal effort she, and the current Chair, are making to engage with staff, which is a great improvement compared with previous incumbents.
Recognition by staff at all levels, including senior management, that there are issues with the quality of care and treatment at the Trust.
Senior management responsible for governance and some middle managers described improvements in the culture around discussing and acknowledging Trust
shortcomings which have caused serious incidents and harm. However, further work is required in this area, see below.
Outstanding concerns including
evidence
Capacity and Capability
A lack of capacity and capability of
senior and middle management to
Planned improvements
Recommended action
The Trust is obtaining support from the
NTDA to speed up key appointments.
Review the leadership structure to ensure the
capacity and capability gaps are filled.
A leadership development plan was put in
Actively develop clinical and other managers,
Priority – urgent, high or
medium
Urgent
15
Outstanding concerns including
evidence
deliver on the pace of change required.
There has been little or no development
of management – The Trust
acknowledged this gap and has
commenced a development programme
but this has yet to fully embed itself.
Planned improvements
place in September 2012, recognising a
lack of organisational development in the
past. Staff appear committed to this
programme.
Recommended action
Priority – urgent, high or
medium
and maintain this going forward.
Further enhance the development framework
for Board members, and cascade to middle
management and clinical leaders.
The organisational development plan for
13/14 was approved by the Trust Board in
March 2013 and the two most significant
programmes are the “high performing
clinical team leaders” for the newly
appointed Clinical Directors, Matrons and
middle management. The second is the
Ward Managers development programme.
The latter starts in June and the former
starts following the consultation and
appointment of the matrons and operational
managers in July 2013.
Clinical Leadership
Consider more support from Northumbria and
the NTDA.
There are weaknesses in clinical
leadership resulting in a failure to
recognise and learn from SUIs. The
review team spoke to staff on wards at
both sites who did not understand the
audit programmes in place or how to
escalate significant concerns. The
audits at local level were haphazardly
displayed and not meaningful to
patients or public. There was evidence
of a lack of visibility of clinical leaders
Planned implementation of development
programmes for nursing managers.
Corporate Risk Register
The Trust has an approved Annual Plan,
and following a review of risks by the
Since April 2013 leadership positions in the
clinical structure were appointed to
appropriately remunerated, published job
descriptions via a competitive, interviewed
process. All leaders meet at CPG once a
month and will be supported with planned
leadership development
Urgent
Develop critical audit progammes from Board
to Ward which are owned at local level and
have clear improvement trajectories
Substantial review of the Trust’s CRR and
BAF document is required. The BAF is a key
High
16
Outstanding concerns including
evidence
The Trust’s risk processes has
significant deficiencies, for example, the
Corporate Risk Register (CRR) failed to
identify quality risks relating to the
estate and theatres due to failure to
escalate from a local level. This does
not allow appropriate prioritisation of
quality risks. The risk of non-delivery of
the CIP (25) is rated more highly than
quality risks, such as the risk that the
Trust does not reduce its mortality and
harm rate (15). More broadly, the Board
Assurance Framework (BAF) is poorly
designed.
Planned improvements
Executive Team (1 May 2013) the Trust
plans to review its Assurance Framework
(June) and Clinical Business Unit Risk
Registers (July).
It was also explained to the review team
how this would be embedded from Board to
ward by adopting the UNIPART way (staff
engagement in continuous learning based
on agreed corporate priorities).
This
involves each team with their strategic
purpose and their contribution to its
success with supporting real time
measurement and support in the training
and development of staff to focus on
continuous improvement. This was the key
message delivered to the staff road-shows
in April 2013 and the first wards are due to
commence this from July 2013.
Board Agenda
Recommended action
Priority – urgent, high or
medium
governance tool and should be aligned and
reviewed alongside key strategic objectives.
Obtain an independent review of the quality
governance arrangements to close gaps. The
review should look outside of Northumbria to
ensure that the solutions are appropriate for
the local hospitals. Other metrics for
improvement should be considered.
Ensure this process is embedded from Board
to ward.
High
Although quality of care appears first on
the Board agenda, the time allocated to
this item further suggests that quality is
not a sufficiently high priority.
The Board is now encouraging challenge
from the non-executive to promote active
engagement and ownership of the agenda.
Continue to increase the amount of time to
quality matters at Board meetings in line with
the agenda.
Northumbria Acquisition
The Trust is working alongside the TDA to Improvement plans need to be developed
consider its options.
immediately including contingency plans
should the acquisition not go ahead.
Signage was amended in the A&E
Undertake a review of signage in all areas of
High
There is over-reliance on the
Northumbria acquisition being speedily
approved by Monitor. The Trust does
17
Outstanding concerns including
evidence
Priority – urgent, high or
medium
Planned improvements
Recommended action
not have a “Plan B”. The Northumbria
logo is in use but acquisition has not yet
formally taken place.
department immediately.
the Trust.
Clinical Governance Process
Development and support of Clinical
Business Unit (CBU) Directors and senior
nursing staff to take the lead on clinical
governance.
Implement appropriate performance
management systems to monitor performance
at CBU level with clear lines of accountability
High
Moving forward the focus needs to be as
much on the ‘hearts and minds’ of staff.
Improve communication and engagement with
staff at all levels, e.g., hold workshops with
staff on their quality priorities to gain “buy-in”.
Simplify the key messages to align with
priorities at a local level.
High
The clinical governance process has
historically been driven “top down” as
the lines of communication between
senior and middle management have
not operated effectively. This was a
consistent theme during interviews and
staff focus groups. The “golden thread”
from Board to ward appears to be
absent.
Quality Goals
Few staff could articulate the
organisation’s quality goals and
priorities. Although posters showing the
quality and safety framework had
recently been displayed across both
hospitals, staff were unsure of their
purpose.
Development of Terms of Reference for
CBU Director’s meeting.
The Trust acknowledged that the plan had
recently been published following
development by clinical leaders and
needed further communication.
The Executive Management Team had
agreed to adopt the UNIPART approach to
provide a structured framework and high
staff engagement process.
Use of information to drive improvements in the quality of treatment and care
KLOE 2 & 3: How is the board using performance information to drive improvements? How does the Trust use information locally?
18
Good practice identified
The Excellence in Safety and Quality Report – April 2013 presented to the Board included a suite of quality indicators in development.
Regular development meetings at the Board level. These meetings are a means of educating the Board on medical matters, for example, the reasons
for serious incidents and never events.
Non-Executive Directors taking on more of a “challenge role” including representation on the Quality Governance Committee.
Outstanding concerns including evidence
Planned improvements
Board Business Intelligence
The Excellence in Safety and Quality
Report – April 2013 presented to
Board and a suite of indicators being
developed. This should support the
triangulation of evidence at Board
level.
Board packs contain a lot of data but little intelligence and assurance
that decisions are sound and that risks are being appropriately
addressed. This makes it difficult to triangulate the information.
There is also a lack of benchmarking data.
The poor quality in reporting is evident in the papers containing
information on serious incidents and “never events”, which do not
explain clearly the trends being seen (a Board report failed to
demonstrate an increase in serious harm being caused), nor the
actions taken to address them. The Board’s Quality report identifies
issues, such as poor mandatory training compliance and review of
mortality rates, but there is no tangible evidence of action taken.
Non-Executive Directors taking on
more of a “challenge role” including
representation on the Quality
Governance Committee.
The Safeguarding report to the Board (January – March 2013) dated
28 May 2013 lacks assurance; delivery against milestones,
identification of gaps and risks and how they will be addressed.
Recommended action
Obtain independent review of
the quality governance
framework to assess all gaps
and implement quality reporting.
Priority – urgent,
high or medium
High
Use improvement science to
define aspirations and
trajectories for improvements in
quality. Report against these.
Ensure that mandatory reports
are received in a timely manner
– for example, Safeguarding,
Infection Prevention & Control
reports. Adhere to board
reporting calendar.
Board reporting has not supported a robust review and challenge of
management and performance by the Board.
Incident reporting
More staff were being trained to
undertake Root Cause Analysis to
Detailed reports on individual incident investigations revealed delays support improved turnaround.
in reporting and investigating, poor quality documentation, and lack
Documents supporting executive
overview of serious incidents,
never events and infection
control, such as C. difficile and
Urgent
19
Outstanding concerns including evidence
of action plans. Some reports were not signed and dated.
