CHIEF INSPECTOR OF HOSPITALS
IMPROVEMENT PLAN UPDATE
JUNE 2015 PROGRESS REPORT
CONTACT DETAILS AND FURTHER INFORMATION
If you have any questions about our improvement plan or require
further information, please contact the Trust’s communication team
on 01228 814344 or communications@ncuh.nhs.uk
To view the Trust Board’s latest public board papers, please visit:
http://www.ncuh.nhs.uk/about-us/trust-board/2015/june/publictrust-board-june-2015.aspx
Re-inspection
The Trust was re-inspected by the CQC week commencing 30 March 2015. The inspection teams were on site on Tuesday 31
March at West Cumberland Hospital and Wednesday 1 April at the Cumberland Infirmary. The CQC team also had some time on
site on the morning of Thursday 2 April for any outstanding queries.
During the inspection the inspection team gathered information in a number of ways which included speaking to patients and people
who use our services, holding focus groups with staff and interviewing individual directors as well as staff of all levels. The Trust is
currently awaiting the report which will be published in due course.
Success Regime
North Cumbria is among first three health and care systems to be included in Success Regime, a new national initiative for
challenged health economies.
The Chief Executive of the NHS, Simon Stevens, has announced at the NHS confederation conference that the North Cumbria
health system is to be one of the first three areas in England to receive specific support under the NHS 'Success Regime', a new
national initiative for challenged health economies that is being jointly created by Monitor/NHS England/Trust Development
Authority.
North Cumbria is one of three areas initially selected along with Essex and North, East and West Devon, as these have been
assessed as the most challenged health systems in England. For north Cumbria, this means that North Cumbria University
Hospitals NHS Trust is part of the Success Regime along with Cumbria Partnership NHS Foundation Trust for services it provides
in north Cumbria, NHS Cumbria Clinical Commissioning Group and Cumbria County Council.
The purpose of this Success Regime is to protect and promote health and care services for patients in local health and care
systems that are struggling with financial or quality problems, or sometimes both.
CHIEF INSPECTOR OF HOSPITALS ‘MUST’ AND ‘SHOULD’ DO SUMMARY
TRUST LEVEL
REQUIRED
MUST SHOULD
20
5
DELIVERED 31/3/15
MUST
SHOULD
9
5
A&E
2
6
1
4
CRITICAL CARE
MEDICINE
1
1
0
4
1
0
0
2
END OF LIFE
SURGERY
2
5
1
4
2
3
2
3
MATERNITY
4
7
3
4
OUTPATIENTS
3
2
2
1
CHILDREN AND YOUNG PEOPLE
5
3
4
3
CUMMULATIVE TOTALS
43
32
25
24
WILL REMAIN ONGOING WITH SUPPORTING ACTION PLANS AS AT 31/03/2015
(9)
 Medical and nurse staffing levels (T1, T2)
 Planning services to meet best practice (T7)
 Clinical supervision & appraisals (T8, T20)
 Culture (T13)
 Estate and environment (T15, T17, T18)
(3)
 Patient flow A&E standard (A&E1, A&E4)
 Triage ( A&E2)
N/A
(3)
 Patient flow in the hospital (MED1)
 Stroke and Diabetes care (MED4)
 Storage for large equipment (MED3)
N/A
(3)
 Patient flow and 18 Wk RTT (SUR4, SUR5)
 Standardisation of EPAU (SUR9)
(4)
 Anaesthetic staffing cover (MAT1)
 Epidural (MAT2)
 Data system for maternity (MAT7)
 Normality in child birth (MAT6)
(2)
 Waiting times and diagnostics (OP1 & OP5)
(1)
 Children with mental health needs (CY4)
1. DELIVERY POSITION PER SERVICE LINE
MUST & SHOULD DO’S FULLY DELIVERED BY 31/03/2015
MUST & SHOULD DO’S WHICH WILL REMAIN WORK IN
PROGRESS WITH SUPPORTING ACTION PLANS AS AT
31/03/2015
TRUST
LEVEL
Must Do (9)
 T1 – medical staff numbers
 T2 – nursing staff levels
 T7 – planning of care and services in accordance with best
practice
 T8 – Provide clinical supervision to all staff
 T13 – promote a culture that supports openness and
transparency
 T15 – redress all estates and equipment deficits
 T17 – storage of equipment safely
 T18 – Action to prevent build up in dirty utility at CIC
 T20 – delivery of staff appraisals (73%)
20 Must
Do
5 Should
Do
Must Do (9)
 T2 – review the use of the acuity tool
 T3 – clinical risk management
 T4 – Improve support given to junior med staff
 T11 – complaint information up to date
 T19 – porters at WCH training and guidance on security and restraint
 T5 – delivery of mandatory training
 T6 – Compliance with NICE and audit
 T14 – Ensure that Board assurance is supported by robust information
 T16 – emergency equipment
Should Do (5)
 T4 – Improve support given to junior med staff
 T9 – Improve training with care bundles
 T10 – Continue to improve complaint responses
 T11 – complaint information up to date
 T12 – show how we have responded to feedback (you said we did)
A&E
2 Must
Do
6 Should
Do
Must Do
 A&E3 – A&E triage
Should Do (4)
 A&E5 – Ensure adequate services for patients who are in A&E overnight
 A&E6 – Make improvements to the major haemorrhage protocol
 A&E7 – safety and security of visitors to A&E
 A&E8 – Improve CT reporting TARN
Must Do (1)
 A&E1 – improve flow to reduce transfer delays, avoid
patients in A&E overnight and delays.
Should Do (2)
 A&E 2 – Paediatric triage
 A&E4 - Effective flow to reduce waiting times
MUST & SHOULD DO’S FULLY DELIVERED BY 31/03/2015
MUST & SHOULD DO’S WHICH WILL REMAIN WORK IN
PROGRESS WITH SUPPORTING ACTION PLANS AS AT
31/03/2015
CC
Must Do (1)
 CC1 – Ensure children cared for in ICU receive care appropriate for their
age

