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Key publications / information

You can find many of the statutory documents that we are required to publish on this page, together with other useful documents. If you can’t find what you are looking for, please contact our Trust HQ team.

PDF file icon LocSSIP for - Verification and Opening of Prosthetic Implants in the Operating Theatre.pdf
PDF file icon LocSSIP for - Verification Safety Standards for Implantation of an Intra-Ocular Lens.pdf
PDF file icon LocSSIP for - Verification and Opening of Devices for Cardiac Implantation (Cardiac Catheter Lab).pdf
PDF file icon LocSSIP for - The Procurement and Use of Skeletal Allografts (Example - Fresh Frozen Femoral Heads).pdf
PDF file icon LocSSIP for - Surgical Site Marking and WHO 5 Steps to Safer Surgery.pdf
PDF file icon LocSSIP for - Specimen Verification, Labelling and Onward Transfer from the Trust Operating Theatre Suite.pdf
PDF file icon LocSSIP for - Site or Lesion Marking and Verification in Dermatology Invasive Procedures.pdf
PDF file icon LocSSIP for - Scheduling Operative Procedures in Theatres and Productivity Meeting.pdf
PDF file icon LocSSIP for - Labelling and Transfer of Patient Specimens from the Endoscopy Units.pdf
PDF file icon LocSSIP for - Labelling and Transfer of Patient Specimens from One Stop Breast Clinic Procedural Rooms.pdf
PDF file icon LocSSIP for - Harvesting and Labelling of Patient Specimens for Maxillofacial Outpatient Clinics.pdf
PDF file icon LocSSIP for - Counts of Swabs, Instruments and Non-Retainable Items in UHMB Operating Theatres.pdf
PDF file icon LocSSIP for - Counts of Swabs and Non-Retainable Items (NRIs) used in Obstetric Invasive Procedures (external to Theatres).pdf
PDF file icon LocSSIP for - 4 Steps for Patient Safety for Radiological Procedures.pdf
PDF file icon LocSSIP for - 4 Steps for Patient Safety for Cardiac Catheter Lab.pdf
PDF file icon LocSSIP for - 4 Steps For Patient Safety (Endoscopy).pdf
PDF file icon LocSSIP for - Chest Drains.pdf
PDF file icon LocSSIP for - Minor Invasive Procedures and Interventional Pain Procedures - 4 Steps and Site Marking.pdf
PDF file icon LocSSIP for - Adult NG Tube Insertion in Intensive Care Unit.pdf
PDF file icon LocSSIP for - Bronchoscopy.pdf

Every year, we are required to publish an annual report covering all aspects of what we do, progress that we have made with delivering our services, and details of our annual financial account.

As with all NHS providers, we are also required to produce a Quality Account every year which reports on the quality of our services. It is an important way for us to show improvements in the services we deliver to local communities and stakeholders.

Our Annual Report and Accounts includes our Quality Account, you can download a full copy of the report here:

Annual Report and Accounts 2021 - 22

Annual Report and Accounts 2020 - 21
Annual Report and Accounts 2019 - 20
Annual Report and Accounts 2018 - 19
Annual Report and Accounts 2017 - 18
Annual Report and Accounts 2016 - 17
Annual Report and Accounts 2015 - 16
Annual Report and Accounts 2014 - 15
Annual Report and Accounts 2013 - 14

Local Clinical Excellence Awards 2020/21 Round

Employer-based Clinical Excellence Awards (CEA) are incorporated within the Terms and Conditions for consultant medical staff and are allocated in accordance with our agreed Trust policy, that operationalises the national framework (including minimum levels of investment). 

The BMA, HCSA and NHS Employers has sought and received ministerial acknowledgement of the current exceptional circumstances and significant pressures that services are under as they respond to the COVID 19 health crisis. 

National guidance for local CEA 2020/21 round has been issued which confirms that, in light of the COVID-19 pandemic, local employer CEA schemes should not be run in 2020/21 to enable us to focus on immediate priorities.

In light of the national steer our Trusts local CEA round which was due to start in April 2020 will not run for the year 2020-21. The existing funding for this awards round will follow the national agreement and be redistributed equally among all eligible consultants as a one‐off, non‐consolidated payment in place of our Trust’s normal CEA round.

In order to receive the one-off payment, eligible consultants must meet the following criteria;

1. Employed on a substantive contract (i.e. not locum) and have fulfilled the minimum expectations set out in the CEA process for the previous 12 months:

  • had a formal appraisal
  • fully engaged in the job planning process
  • fulfilled their contractual obligations
  • complied with the private practice code of conduct

2. Have commenced employment as a consultant on or before 31st March 2019

3. Must not be subject to a current disciplinary sanction imposed by the Trust or be subject of any restrictions / warnings imposed under the Fitness to Practice Regulations of the GMC

4. Not hold a CEA Award at level 9 or above

These arrangements include any Consultants who are not at work due to sickness or self-isolation relating to the COVID-19 pandemic, and those consultants who are absent on maternity, paternity, adoption or parental leave.

We hope to have the process of the local CEA allocation completed by December 2020.