In addition, management was unable to furnish these reports
immediately following our request for them suggesting issues in the
timeliness of completion.
Learning from Events
The review team held numerous discussions with staff (including
staff in theatres, on a surgical ward, a maternity ward, a focus group
and senior clinical leaders) which suggested that learning from
serious incidents is still not adequately shared. The review team
spoke to many staff who were not aware of (or could not tell us the
detail of) serious incidents which caused significant harm in their
own departments.
There appears to be a lack of transparency and openness in relation
to sharing learning. At a focus group, and at staff drop in sessions,
staff raised an issue that blame is apportioned when discussing
shortcomings in care.
Planned improvements
At the request of the review team the
Trust has obtained support from
Cumbria CCG and the TDA to work in
partnership with the Trust to enhance
the serious incident investigation
process. This included a review of its
outstanding investigations.
The Trust has established formal
routes for sharing lessons from
incidents throughout the Trust. This
starts with the Clinical Policy Group to
ensure the lessons to be learnt from
either a serious incident or serious
complaint is cascaded via the Clinical
Business Unit Boards. The next stage
in development is the ward managers
meetings to be formal and structured.
Patient safety days involving 100+
staff in teams is another measure to
cascade learning.
Recommended action
Priority – urgent,
high or medium
MRSA, need to explain trends
and actions taken to address
them. This must be supported by
a change in culture around
serious incidents and improved
communications and evidence of
embedded multi-disciplinary
learning via audit.
The Trust should continue to
establish formal routes for
sharing lessons from incidents
throughout the Trust. This may
be through specific forums or by
adding it to the agenda of
existing ward level meetings.
Urgent
The Trust should consider
targeted approaches to training
following never events or serious
incidents occurring within
specialist area, that is, theatres.
Consider using safety
newsletters to feed back learning
and trends.
Staff indicated that feedback is not routinely provided to those
reporting incidents, which could discourage further reporting.
The recurrence of some types or categories of events (for example,
a second retained guide wire, misplacement of naso-gastric tubes
and wrong site surgery) also suggests that the organisation is slow
to learn from serious incidents.
Manual Systems
Adoption of Northumbria IT system
post-acquisition.
Improve communication and
engagement with staff.
Medium
Manual systems are “creating work” and do not provide good data,
20
Outstanding concerns including evidence
for example in the maternity ward. The panel also identified that the
medical engineering IT system is not shared with wards and
departments. Staff have not been informed that the EuroKing system
will be implemented should the acquisition be successful which
would boost morale.
Planned improvements
Recommended action
Priority – urgent,
high or medium
Other options should be
considered to reduce the burden
of manual working.
21
Clinical and operational effectiveness
Overview
The review into clinical and operational effectiveness focused on how the Trust is implementing actions to monitor mortality performance and identify areas where clinical
effectiveness is potentially impacting patient quality and safety, this included the following:

How the Trust reviews deaths to understand if trends can be identified and lessons learned

How clinical effectiveness is monitored

How actions to improve mortality performance are implemented in the Trust
The panel used the mortality and other clinical data in the data pack, as well as other intelligence, for example, that provided by the Cumbria CCG to prepare for the review.
This insight was then used when conducting interviews with management, examining the Trust’s documentation and observing conditions on the wards.
Detailed findings
Governance arrangements for clinical and operational performance
KLOE 4: What governance arrangements does the Trust have to monitor and address clinical and operational performance data at a senior level?
Good practice identified
Improvements to reporting including the introduction of a performance dashboard following the links with Northumbria have improved monitoring of clinical and operational
performance at the Trust.
World Health Organisation checklist safety briefings at Whitehaven main theatres were reported to be working well.
Stroke thrombolysis is supported by telemedicine.
22
Outstanding concerns including evidence
Planned improvements
Recommended action
Limited learning from clinical audits
The Trust had approved the
clinical audit programme for
2013/14 and has approved the
launch of service reviews,
focused on consultant outcomes
and surgical services.
The number of audits conducted
should be reduced, to allow
greater focus on the quality of
the audits conducted, the
outcomes, and the actions taken
as a result.
Nurses reported not fully understanding the purpose
of the audit charts displayed on ward notice boards.
There was limited evidence of actions being taken as
a result of these audits.
The panel observed that the majority of charts on
wards observed at Cumberland Infirmary showed
results of 100% for hand hygiene and infection
control; however, this was neither reflected in the
wider outcomes at the Trust, nor in practice directly
observed by the Keogh review team. The panel was
informed of an instance where results were
manipulated, see below.
Priority – urgent, high
or medium
High
Ensure the plan shows a clear
linkage between the clinical
audit programme and mortality
review.
The Trust should consider a
focused and transparent
publication of results and trends
including within ward areas.
The Trust has approved a clinical audit plan but the
panel were not persuaded this clearly incorporated
mortality review.
Spot checks of local audits
should be undertaken to ensure
accuracy of reporting.
The ongoing appraisal and
supervision processes should be
used to identify and support staff
who do not fully understand the
clinical audit process.
Limited provision of a 24 hour service
The Trust does not provide a 24 hour service in all
cases; several patients that the panel met reported a
delay to their discharge because the relevant service
(for example, a specific nurse practitioner) was not
available that day.
The Trust is challenged by its geography; the two
The Trust recognises the need
for 24 hour services and has
taken steps to reconfigure
services to allow enhanced
support, e.g., vascular and
trauma and acute care
physician model on both
hospital sites.
The Trust should review its
discharge planning to ensure
that this commences on
admission and allows patients to
be discharged on a timely basis.
High
The Trust should consider the
provision of services across its
two sites (including pharmacy,
23
Outstanding concerns including evidence
sites are approximately 40 miles apart. Staff spoke of
examples where on call staff were located at the
other site, and did not have transport to travel
between sites.
Planned improvements
Recommended action
Priority – urgent, high
or medium
physiotherapy and dietetics) to
ensure that there is sufficient
provision of services to allow
timely discharge.
Difficulties were expressed in relation to ambulance
arrangements for taking patients home from the
Emergency Department at West Cumberland,
resulting in unacceptable delays.
There is a lack of a clear process in respect of
Consultant Job Planning and this potentially
compromises efficiency but also affects staff morale.
In addition the arrangements for enhanced appraisal
informing Revalidation were unclear.
Difficulties with bed planning and patient flow at
Whitehaven are compromising the smooth running of
elective surgical lists. Problems with flow also are
reported to result in patients being placed in
inappropriate areas both on the ward and in the
Emergency Department at Whitehaven.
The Trust indicated to the review team that the
Deanery raised concerns about the need for ward
based junior doctor teams and standardisation of the
acute physician model at West Cumberland Hospital
to support better patient care and enhance patient
flow.
Further findings not fully investigated
Due to the length of the visit and the number of matters identified, the panel did not have the opportunity to fully investigate all issues identified. These additional matters are
listed below. We recommend that the Trust reviews these matters further:
24

A Link Nurse reported being told by the Infection Control Team to exclude doctors from an infection control audit because they were lowering the
results. A member of staff reported only putting results up on wards once 100% compliance was reached.
Monitoring mortality and clinical effectiveness
KLOE 5: What processes does the Trust have in place to support monitoring mortality data and clinical effectiveness?
Good practice identified
Trust Board receives monthly updates on mortality through the Safety, Quality and Patient Experience Report.
The Trust requested a review of mortality by the Advancing Quality Alliance (AQuA) which reported in December 2012.
The creation of a ‘Harm Group’ in line with governance arrangements at Northumbria Healthcare NHS Foundation Trust.
Outstanding concerns including evidence
Planned improvements
Recommended action
Quality of review of all deaths in financial year 2011/12
Themes identified from this review
have been used to update the
Trust’s mortality framework. An
action plan linked to the four themes
(clinical care, leadership & reporting
culture, improved use of clinical
information and improved
identification and care for dying
patients) is now being implemented
by the Trust.
Ensure all staff using the IHI GTT for
future case note reviews receive the
appropriate training.
The Harm Group conducted a review of 1,150 case notes
from 1,200 deaths in financial year 2011/12. This review was
conducted using a locally devised audit tool and the IHI GTT.
