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CQC Inspections

CQC logoThe Care Quality Commission (CQC) regularly inspect our services as part of its inspection regime of health and social care providers. As a Trust, we welcome and fully support these inspections as they are an important part of assuring ourselves, our partners and the public of the quality and safety of our services. 

You can access information about the Trust's registration with the CQC and latest reports on the CQC's website

A team of inspectors from the Care Quality Commission (CQC) visited Furness General Hospital (FGH) and the Royal Lancaster Infirmary (RLI) at the beginning of April 2023. Whilst they were with us, inspectors visited Medicine at the RLI and our Maternity services at FGH and the RLI. The inspection team then returned in mid-May to undertake the Well-Led element of the Inspection. 

Following the inspections, we received the below feedback:

We await the publication of the final report from this inspection and will share that and our response as soon as it is available.

In March 2022, a team of inspectors from the Care Quality Commission (CQC) carried out an unannounced inspection of the Trust’s urgent and emergency care (UEC) services at Furness General Hospital (FGH) and the Royal Lancaster Infirmary (RLI). This was as part of a system wide inspection around urgent and emergency care services that took place across Lancashire and South Cumbria Integrated Care System between March and April 2022.

Whilst they were at the Trust, inspectors also inspected medical services at FGH as this was not assessed in the Trust's last inspection.

The full CQC inspection reports are available on the CQC website.

Our response to the report can be found in the news section of our website.

The Care Quality Commission (CQC) carried out an unannounced inspection of the Trust’s urgent and emergency care services, surgery, and maternity services at the Royal Lancaster Infirmary (RLI), Furness General Hospital (FGH) and Westmorland General Hospital (WGH) in April and May 2021.

On Friday 20 August 2021, the report from that inspection was published. The overall rating of the Trust remains ‘requires improvement’ - as does the rating for safety and responsiveness. The rating for care also remains as good with inspectors noting that: Staff treated patients with compassion and kindness and took account of their individual needs and helped them understand their conditions. They provided emotional support to patients, families and carers.”

However, the rating for effectiveness moves from ‘good’ to ‘requires improvement’ and the rating for well led moves from ‘requires improvement’ to ‘inadequate’. The decline in the well led rating is due to concerns highlighted in relation to risk management processes and not making changes and improvements quickly enough.

The safety of our patients and staff is our absolute priority and we have already taken action to improve services for our patients. Some of the immediate actions we have taken include:

  • A number of changes to improve the stroke pathway and quality of care for patients, including the creation of dedicated stroke beds, recruitment of additional clinical leads, approval of funding and additional space for the Therapy team and improvements in training compliance and monitoring
  • Continuing to recruit to vacant posts with the recent appointment of three nurses in emergency care. Staffing levels are matched to rotas to ensure safe staffing levels
  • Developing plans with partners to expand our ambulatory care services, increase primary care capacity and introduce Mental Health Urgent Assessment Centres to improve waiting times for patients in the Trust’s Emergency Departments
  • Launching Badgernet - an electronic patient record system specifically for maternity services. The system will help to improve the quality and safety of the service by giving pregnant people much more control over their records and care notes and ensuring that women and families have a more personalised and positive experience throughout the pregnancy.  As well as making it easier for women and midwifery staff to monitor the progress of a pregnancy, Badgernet also makes it easier for staff to capture data to help teams monitor the service and ensure safe and high quality care
  • Completing and signing off 80% of leadership appraisals with the remaining 20% due to be signed off by end August
  • Increasing our Trust wide Safeguarding Level 3 training compliance from 79.3% to 92%
  • Reminding all colleagues of the importance of adhering to social distancing and wearing face masks at all times to protect themselves and our patients and visitors. We have also introduced regular spot checks to ensure compliance, and all colleagues are being encouraged to challenge if they see team members not wearing PPE correctly

Our staff have worked incredibly hard throughout the pandemic and we are pleased the CQC recognised some of the improvements the Trust has made since its last inspection, but clearly there is still work to be done and we know our colleagues, patients and local populations deserve better.

We recognise that improvements must quickly be made so that we can deliver the best possible care to our communities, and we welcome any additional support from NHS England and Improvement to help us accelerate the changes we have already begun to make.

While we know we still have a lot more to do to consistently deliver safe, high quality care, our Board, leadership teams and staff across the Trust remain committed to providing the high standard of care than our communities deserves.

Professor Mike Thomas, Chair                           Aaron Cummins, Chief Executive

RLI Inspection Report

The Care Quality Commission (CQC) released a further report on 27 October 2021 following an unannounced inspection of wards located in Medical Unit 2 at the Royal Lancaster Infirmary (RLI) in August 2021. This report is the last part of the CQC hospital inspection report that was published in August 2021.

