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CQC Inspections

The Care Quality Commission monitors, inspects and regulates hospitals, care homes, GP surgeries, dental practices and other care services to make sure they meet fundamental standards of quality and safety and publishes what it finds, including performance ratings to help people choose care.

The Trust was rated as ‘Requires Improvement’ following an inspection by the Care Quality Commission (CQC) during November and December 2018 and a new Use of Resources Inspection.

Following this rating, we produced a plan to set out how we will successfully address the actions needed in order to improve.

The plan reflects our continued partnership working across the system and aims to strengthen this further. Together with the support of our partners, clinical and non-clinical colleagues, we have been committed to making sustainable improvements for the benefit of everyone who uses or works across our services. We are pleased that all of the actions in this plan have now been completed.

Our improvement plan is available here (live document subject to change)

Further information about the inspection can be found on the CQC website.

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 (

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:
FGH final report:

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

At the end of April 2021, the CQC carried an unannounced inspection of our emergency and urgent care, maternity and surgical services. 

Unannounced inspections are part of the CQC’s usual inspection regime and allow them to visit areas where there may have been improvement actions identified in previous inspections to check on progress, see the care we are delivering, and speak with colleagues first-hand. 

Following this unannounced inspection, the CQC carried out the Trust’s well led review at the beginning of May 2021. This review checks whether an organisation’s leadership, management and governance can assure the delivery of high-quality care for patients, support learning and innovation, and promotes an open and fair culture. 

As always, our teams welcomed and fully supported these inspections as they are an important part of assuring ourselves, our partners and the public of the quality and safety of our services. 

Whilst we are still awaiting the CQC’s final assessments and findings from the inspection and well led review, we have received the below post-inspection feedback letters which were shared with colleagues and presented at our public Trust Board meeting at the end of May 2021.  

We expect to receive the final report in the coming weeks and will publish it as soon as it becomes available.