The use of the IHI GTT requires specific training; the review
team has not identified evidence to show that the staff
performing this review have received the necessary training.
Consequently, the quality of the review, the themes identified
and the actions devised may not be of sufficient quality to
improve care at the Trust, or reflect the amount of resources
committed to the project.
Priority
(urgent, high or medium)
High
Consider using the GTT as a metric
for a cross section of patients who
have been discharged.
Consider using external experts to
perform reviews of specific
diagnoses subject to mortality alerts.
Staff raised concerns about the experience and independence
of the individuals performing the review. All reviews were
conducted by individuals working at either North Cumbria or
Northumbria, and were not performed by specialists in that
25
area (for example, using a paediatrician to perform a review of
adult case notes).
There has been no specific recent review of diagnostic groups
associated with high mortality indicators, nor are the
arrangements for regular, clinician led mortality review in
place. There appears to have been an over reliance on the
initial mortality review detailed above.
Engaging with stakeholders on the QIPP agenda
KLOE 6: How does the Trust work with stakeholders on the QIPP agenda?
Good practice identified
Introduction of the National Early Warning System (NEWS) to identify and escalate deteriorating patients.
Introduction of the Sepsis 6 bundle in response to the AQuA review of mortality.
Within Paediatrics at the Carlisle site, the ward environment was good and recent reviews by the Neonatal network team were noted. Consultant cover was good at West
Cumberland but concerns were raised regarding a need for 24/7 Nurse practitioner presence.
Outstanding concerns including evidence
Planned improvements
Recommended action
Lack of staff confidence in the introduction of the
National Early Warning System (NEWS)
NEWS training continues across the
Trust to improve engagement, skills
and buy-in. Monthly audits of the
use of NEWS have been reported to
the Trust Board since April 2013;
and further training of doctors
initiated as a result.
All relevant staff who have not
received training on NEWS should
receive this training as a matter of
urgency.
The Trust introduced the NEWS system in 2013 to better
identify and escalate deteriorating patients. The introduction of
the system aimed to strengthen clinical effectiveness in the
Trust.
Priority – urgent, high or
medium
Urgent
The ongoing appraisal and
supervision processes should be
used to identify staff lacking
26
Outstanding concerns including evidence
Planned improvements
Staff expressed concerns about the use of this system,
specifically related to the training received. Staff reported
uncertainty regarding the escalation procedures for acutely
deteriorating patients at both sites.
A Deterioration group met in April.
Some consultants commented that they were being alerted
too often, and that the system lacked the flexibility to escalate
concerns for patients who were already acutely ill, but then
deteriorated further.
Recommended action
Priority – urgent, high or
medium
confidence in using NEWS, who
should be provided with further
The
planned
improvements training and development
expected of the consultants and the opportunities.
ward managers were set out in a
letter by the Medical Director and Measure number of patients being
the Director of Nursing.
admitted to intensive care from ward
and the reason for the transfer to
inform outreach team
The panel observed examples of patient notes where
observations had not been conducted on a sufficiently regular
basis in line with NEWS guidelines. This was linked to low
staffing levels on wards.
Intensive care still reported many patients being transferred
from wards unexpectedly which suggest the system is not yet
embedded.
The escalation process for the deteriorating patient was not
observed to be consistent.
Ventilator acquired pneumonia
Urgent
Compliance with the VAP care
bundle should be prioritised, and
compliance monitored.
The panel was concerned to note several cases of ventilator
acquired pneumonia (VAP) and were not assured that this
was being afforded appropriate priority in respect of ensuring
compliance on the Intensive Care Unit at West Cumberland
with the VAP care bundle.
Pace of change in introducing pathway to improve patient
care
As a result of the AQuA review of mortality (report published
in December 2012), a number of projects have been
The Trust is in the process of setting
up a group to co-ordinate and
monitor these actions, which will
report to the Governance & Quality
Committee and to the Clinical Policy
The new group should ensure that
staff are held to account for the
completion of all actions identified,
including the introduction of relevant
pathways in the shortest possible
High
27
Outstanding concerns including evidence
Planned improvements
Recommended action
developed to improve quality of care. However, there is limited
evidence that many of these have been introduced at the
Trust, for example, the Sepsis 6 bundle is the only care
pathway to have been introduced as at the date of the review.
Group.
timeframe.
Priority – urgent, high or
medium
The Trust may not have the capacity to make changes at the
pace required to improve patient safety.
Purchased equipment is not used to improve patient care
None identified.
A blood gas analyser that had been purchased for the A&E in
Whitehaven had not been brought down from storage and set
up in the department. There was no alternative blood gas
analyser in the department, and consequently patients were
waiting for tests to be conducted elsewhere in the hospital.
Urgent
During our review we recommended
that management immediately
implement the blood gas analyser in
A&E and check for other missing
equipment.
Further findings not fully investigated
Due to the length of the visit and the number of matters identified, the panel did not have the opportunity to fully investigate all issues identified. These additional matters are
listed below. We recommend that the Trust reviews these matters further:

There is a lack of an epidural service at Carlisle, although this is in place at Whitehaven.
28
Patient experience
Overview
The two KLOEs in this area consider how the Trust engages with patients and how it is responding to the challenges relating to the duty of candour. This KLOE was tested by
speaking to patients and family on wards (where appropriate) and during the patient / public listening events.
It looks at how the Trust deals with complaints and how it responds to emerging issues were explored during these sessions, as well as interviews with management.
Detailed findings
Engagement
KLOE 7: How does the Trust engage with stakeholders?
Good practice identified
The Trust reported using patient stories to feedback to staff, for example, a serious complaint from a senior clinical professor was videoed with his consent and played back
to staff during Chief Executive road shows. The governance team informed the panel that the whole team was taken out (nurses and doctors) for reflection and the
establishment of an action plan to address the issues.
The review team met many caring staff whilst at the hospitals in Whitehaven and Carlisle, who are passionate, committed and want to do the best they can to care for their
patients, albeit under frequently challenging circumstances. This was confirmed by stories from patients which described excellent care provided by the Trust, although
many patients also recognise the low staffing levels.
Several patients’ families spoke highly of the care given by staff at the public events.
There was evidence of staff obtaining and using patient feedback. For example, there were “experience rating” boxes up on the walls of both A&E departments and staff in
the A&E at Carlisle described (and showed) how they had used patient feedback to obtain a water cooler for the department and clocks for each of the cubicles.
Outstanding concerns including
evidence
Poor Communication
A recurring theme from engagement
Planned improvements
Recommended action
Following a serious complaint with this Identify leads to address issues with
theme at the centre of the complaint, the communication to patients.
Trust Board and the Clinical Business Unit
Priority – urgent, high or
medium
High
29
Outstanding concerns including
evidence
with patients and the public was poor
communication, for example patients
not being fully informed of potential
complications, relatives not being told a
patient was transferred to another ward,
poor communication to patients
awaiting transfer from one site to
another and delays in informing GPs
about a patient’s death so that the
family could be informed. The Quality
Report presented to the March Board
showed 30 complaints relating to
communications.
Planned improvements
Recommended action
Priority – urgent, high or
medium
Directors agreed with the complainant to Further enhance communications team,
produce a DVD of the story and share this potentially with support from Northumbria.
with staff via the staff road-shows, cascade
to every ward and service management
meeting and report feedback and action
that they were taking to the Trust Board in
June 2013. It was arranged for the clinical
team to have time out in April to consider
the experience of the patient and what
systems, processes and behaviours
needed to be improved to affect a better
outcome and experience. It is planned to
present this to the Trust Board in May.
During the review, there was evidence
of excellent staff communication around
moving trauma, vascular and elective
orthopaedics.
Delayed Discharge
The review team observed delays in
care pathways which resulted in
patients being kept on wards
unnecessarily; for example, patients
delayed as prescriptions were not
available due to reductions in pharmacy
hours. It was recognised that discharge
was being impacted by lack of support
from the wider health and care system
There is a service improvement plan and
this is reported to the Trust Board and has
been shared with stakeholders with the
intention to transform the system to support
patient flow. In the meantime, the Chief
Executive newsletter confirms the
improvements planned to enhance
discharge planning, including appointment
of two additional pharmacists.