Must Do
 N/A
Must Do (1)
 MED1 - Improve patient flow across hospital to improve
A&E
Should Do (2)
 MED4 - Improve the management of people with diabetes
and stroke in line with national guidance
 MED3 - Improve access to equipment and provide more
suitable storage for larger pieces of equipment
 N/A
1 Must
Do
MED
1 Must
Do
4 Should
Do
EOL
2 Must
Do
Should Do (2)
 MED2 – Take action to reduce patients being moved between wards at
night
 MED5 – Improve the management of people living with dementia
Must Do (1)
 EOL1 – Implement care plans to replace LCP.
 EOL3 – Address problem caused by ventilation in mortuary
Should Do (1)
 EOL2 – Develop a clear vision and strategy
N/A
1 Should
Do
SUR
5 Must
Do
4 Should
Do
Must Do (2)
 SUR2 – Policies and procedures to support major incident for surgery are
robust
 SUR3 – Develop standard governance system and dashboard for
dissemination to all specialties
 SUR1 – Redress imbalance of elective work between sites
Should Do (3)
 SUR6 – Major incident plan for surgery is tested
 SUR7 – Develop audit process for WHO checklist
Must Do (2)
 SUR4 – improve flow to cope with routine and reduce
waiting times
 SUR5 – 18 weeks RTT
Should Do
 SUR9 – Lack of standardisation for Early Pregnancy

SUR8 – PROMS
MUST & SHOULD DO’S FULLY DELIVERED BY 31/03/2015
MUST & SHOULD DO’S WHICH WILL REMAIN WORK IN
PROGRESS WITH SUPPORTING ACTION PLANS AS AT
31/03/2015
MAT
Must Do (1)
 MAT1 – national guidelines for having an anaesthetist
available e at WCH at all times for Obstetrics
Must Do (3)
 MAT3 – Clear action plans for lack of second theatre
 MAT4 – Ensure maternity service reviews its identified risks
 MAT 5 – Ensure risk management processes are embedded
Should Do (4)
4 Must
Do
7 Should
Do
OP
3 Must
Do
2 Should
Do




MAT8 – Ensure the service has the ability to undertake grade 3 sections
MAT10 – Develop a local risk register for penrith birthing centre
MAT11 – clarify the maternity service liaison committee
MAT9 – Ensure there is a SLA for Penrith birthing centre with CPFT
Must Do (2)
 OP2 – Improve how patient records are made available for outpatient
clinic appointments
 OP3 – Take action to ensure that patient records are fully complete and
up to date and are made available in a timely way for OP
Should Do (1)
 OP4 – Ensure the infrastructure is in place before establishing additional
outpatient clinics
Should Do (1)
 MAT2 – Epidural service at CIC
 MAT7 - Improve the use of technology and data for
maternity
 MAT6 – clarify a leadership role to promote normality in
child birth
Must Do (1)
 OP1 – Support outpatients to meet national targets and
ensure records available
Should Do (1)
 OP5 – Improve access to CT/MRI
MUST & SHOULD DO’S FULLY DELIVERED BY 31/03/2015
MUST & SHOULD DO’S WHICH WILL REMAIN WORK IN
PROGRESS WITH SUPPORTING ACTION PLANS AS AT
31/03/2015
CY
Must Do (1)
 CY4 – Take action to protect the health and welfare of
children with mental health needs
5 Must
Do
3 Should
Do
Must Do (4)
 CY2 –Ensure children are consistently risk assessed at time of arrival into
the department
 CY3 – Ensure the risk register for the hospitals children’s ward reflects
the risks in the completed clinical audits
 CY5 – Ensure good practice in infection control is followed in the SCBU
 CY6 – Improve the standard of nursing records
Should Do (3)



CY1 – Improve infection control in SCBU
CY7 Ensure staff are aware of and have access to a robust policy for
transferring sick children
CY8 – Ensure staff on children’s ward document whether children have
been involved in their decisions about care and treatment
Should Do
 N/A