Following this inspection, the overall rating for medical care services at the RLI is rated as 'inadequate'. It is also rated as 'inadequate' for being responsive to people’s needs and for how well-led the service is. It is rated as 'requires improvement' for being safe, effective and caring. At the previous inspection in December 2018, the service was rated as 'good'. 

This inspection did not change the overall rating for the RLI, which remains as 'requires improvement' nor the Trust rating which remains 'requires improvement'.

Jackie Bird, Interim Executive Chief Nurse, UHMBT, said: "We fully accept the findings of the report, which is the last part of the CQC Hospital Inspection Report that was published in August. 

"We were aware of the issues within the wards inspected and had shared the improvements we were implementing and working on with the CQC during their inspection.  

"We are grateful they have recognised the work being done and which has been undertaken since they inspected and have been continuing our work with the improvement team at NHS England/Improvement to improve the wards. 

"We have already taken a number of actions, including moving one of the wards to new purpose-built facilities, enhancing the level of care offered to the patients. We are also pleased that the levels of care in those areas have already improved. 

"There has been some really great work to improve the safety of patients, the care offered and the culture within the wards the CQC visited. 

"We also want to pay tribute to our colleagues working in the areas inspected who have worked tirelessly throughout the pandemic and now are continuing to improve the care offered." 

Additional information

Our latest inspection, which was carried out between October and December 2018, was the first time the Trust had experienced the new CQC and NHS Improvement combined inspection, i.e. inspecting our hospital services, conducting a Well-Led Review and a Use of Resources Review (which highlights the Trust’s financial performance) simultaneously. The unannounced site based inspection was conducted only for our urgent care and surgical services.

The areas the CQC said we must or should work on can be grouped into a number of topics:

  • Staffing: (including recruitment, training, appraisal, and engagement)
  • Governance: (including Corporate Governance Framework, Clinical Governance Framework, Clinical Audit, incident reporting, risk register and Patient Relations)
  • Medication Management: (including drug fridge management and storage)
  • Clinical Treatment/Performance: (including attendance at the Emergency Department, referral to treatment times and length of stay, and the Urgent Treatment Centre at WGH)
  • Quality/Safety Assurance Checks
  • Improvements in productivity and efficiency.

As a result of the current financial challenges (both local and national) NHS Improvement rated us as Inadequate for Use of Resources – contributing to the overall Trust rating.

Every area of the Trust was rated as “Good” for the care provided for our patients. This has been the highest priority for the Trust on its improvement journey to this point and will continue to be as we seek to improve further and address the issues highlighted in the report. It was also great to see some areas of outstanding practice highlighted.

These included:

  • The introduction of a mobile ‘phone App for patients with arrhythmia, that enables them to record their cardiac rhythm as and when symptoms occurred; and a nurse led cardioversion service which frees up consultant time at the Cardiac Centre at Westmorland General Hospital
  • Patients’ meals ordered electronically using a new system meaning patients have more choice of what to eat, and waste is substantially reduced
  • The Trust was rated good for caring. In surgery the CQC noted that they observed positive, caring and kind interactions between staff and patients and staff caring for patients with compassion
  • Royal Lancaster Infirmary’s Ward 37 and Furness General Hospital’s Ward 7 have both achieved the end of life care Gold Standard Framework accreditation
  • Medical Care was well-led and rated as Outstanding. The Trust’s work with patients, staff, the public and local organisations to plan and manage care was particularly singled out. It was also noted that that the culture had changed beyond recognition over the last five years with high staff morale
  • It was also noted that across the Trust staff understood their responsibilities in relation to reporting incidents and the Duty of Candour. The CQC saw evidence of action taken as a result of incidents being reported.

The full Inspection reports for the Trust will be able to be found on the CQC website (www.cqc.org.uk)

The Care Quality Commission undertook a focused unannounced Inspection of Maternity, Children and Young People’s Hospital services at the Royal Lancaster Infirmary (RLI) and Furness General Hospital (FGH) in December 2019.

Sue Smith OBE, Deputy Chief Executive and Executive Chief Nurse, UHMBT, said “This was a 'focused inspection' by the CQC meaning the services do not receive a new rating. Last time these services were inspected, the CQC rated maternity services as ‘Good’ for caring at both hospitals. Good is their 2nd highest rating.

“Clearly there is still work we can do to demonstrate our continued delivery of safety and quality in all areas, but I am confident that we have the workforce to deliver this challenge. Local people can be rightly proud that overall the ratings for maternity, children and young people’s services at both hospitals were previously rated as ‘good’ overall and this inspection does not alter this.”

“As can be seen from the reports as soon as any issues were raised with the Trust during the Inspection we’ve taken immediate action wherever we could. We will now continue to keep the CQC updated as we address any outstanding issues.”

RLI final report: https://www.cqc.org.uk/location/RTX02
FGH final report: https://www.cqc.org.uk/location/RTXBU

Maternity, Children and Young People’s Hospital services - focussed inspection action Plan