Care pathways should be reviewed to avoid
delayed discharges.
Outpatient services could support specialist
nurse follow up rather than delay discharge.
A system wide action focused, approach
needs to be developed to ensure a pull
through approach is adopted to reduce
pressures on the acute Trust
Ward Environment
The environment at Whitehaven (in
High
Medium
The Trust plans to implement the “15 steps” Rectify major issues and quick wins (for
30
Outstanding concerns including
evidence
particular Jenkin and Kirkstone wards
visited) is not conducive to a positive
patient experience – overly clinical and
drab, cluttered, there are large chips
missing from some wall surfaces, and
painting is needed in some areas.
Planned improvements
Recommended action
methodology on ward visits – this is
something that Northumbria has
undertaken.
example, de-cluttering wards) ahead of
completion of the redevelopment at
Whitehaven.
Priority – urgent, high or
medium
Implement focused deep clean and ward
maintenance programme annually.
Further findings not fully investigated
Due to the length of the visit and the number of matters identified, the panel did not have the opportunity to fully investigate all issues identified. These additional matters are
listed below. We recommend that the Trust reviews these matters further:

One observation noted inappropriate behaviour from junior doctors and cleaning staff using inappropriate language. This suggests a lack of consideration for patients.

We were informed of instances where Pharmacy staff on call sometimes could not drive making cross-site working a challenge and delaying dispensing of take home
medications.
Duty of candour
KLOE 8: How is the Board responding to the challenges relating to the duty of candour?
Good practice identified
None identified.
Outstanding concerns including
evidence
Planned improvements
Recommended action
Transparency
None identified.
The Trust should review how it is fulfilling its
duty to demonstrate candour.
There is a lack of openness from the
Trust in its communications to patients
Priority – urgent, high or
medium
Medium
Quality performance metrics should be re31
Outstanding concerns including
evidence
Planned improvements
and the public as evidenced through
the patient public listening events.
Complaints Handling
The Trust does not have sufficient
resources to deal with the current level
of complaints on a timely basis. Of the
23 complaints closed in March, 14
(61%) were over 30 days old. It is not
clear whether there is an understanding
of key themes from complainants, and
a robust triangulation of data on
complaints, incidents and litigation.
The Trust is failing to meet the 25 day
target in responding to complaints.
Recommended action
Priority – urgent, high or
medium
developed and displayed within ward areas,
with staff fully engaged and owning
improvement.
None identified.
Compare complaints, incidents and litigation,
to identify themes and/or common problem
areas on an on-going basis.
High
All complaints should be responded to within
the 25 day target.
Further findings not fully investigated
Due to the length of the visit and the number of matters identified, the panel did not have the opportunity to fully investigate all issues identified. These additional matters are
listed below. We recommend that the Trust reviews these matters further.

Several patients at the listening events reported that delays in outpatient clinics are not communicated during the clinic and that this was unacceptable. It is common
practice in many organisations to have a Whiteboard with any current delays in outpatient clinics shown in real time to inform patients of likely delays.
32
Workforce and safety
Overview
We sought to understand the Trust’s workforce strategy in the context of the review, and themes from staff engagement, through a review of data on staffing, the staff survey,
interviews with management and numerous discussions with staff at focus groups, drop-in sessions and on wards. We were also able to observe actual staffing levels and mix
on ward observations.
Given concerns raised by staff in areas affecting patient safety, we expanded our focus on safety issues such as infection prevention and control and equipment maintenance
during the review process.
Detailed Findings
Key themes from staff engagement
KLOE 9: What are the key themes from staff engagement by the Trust?
Good Practice identified
The governance team interviewed explained that regular ward walk-arounds by Executive and Non-Executive Directors had been implemented over the past year. Every
month prior to the public Board, two non executive directors perform a walk-around / visit of departments, and observations are fed back in the public Board. For example,
poor lighting has been raised twice, prompting a full lighting audit to be done at the site and clutter was also observed at a falls hotspot. Improvements to address the latter
were fed back at the following Board meeting.
Staff that we spoke to at Cumberland Infirmary commented that communication has improved with the new interim Chief Executive, and that a “can-do” attitude is being
conveyed from the top. Staff felt that patient care is beginning to emerge as a priority, whereas historically financial issues seemed to take precedence.
The medical staff handover observed at West Cumberland Hospital was positively reported on by the panel and morale amongst the junior doctors appeared good and
doctors reported that generally they were well supported by their Consultants.
The Trust had a planned strategy to reduce locums and increase substantive appointments for medical staff as part of its drive to improve quality and reduce costs.
33
Outstanding Concerns including evidence
Planned improvements
Recommended Action
Staffing Levels
The Trust has introduced a
‘bench’ of staff to be accessed
by wards and departments who
require urgent access was noted
as good practice, but staff
expressed that in some areas
these had ‘been swallowed up’.
During our review we recommended to management
they urgently address cases where staffing was at 1-1
(or planned to be at 1-1) overnight: stroke / cardio at
WCH, ITU at WCH and renal ward at CIC. The Trust
needs to urgently review its staffing levels, including
the ratio of qualified registered nursing staff to nonqualified. This needs to be done in light of the Francis
report and the overall quality agenda.
Staff at both Cumberland Infirmary and West Cumberland
Hospital spoke about inadequate nurse and medical staffing,
especially out of hours. This was evidenced through a
review of ward staff rotas and staffing audit charts whilst onsite (for example in the Emergency Assessment Unit and
stroke/cardio ward at West Cumberland Hospital, and on the
renal ward at Cumberland Infirmary), and by information
provided which indicated low medical cover of some areas,
including acute physician cover and the vascular rota. Staff
at both sites reported working a significant amount of
overtime, and during the unannounced visit we spoke to
members of staff who were still working several hours after
their shift had ended due to low staffing levels on the
following shift. They also reported an inability to take breaks
at night.
This is upheld by the information in the data pack reflecting a
red flag for FTE nurses per bed day.
The CEO has ‘unblocked’
nursing vacancies since her
appointment, but the full impact
of this had not yet been felt due
to delays in appropriate staff
applying and recruitment
processes (i.e. CRB check).
The Trust is working with the
TDA to ‘refresh’ the nurse
staffing strategy.
Priority –
urgent, high
or medium
Urgent
An investigation into the link between serious
incidents, such as pressure ulcers and falls, and
staffing levels is required.
An assessment of imminent staffing pressures should
be undertaken.
The Trust needs to investigate the impact that
overtime working is having on staff and patient safety.
The role of the housekeeper has brought benefits to
other Trusts in the areas of maintenance, infection
control and to relieve nurse staffing pressures.
Management should consider this role in reviewing its
workforce.
The review team was also informed of an impending crisis in
Maternity due to several Consultant retirements planned for
this summer.
Several patients at both public events commented on a
detrimental effect staffing is having on care, as did several
senior clinicians, nursing and medical.
Over-reliance on Locum Staff
There is an over-reliance on locum appointments at middle
grade and consultant level, evidenced by the Trust’s spend
The Trust is planning to increase
its number of substantive
appointments in a number of
areas as part of a recruitment
Priority over recruitment including appropriate
induction needs to be given in consultation with the
wider health economy and stakeholders.
Urgent
34
Outstanding Concerns including evidence
Planned improvements
on locums and feedback from staff.
drive and help deliver financial
savings.
General Medicine and Acute General Medicine at
Whitehaven Hospital are a particular and relatively urgent
cause for concern. There is a high dependence on locum,
very few substantive posts and the existing substantive staff
have concerns regarding proposed arrangements for crosscover from Carlisle. All of the medical registrars working out
of hours at the Whitehaven hospital are reported to be
locums.
Recommended Action
Priority –
urgent, high
or medium
The Trust is working
collaboratively with Northumbria
to ‘fast-track’ consultant
appointments and had recently
been successful in making some
senior appointments but these
had not yet started,
There is poor evidence of adequate locum induction, training
and appraisal.
High locum dependency can have a negative impact on the
quality of patient care, is costly and likely to prolong
admissions, further aggravating problems with patient flow
most particularly at Whitehaven.
The review team note actions by the Deanery to address
complaints around lack of supervision have meant junior
staff were removed in some areas. This has exacerbated the
medical staffing problem.
Mandatory Training
Several staff at each site reported that they do not have
sufficient time to complete mandatory training – this is
confirmed by the low compliance with mandatory training
shown in a quality report to the Board – meaning that
staffing shortfalls are having a compounding effect on risks
to patient safety. Staff also feel that they have lost access to
important face-to-face training, which can be more effective
than e-learning. For example, fire safety training is
performed via e-learning, meaning staff do not have the
opportunity to practice evacuating patients.
Adopting Northumbria
The Trust should urgently address these training
recruitment process which
shortfalls and reconsider its methods for the delivery
of training.
should result in increased
staffing levels freeing up staff
time to undertake mandatory
training. For example, the Trust
had funded and had a
recruitment process in place for
two new posts, a Fire Officer and
a Resuscitation Training Officer.
Urgent
35
Outstanding Concerns including evidence
Planned improvements
Recommended Action
Priority –
urgent, high
or medium
Training in other staff groups such as estates and medical
engineering is lacking (for example, no-one is qualified to
undertake revalidation of medical equipment) and staff on
wards have reported no formal training on medical
equipment, for example, renal dialysis.
Appraisal Compliance
None identified
Appraisal rates are variable. Although this has been
recognised as a high priority by the Interim Chief Executive.
Clinical Business Unit Directors and Deputy Directors
confirmed their trajectories; staff reported that appraisals
were not being done properly, but rather as a tick-box
exercise to get the numbers up.
Staff Support
Openness and support needs to be driven from senior and
middle management. Discussions with staff suggest that
they do not feel supported, and in many cases, intimidated
and bullied (the Trust was in the worst 20% for staff bullying
according to the latest staff survey); nor do they seem to be
receiving effective communication.
Bullying and harassment is also referred to repeatedly in a
Deanery report of Feb 2013.
The review team were also provided with evidence of three
staff allegations around potential racism.
At both sites, some staff requested we shut windows when
talking to them in private drop-in sessions – suggesting fear
in speaking openly about issues. Others were visibly upset.
The Trust is currently consulting
on a revised strengthened
management structure which
includes operational managers
and matrons
Appraisals are an important part of staff development
and should be meaningfully undertaken by all grades.
The Trust should endeavour to measure the quality of
appraisals alongside actual rates undertaken.
High
Serious concerns around bullying and potential racism
need to be addressed through implementation of
diversity type training.
Urgent
Communication between all levels of staff needs to be
improved and the Trust should explore other
opportunities for communication such as “screen
saver” message boards and directed newsletters if not
already doing so.
Although staff recognise the potential benefits of the
impending acquisition by Northumbria, the review
team detected some sceptism, and it will be extremely
important not to let staff feel disengaged and
disempowered in the process. Due consideration
should be given to different models and ways of
working, whether the Northumbria way or something
else.
Nurses reported they are struggling to escalate acute
36
Outstanding Concerns including evidence
Priority –
urgent, high
or medium
Planned improvements
Recommended Action
None identified
The review team recommend standardising uniforms
within and between hospitals to help create a common
identity for staff.
staffing shortfalls – a number of staff reported they were
directed by the bed management team to find staff
themselves to close the gaps, but this meant that more time
was taken away from patient care.
Staff Identity
There was inconsistency in the wearing of nursing uniforms
leading to a lack of clarity of “who was who” on wards.
Workforce strategy
KLOE 10: Describe the Trust’s workforce strategy
Good practice identified
The Trust is actively recruiting to key medical and nursing posts and attempting to consolidate a significant number of locum posts into permanent posts across a range of
disciplines – this is evident from its Cost Improvement Plan (CIP) for 2013/2014.
The Trust is linking with Northumbria to fast track appointments as the Trust has a lag in obtaining approvals when they recruit on their own. They have recently made
“some good” medical appointments, but the doctors are not yet in post.
Outstanding concerns including evidence
Planned improvements
Nursing Review
The Nurse Director is now working
closely with the TDA to undertake a
refreshed staffing review.
The review team was provided with a report on a nursing and
midwifery review which has recently been performed by
management. However, it was inadequate in that it did not offer
Recommended action
In light of the Francis
Report, the Trust needs to
urgently review the nursing
workforce strategy in line
with patient acuity
Priority – urgent, high or
medium
Urgent
37
Outstanding concerns including evidence
Planned improvements
assurance and demonstrate due thought to the changes that
are being made. It was difficult to properly assess the impact of
the changes. The length of time this review has taken has
seriously impacted staff morale. The NHS staff survey reflects
that the Trust is in the bottom 20% of acute trusts for both
morale and staff engagement, although there has been no
significant movement in these results over the past two years.
Recommended action
Priority – urgent, high or
medium
measures, RCN guidance,
professional judgment and
ward geography.
Cost improvement plans
KLOE 11: What is the Trust’s process to assess the impact of cost savings plans on quality of patient care and its workforce?
Good practice identified
Following an external review of the Trust’s CIP process a safety/quality assurance process was implemented whereby CIP plans were signed off by the Trust’s Director of
Nursing and Chief Medical Officer.
CIP plans for 2013/14 are focused on consolidating locum costs into substantive appointments which should improve the quality of care.
The Trust Board has approved a process for 2013/14 by which each CIP has a clinical lead and is signed off by the Medical Director and Director of Nursing.
Outstanding concerns including
evidence
CIPs
A review of the Trust’s information
indicates that significant cost savings
were being made at the Trust partly
through consolidating locum costs into
Planned improvements
Recommended action
Business case presented to Board on erostering to improve the safe management
of rotas.
The Implementation of a robust PMO
arrangement to oversee the Trust’s CIP plan
needs to retain its high priority.
Priority – urgent, high or
medium
High
The Board considered the CIP in March
and views of the Medical Director and
38
substantive posts. Consequently, there
should be no impact on front-line staff.
However, recruitment of staff is an
issue which may adversely impact on
these planned savings.
A PMO has been in place for eighteen
months but has not delivered effectively
Director of Nursing have been taken on
clinical safety.
CIP plans for 2013/14 are focused on
consolidating locum costs into substantive
appointments which should improve the
quality of care.
The Trust is refreshing the PMO function.
Other Trust Specific Issues
Estates and equipment
Outstanding concerns including
evidence
UCV Theatres
The Trust failed to respond on a timely
basis to a report that its ultra-clean
ventilation (UCV) theatres at the
Whitehaven site were not meeting
relevant standards, and could not
provide evidence that other operating
theatres had been adequately tested.
There was no planned maintenance
programme for all theatres.
Planned Preventative Maintenance
Planned improvements
Recommended action
Two UCV operating theatres at Whitehaven
were closed by the Trust during the review,
and an urgent, independent review
performed of all others.
The Trust urgently needs to gain assurance of the safety
over all other operating theatres, treatment rooms,
endoscopy suites and interventional diagnostic suites
(such as Catheter labs or interventional radiography
rooms).
A further member of staff has been given
an Honorary Contract with the Trust to
oversee the programme of works to the
theatres at WCH and CIC
The Trust has seconded a member of staff
from Northumbria as Interim Director of
Priority – urgent,
high or medium
Urgent
The Trust have shut theatres 4 and 5, prior to setting back
in use, it is recommended that a full compliance audit is
undertaken, remedial actions executed where possible,
mitigations agreed with the DIPC, due to the lack of
perceived baseline, it is recommended that exceptionally
microbiological plate testing of these theatres is executed
once remedial actions are completed.
An urgent external review of the estates
department should be undertaken to ascertain their
professional, management and technical competence and
Urgent
39
Outstanding concerns including
evidence
Priority – urgent,
high or medium
Planned improvements
Recommended action
A review of the Trust’s planned
preventative maintenance programme
indicates that it has been severely
reduced over recent years resulting in
the poor condition of the estate
especially at the West Cumberland
Hospital. This raises serious concerns
over the Trust’s ability to keep the
estate fit for purpose until the
completion of the redevelopment due to
limited capital expenditure.
Estates and Facilities for two days a week.
capability. At the same time the Trust should execute a
statutory compliance review covering as a minimum;
 Water systems
 Asbestos management
 Electrical systems
 COSHH & PPE
 H&S
 Pressure and Gas systems
 Medical Gas systems
 Ventilation systems (Clinical and non clinical)
 Sterilisers
Medical Equipment Compliance
Standards
Accenture appointed to explore cost
investment opportunities.
The Trust should undertake an in depth review to
develop and or validate a risk based medical device
management system and replacement programme, to
include a review of compliance with MRHA DB 2006
(05), (note: it is likely that this will be replaced in replaced
in Jun 13 with a suite similar to CFPP for
decontamination) and MDD 93/42 EEC.
High
The Trust is out to recruit a fire safety
officer at this time
An ongoing and robust review of the Corporate Risk
Register should be in place to ensure key risks are
identified and mitigated through robust action plans which
are monitored and reported on.
Urgent
Assurance could not be provided that
key medical equipment was in
compliance with HTM guidance. Key
equipment such as the Trust’s renal
dialysis machines are reaching the end
of their useful economic life.
The review team saw medical
equipment that was labelled as being
beyond its servicing date, and staff
reported that labels were sometimes
placed on equipment without it being
properly tested or serviced.
Fire Safety
There are fire safety concerns
expressed by staff at the renal ward in
Carlisle – apart from there being only elearning on fire evacuation training,
40
Outstanding concerns including
evidence
Planned improvements
Recommended action
Priority – urgent,
high or medium
there is a fire hazard from clutter and
staff are unsure of how to get a bed
downstairs. General concerns were
raised within the Corporate Risk
Register which states no fire safety
officer in post on one site and no
evacuation training.
Further findings not fully investigated
Due to the length of the visit and the number of matters identified, the panel did not have the opportunity to fully investigate all issues identified. These additional matters are
listed below. The review team recommend that the Trust reviews these matters further.

The Board were presented with a “97% compliance rate” on estates, but there was no information or challenge given around the remaining 3% and there are
concerns that they represent serious gaps. An independent review of estates, including equipment maintenance, needs to be performed to identify the significant
gaps in this area.
41
Infection and prevention control practices
Good practice identified
Improvements to the governance and implementation of infection control have recently been made or are planned, for example, a new DIPC has been appointed and the
Chief Executive has been appointed as Chair of the Infection Control Committee. Cleaning products are under review.
Outstanding concerns including evidence
Planned improvements
Recommended action
IPC Training
A new DIPC has been
appointed (but this is not a
member of the Board). All
processes and policies are
planned to be reviewed.
Training on infection and prevention control
should be undertaking supported by an
awareness campaign throughout the Trust.
There is a lack of training on infection prevention and control
evidenced by a lack of understanding and appreciation of audits
by staff.
The review team observed a number of senior and junior
medical staff who were not bare below the elbows, and spoke
to junior doctors who were unfamiliar with Aseptic No Touch
Technique (ANTT) training.
Nurses were in some areas in West Cumberland Hospital
retaining buckles as part of their uniform. This is widely
accepted as poor infection control practices.
Deep Cleaning
Whilst the panel were informed there is a deep cleaning team in
place, including a rapid response team with a rolling deepcleaning programme, there was both ingrained dirt and dust on
surfaces in the wards and corridors the review team visited at
the Whitehaven site. The review team observed numerous
cluttered wards e.g. Elm and Beech Wards which would make
proper cleaning difficult.
Whilst the panel acknowledge that there is currently a
Terms of reference for the
IPC committee have been
drafted and this will be
chaired by the CEO to add
drive.
Priority – urgent,
high or medium
High
The uniform policy should be updated with
specific reference to buckles and bare below
the elbow. This should be robustly
implemented with strong support for challenge
across the organization.
The Trust has received
support from the TDA to fasttrack these improvements.
None identified.
A further review needs to be performed by a
specialist in healthcare cleaning, supported by
a decontamination expert and ICT nurse
specialist, with a view to developing a formal,
annual deep-clean programme supported by
input from the IPC team and estates.
High
Given the amount of redevelopment going on
at the site, the estates team should review the
asperguillus policy and management
arrangements and agree with the DIPC a new
42
Outstanding concerns including evidence
Planned improvements
An urgent de-clutter amnesty needs to be
granted followed by a monthly refresh.
None identified.
The Trust should review the operational policy
for HPV fogging and agree with the DIPC a
deployment process and trigger point. The
Trust should focus this deployment, in a
careful and structured way to optimise the
benefit against cost.
High
None identified
Compliance reviews of all Trust policies should
be undertaken by an independent body e.g.,
internal audit.
Medium
HPV Fogging is not used in a structured and coordinated way.
Compliance with Policies and Procedures
Priority – urgent,
high or medium
policy.
redevelopment programme underway at the site, the review
team note that there are compromised surfaces which could
negatively impact on the prevention and control of infection.
HPV Fogging
Recommended action
There are weaknesses in content, knowledge and compliance
of the antibiotic prescribing policy. There is also a lack of use of
antibiotic prescribing charts. Panel members also observed a
general lack of internal compliance reviews for procedures such
as DNACPR (Do Not Attempt Cardiopulmonary Resuscitation),
quality of internal note keeping, serious incidents etc.
The antibiotic policy needs strengthening and
re-launching with clear audit of compliance and
accountability frameworks
Whilst on-site the review team recommended to management
that all drug storage should be urgently secured, as examples
of unlocked fridges and drugs fridges that contained food and
drink were found. Security of drugs needs to be audited
frequently.
Bed Proximity
There are beds that are too proximate in wards at the Carlisle
site, especially the stroke unit (Elm A).
None identified
Review of beds on all wards should be
undertaken to ensure patient dignity and
effective space utilisation/reconfiguration.
Medium
43
Outstanding concerns including evidence
Planned improvements
IPC Learning
The Chief Executive has
sought the support of the
Intensive Support Team and
they had arranged a visit to a
best practice site in April
resulting in the Trust Board
approving a new service
improvement plan in
recognition of the absence of
a robust plan for the past
three years.
Reports provided by the Director for Infection Prevention and
Control (DIPC) showed that the improvement rate over the past
three years is not evident. For example, the C. difficile rates
have not improved for the last three years, even though for two
of those the Trust was below trajectory. The rates over this time
have remained between 50 and 60 cases. The report offered no
assurance that there is true learning or that in the past the
clinicians have been held to account or been involved in the
Root Cause Analysis. There is also a lack of benchmarking and
looking at what other Trusts have done outside of Northumbria.
Recommended action
A review of infection control practices should
be undertaken and a more multi-disciplinary
approach needs to be adopted including more
involvement from estates.
Priority – urgent,
high or medium
High
44
5. Conclusions and action plan
Conclusions
This is a Trust undergoing multiple changes at Board and executive level with a new Chair appointed in February 2013, an interim Chief Executive seconded from
Northumbria University Hospitals NHS FT in September 2012, a Director of Transformation also seconded from Northumbria University Hospitals NHS FT, and an interim
Director of Finance who started in November 2012. The Director of Nursing has been acting up and the current Medical Director is due to step down in the near future.
Whilst the leadership team is undergoing change, the members of the Trust Board need to ensure that remain focussed on delivering significant improvements in patient
safety and quality and that the pace of change which is required to deliver on the quality agenda has to be stepped up. The Trust has been under scrutiny for an ongoing
period and has undergone a number of reviews. As a result, the Trust has generally been reactive rather than proactive in dealing with issues and staffing levels including the
use of locums and agency staff has meant staff morale has suffered. Two significant areas to enable improvement at the Trust is, firstly, a period of stability and an increased
focus on safety and quality at the Board and Executive level and, secondly, the acquisition of the Trust by Northumbria University Hospitals NHS FT would provide further
impetus to the pace of change required.
The Trust operates two District General Hospital sites each with their own extreme service pressure. Cost Improvement Programmes have undoubtedly impacted the quality
and safety of patient care and urgent attention is needed to readdress the impact of these programmes and where necessary reverse decisions around capital expenditure
and investment in the sites. The Trust have embarked on a major redevelopment of the West Cumberland Hospital site but there are immediate concerns over the
maintenance of existing medical equipment and the existing site as being fit for purpose.
The review identified some areas of good practice, although these generally related to specific areas, wards or specialities. Therefore there is more for the Trust Board to do
in ensuring good practice consistently across all of the Trust, all of the time. Our review also identified a number of areas of outstanding concern across all key lines of
enquiry. For some of the areas of concern, a number of improvements were identified that are already underway at the Trust or planned improvements evidencing the Trust’s
desire for progress and improvement, however, there remain a significant number of areas where improvements need to be made. Some of these require support and advice
from the wider health economy including stakeholders such as the TDA, CCG and CQC. Further recommended action for each area has been included and prioritised as
urgent, high, medium or lower priority.
45
Action Plan
This section summarises the immediate actions arising from the review.
High Priority actions for consideration at the Risk Summit
Problem identified
Recommended action for discussion
Support required by the Trust
1. Inadequate governance, and pace and focus
of change to improve overall safety and
experience of patients
a. Urgent review of the Trust’s Corporate Risk Register
(CRR) and Board Assurance Framework (BAF).
b. Full, independent review of quality governance identify
areas for improvement and develop an action plan.
c. Review of the leadership structure to ensure that the
capability and capacity gaps are filled.
d. Implementation of a formal programme of
organisational development and support for
management staff. Implementation of appropriate
performance management system.
e. Dedicate more time to quality at Board meetings.
To be discussed at the risk summit
2. Slow and inadequate responses to serious
incidents and a culture which does not support
openness, transparency and learning
a. Develop the serious incident investigations process,
including a review of all outstanding investigations.
b. Increase resources in the complaints team to ensure
that all complaints are appropriately responded to within
25 working days.
To be discussed at the risk summit
3. Staffing shortfalls and other workforce issues
across both nursing and medicine which may
be compromising patient safety
a. Staffing arrangements in the Trust should be urgently
reviewed to ensure they meet minimum standards. Any
review should be concluded rapidly to minimize the
impact on staff morale.
b. Staff should be allowed time to complete mandatory
training.
c. Mandatory training programmes should be revisited to
include a face-to-face element where appropriate.
To be discussed at the risk summit
4. Lack of support for staff and effective, honest
communication from a middle and senior
management level
a. Increased emphasis on an open, honest and supportive To be discussed at the risk summit
culture throughout the Trust.
b. Introduce a development programme for senior and
middle management.
46
5. Failure in governance to ensure adequate
maintenance of the estate and equipment
a. Urgent review of the estates department to ascertain
competence and capability, including an assessment of
current arrangements relating to water management
and equipment maintenance.
b. Independent assessment of all theatres for compliance
with relevant standards.
c. Urgent review of the Trust’s compliance status for the
SSD and endoscopy, involving the DIPC.
d. Governance arrangements for decontamination should
be reviewed, and form an integral part of the Infection
Control Committee agenda.
e. Implement a formal, annual deep clean programme.
To be discussed at the risk summit
6. Significant weaknesses in infection control
practices
a. A review of infection control practices including the
infection control policy, implementation, governance
and audits.
b. Adopt a more multi-disciplinary approach to infection
control, including more involvement from Estates,
c. De-clutter wards to allow better cleaning and an
improved patient environment.
d. Urgently secure all drug fridges, and ensure food and
drink are stored separately from drugs. A regular audit
programme should be introduced to monitor this.
To be discussed at the risk summit
Other areas for action in the medium to long term by the Trust
Although staff recognise the potential benefits of the impending acquisition by Northumbria, the review team detected some scepticism, and it will be extremely important not
to let staff feel disengaged and disempowered in the process. Due consideration should be given to different models and ways of working, whether the Northumbria way or
something else.
Identify leads to address issues with communication to patients in each area.
Compare complaints, incidents and litigation, to identify themes and/or common problem areas on an on-going basis.
47
Appendices
48
Appendix I: SHMI and HSMR definitions
HSMR definition
What is the Hospital Standardised Mortality Ratio?
The Hospital Standardised Mortality Ratio (HSMR) is an indicator of healthcare quality that measures whether the mortality rate at a hospital is higher or lower than you would
expect. Like all statistical indicators, HSMR is not perfect. If a hospital has a high HSMR, it cannot be said for certain that this reflects failings in the care provided by the
hospital. However, it can be a warning sign that things are going wrong.
How does HSMR work?
The HSMR is a ratio of the observed number of in-hospital deaths at the end of a continuous inpatient spell to the expected number of in-hospital deaths (multiplied by 100)
for 56 specific groups (CCS groups); in a specified patient group. The expected deaths are calculated from logistic regression models taking into account and adjusting for a
case-mix of: age band, sex, deprivation, interaction between age band and co-morbidities, month of admission, admission method, source of admission, the presence of
palliative care, number of previous emergency admissions and financial year of discharge.
How should HSMR be interpreted?
Care is needed in interpreting these results. Although a score of 100 indicates that the observed number of deaths matched the expected number; in order to identify if
variation from this is significant confidence intervals are calculated. A distribution model is used to calculate 95% and 99.9% confidence intervals and only when these have
been crossed is performance classed as higher or lower than expected.
SHMI definition
What is the Summary Hospital-level Mortality Indicator?
The Summary level Hospital Mortality Indicator (SHMI) is a high level hospital mortality indicator that is published by the Department of Health on a quarterly basis. The SHMI
follows a similar principle to the general standardised mortality ratio; a measure based upon a nationally expected value. SHMI can be used as a potential smoke alarm for
potential deviations away from regular practice.
How does SHMI work?
1) Deaths up to 30 days post acute trust discharge are considered in the mortality indicator, utilising ONS data
2) The SHMI is the ratio of the Observed number of deaths in a Trust vs. Expected number of deaths over a period of time
49
3) The Indicator will utilise 5 factors to adjust mortality rates by
a. The primary admitting diagnosis
b. The type of admission
c.
A calculation of co-morbid complexity (Charlson Index of co-morbidities)
d. Age
e. Sex
4) All inpatient mortalities that occur within a Hospital are considered in the indicator
How should SHMI be interpreted?
Due to the complexities of hospital care and the high variation in the statistical models all deviations from the expected are highlighted
Some key differences between SHMI and HSMR
Indicator
Are all hospital deaths included?
When a patient dies how many times is this counted?
HSMR
No, around 80% of in hospital deaths are included,
which varies significantly dependent upon the
services provided by each hospital
If a patient is transferred between hospitals within 2
days the death is counted multiple times
Does the use of the palliative care code reduce the
relative impact of a death on the indicator?
Does the indicator consider where deaths occur?
Yes
Is this applied to all health care providers?
Yes
Only considers in hospital deaths
SHMI
Yes all deaths are included
1 death is counted once, and if the patient is
transferred the death is attached to the last
acute/secondary care provider
No
Considers in hospital deaths but also those up to 30
days post discharge anywhere too.
No, does not apply to specialist hospitals
50
Appendix II: Interviews held
Interview
Date held
Ann Farrar, Interim Chief Executive and Ian Gordon, Interim Chairman
7 May
Chris Platton, Director of Nursing, Mike Walker, Director of Medicine and Jeremy Rushmer, Director of Clinical Transformation
7 May
Michael Bonner (Non-Executive Director, chaired most meetings for Governance and Quality Committee), Ramona Daguid, Director of
Governance / Company Secretary and Chris Platton, Acting Director of Nursing
7 May
Corrine Sidall, Director of Operations
8 May
Steve Shanahan, Interim Director of Finance
8 May
Ramona Daguid, Director of Governance / Company Secretary and Kathy Barnes, Head of Patient Safety and Clinical Governance / Medical
Governance and Clinical Standards
8 May
Sheena Bosche, Patient Relations Manager
8 May
Denis Burke, Clinical Business Unit Director of Medicine and Emergency Medicine
8 May
Patrick Armstrong, Clinical Business Unit Director of Emergency and Elective Surgery
8 May
Non-Executive Directors
9 May
51
Appendix III: Observations undertaken
Item
Location
Date
Stroke unit
CIC - Carlisle
7 May
A&E
CIC - Carlisle
7 May
Maternity
CIC - Carlisle
7 May
Pediatrics
CIC - Carlisle
7 May
Willow A
CIC - Carlisle
7 May
Orthopedics
CIC - Carlisle
7 May
Theatres
CIC - Carlisle
7 May
Beech C&D
CIC - Carlisle
7 May
Cardiology
CIC - Carlisle
7 May
Renal
CIC - Carlisle
7 May
Emergency assessment unit
CIC - Carlisle
7 May
Pediatrics
WCH - Whitehaven
8 May
Maternity
WCH - Whitehaven
8 May
Cardiac/Stroke
WCH - Whitehaven
8 May
Theatres
WCH - Whitehaven
8 May
A&E
WCH - Whitehaven
8 May
Cardiology
WCH - Whitehaven
8 May
Trauma & Orthopedics
WCH - Whitehaven
8 May
52
Item
Location
Date
Surgery
WCH - Whitehaven
8 May
General Medicine
WCH - Whitehaven
8 May
53
Appendix IV: Information available to the RRR panel
Patient safety alert on anticoagulant therapy
Report of delivery against 2012/2013 CIP
Clinical Policy Group ("CPG") Terms of Reference
Paediatrics mortality / morbidity report
2013/2014 Cost Improvement Plan
Agenda Clinical Policy Group 16.11.12
Positive patient feedback letters (x2)
2013/2014 Trust Board Presentation - Maintaining Patient Quality &
Safety through Cost Improvement March 2013
HSMR and Mortality for NCUH Board paper by Dr Jeremy Rushmer
Strategic Plan 2010-2015
The Trust Development Authority self-certification for Quality
Governance encl 5.4 26.3.13
Understanding Mortality & Reducing Harm CPG dated 16.11.12
Strategic Plans on a page for the four Business Units and
Organisational Strategic Plan (Corporate, Emergency Care &
Medicine, Elective and Emergency Surgery, Clinical Support and
Cancer Services and Paediatrics)
External assessment on Monitor's Quality Governance Framework by
Professor Robert Wilson's (September 2012).
Interim Chief Executive Overview Clinical Policy Group Nov 12
Quality Strategy and Measuring and improving Patient Experience
presentation by Annie Laverty 27.11.12
Progress report on Monitor's Quality Governance January 2013
Minutes of CPG 16.11.12
Patient Experience Priorities and Action Plan
Organisation structure and CVs of Executive team
Minutes of CPG January 2013
Implementing our safety & quality priorities for 2013/2014
Trust Governance, Risk Management & Quality Strategy, January 2012
Audit meetings - January to March 2013
Risk Register with Assurance Framework dated 19.3.13
Review of Clinical Governance Report January 2011
M&M audit data for April 2013 Anaesthetics meeting
Risk rating Matrix strategic
Final Report on the Review of Clinical Governance July 2011
M&M audit data for April 2013 General Surgical meeting
Integrated Risk Register and Assurance Framework update Q4
2012/13 Review
Annual review of the Governance & Quality Committee ("GQC") Terms
of Reference report to June 2012 Board with Appendix A Governance
M&M audit data for April 2013 Gynaecology meeting
54
and Quality Committee Terms of Reference and structure chart of GQC
Draft Clinical Audit Plan 2013/14
Governance Structure Chart updated April 2013
M&M audit data for April 2013 Head and Neck meeting
Delivery of the Clinical Audit Plan 2012/2013 report to March 2013
Board with Appendix 1 (Trust position against national audits)
Trust Mortality & Reducing Harm Framework issued April 2013
M&M audit data for April 2013 Ophthalmology meeting
Trust Board meeting 26.2.13 (Papers and minutes)
Terms of reference for the Clinical Policy Group
M&M audit data for April 2013 Orthopaedic meeting
Trust Board meeting 26.3.13 (Papers and minutes)
Agenda Governance and Quality Committee ("GQC") 12.03.13
Overview of Operating Plan for 2013/14 26 March 2013 (as sent to TDA
on 5 April 2013)
CQC Alert October 2012
Enclosures 1 11 for meeting of GQC of 12.03.13
CQC letter dated 7.12.10
Trust submission on 9 November 2012
Agenda GQC 09.04.13
Trust response dated 10.01.11
CQC letter dated 04.01.13
Enclosures 1 5 for GQC of 09.04.13
CQC letter dated 24.01.11
External Agency Visits Register
Review of Compliance dated August 2012 (CQC)
Trust Action Plan following CQC inspection of June 2012 (updated
23.1.13)
List of Local Providers
Cumberland Infirmary Inspection report 28 January 2013 (CQC)
ADQM Quality Report (northern deanery) dated 3.4.13
Memo to staff on Enhanced Patient Flow
Cumberland Infirmary Estates Maintenance schedule
Elective Intensive Support Team (IST) Terms of Engagement
Further information on water testing
Cumberland Infirmary Medical Engineering register
Trust Development Authority Report on CDiff (IST) April 2013
Evidence of renal water testing for Cumberland Infirmary
Equipment maintenance register for the West Cumberland Hospital
National Cancer Action Team Report April 2013
55
Evidence of renal water testing for West Cumberland Hospital
Details of the capital replacement programme
National Cancer Peer reviews Oct/Nov 2012
1-year and 3-year planned maintenance records for the dialysis
machines at the West Cumberland Hospital
Cleaning Logs – Cumberland Infirmary
Intensive Support Team for Emergency Care Jan 2012
Documents from DIPC:
Trust board annual report
Trust board report on c diff
Cleaning Logs – West Cumberland Hospital
AQuA Mortality Review Report December 2012 & CEO letter to staff –
dated 23.11.12
Details of team
Cleaning Audit reports (CIC & WCH) – June 2012 to March 2013
Details of the nursing review (consultation only)
Information on fogging
Details of complaints from staff
Bed compliment
Deanery report
Letter from staff member at WCH (theatre team)
Nursing establishment data and updates on the nursing & midwifery
review
Breakdown of mandatory training completion rates by staff type /
specialty; appraisal information
Hardcopy complaint letter from staff member (WCH)
Ward rotas
Restriction list for Consultants
Staffing on Fairfield ward
Draft notes on the recent anticoagulant SUI (this hasn't been written up
into an RCA yet)
Record of training provided to the 60 people undertaking the GTT
case note review
Highlights in board papers of documentation of patient safety
walkabouts
Reports for the following never events - retained guide wire, incorrect
lens, retained gauze, retained foreign body and misplaced NG tube. Not
all are final reports
Locum mandatory training
CIP plans signed off by the Medical Director
Information on all incidents classified as catastrophic
SUI action plan and SUI report
Notes / forms from both sites
Various SUI reports / documents –
List of incidents originally graded as catastrophic
RCA timeline completed for Ulysses 18307
56
SUI report for 2012/30218
SUI report for 2013/5523
SUI report for 2013/1683 (never event)
SUI report for 2012/31943
Notes on heparin SUI
Surgical business unit governance minutes
Notes of the Governance and Risk Board
Naso-gastric policy
Patient safety walkabout details
Documentation on organisational changes
Antibiotic prescribing policy
Information on the redevelopment of WCH
Emergency Care and Medicine BU - Governance and Risk Board
Incident management policy
Minutes of the medical staff committee meeting
Annual safeguarding report (Jan 2012)
Major incident plan
Business level risk registers
Pathways
IG annual report for 2011/12. The 2012/13 report will not be presented
to Trust Board until June/July this
Escalation process
Antithrombotics - national clinical guideline
MSC minutes
57
Appendix V: Agenda for unannounced visit
Item
Location
Date
Accident & Emergency
CIC – Carlisle
16 May
Emergency Assessment Unit
CIC – Carlisle
16 May
Beech C&D – Surgery
CIC – Carlisle
16 May
Larch C – Medicine
CIC – Carlisle
16 May
Theatres
CIC – Carlisle
17 May
Renal Dialysis
CIC – Carlisle
17 May
Elm A – Stroke
CIC – Carlisle
17 May
Endoscopy suite
CIC – Carlisle
17 May
Accident & Emergency
WCH – Whitehaven
16 May
Emergency Assessment Unit
WCH – Whitehaven
16 May
Surgery ward
WCH – Whitehaven
16 May
th
th
th
th
th
th
th
th
th
th
th
58
Item
Location
Date
Trauma & Orthopedics
WCH – Whitehaven
16 May
Obstetrics
WCH – Whitehaven
16 May
Theatres
WCH – Whitehaven
17 May
Endoscopy
WCH – Whitehaven
17 May
Honister
WCH - Whitehaven
17 May
ITU
WCH – Whitehaven
17 May
th
th
th
th
th
th
59