If you have any queries relating to our local Clinical Excellence Awards please contact, Marie Spencer, Business Manager for the Executive Medical Director;

2019 Applications

Further information

University Hospitals of Morecambe Bay NHS Foundation Trust and the people who work with and for us, collaborate closely with other organisations, delivering high quality care for our patients.

Collaborative partnerships such as these have many benefits and should help ensure that public money is spent efficiently and wisely. But there is a risk that conflicts of interest may arise.

All staff are required to declare any interests which may cause a conflict in doing their day to day work, together with any gifts and hospitality received during the course of their work. In particular, the Trust asks that all senior employees, whose role encompasses purchasing decisions, make an annual declaration of interests. This includes providing a Nil Return where they have nothing to declare.

New Guidance regarding Standards of Business conduct developed by NHS England came in to force on 1 June 2017.

Following publication of the guidance, a new Managing Conflicts of Interest Policy has been introduced. The policy covers a number of common situations which could give rise to risk of conflicts of interest -

  • Gifts
  • Hospitality
  • Outside employment
  • Shareholdings and other ownership interests
  • Patents
  • Loyalty interests
  • Donations
  • Sponsored events
  • Sponsored research
  • Sponsored posts
  • Clinical private practice

NHS England has developed further guidance for staff and organisations which can be found here.

A Trust policy has also been developed to support staff with the new requirements and help them meet their responsibilities. The up to date policy can be found in the 'Procedural Documents' list below.

The Standards aim to ensure that all individuals acting on behalf of the Trust, observe and comply with all applicable legislation and regulations and undertake ethical business practices, acting with high standards of business integrity at all times and sets out the minimum expectations for the Board, staff governors and volunteers.

For more information, and our Trust's register of interests, please visit

Conflicts of Interest Breaches 

We work to ensure that all UHMB staff members are supported and feel confident to voice any concerns they may have regarding conflicts of interests and possible breaches that may occur. You can read our managing conflicts of interest policy here.

There have been no reported breaches of the managing Conflict of Interest policy.

CQC review of DNACPR decisions during COVID-19 pandemic 

On 18 March, the Care Quality Commission (CQC) published its review of ‘do not attempt cardiopulmonary resuscitation’ (DNACPR) decisions during the coronavirus (COVID-19) pandemic. 

As a Trust, we received positive feedback and along with Morecambe Bay Clinical Commissioning Group, we welcome the report and remain committed to building positive relationships between health care professionals and our population. 

You can read the full report on the CQC website

As of April 2014, all trusts that have inpatient beds are required to publish their ward staffing levels. This will be accompanied by what percentage of ward shifts have met the safe staffing guidelines.

Information about staffing levels are published on this page, on the Trust's NHS Choices pages and presented to public meetings of our Board of Directors.

Patient safety and experience is a priority for UHMBT and we take it very seriously. We have many procedures in place to ensure that all of our wards across our sites are safely staffed. Please click on the links below to view our latest staffing figures.

Staffing fill rate data submission June 2021











The Patient-Led Assessment of The Care Environment (PLACE) Assessment was introduced in April 2013 to replace the former Patient Environment Action Team (PEAT) Inspections. The PLACE Assessment, which is Patient Led, assesses the quality of the patient environment on a yearly basis. The Assessment does not cover clinical care provision, or evaluate how well staff are doing their jobs.

  • The assessments involve members of the public, former and current patients and members of Healthwatch, who look at a selection of wards and departments against different criteria which is comprised of;
  • Cleanliness
  • Condition, appearance and maintenance
  • Privacy, Dignity and Wellbeing
  • Dementia
  • Access
  • Disability
  • Food

The results not only show how we are performing individually and nationally, but also how we can drive improvement across our hospital sites, enhance our services and better the patient experience.

The most recent PLACE Assessment results are shown below.

2019 PLACE Assessment

2018 PLACE Assessment - Westmorland General Hospital

2018 PLACE Assessment - Royal Lancaster Infirmary

2018 PLACE Assessment - Furness General Hospital

The Trust and NHSE/I jointly commissioned the Royal College of Surgeons to undertake a wider review of 43 patients’ records following concerns being raised. This was a review of a selected number of cases, undertaken specifically to look at learning for the Trust and to examine if there have been any patients who received less than optimal care.

The full T&O report was published on 24 November 2021. The report agreed with concerns in 26 of those cases. The Trust has undertaken many of the actions recommended in the report and has met and discussed with the colleagues who raised the initial concerns.

The Trust’s response to the T&O report at the time of the publication can be found on our website.

External review of concerns within orthopaedic service - redacted to protect personal information.

During 2019 the Trust began to investigate concerns which had been raised regarding the urology service. As a result of the initial enquiries it asked NHS England/Improvement to commission an independent external investigation into the service and the allegations that had been made.

NHS England/Improvement then asked Niche Health and Social Care Consulting to carry out this investigation.

The full Urology investigation report was published on 24 November 2021. The report made it very clear that the Trust and the entire health system had taken significant action over a period of time to tackle various concerns that arose. However, it is also clear that the actions that were taken were not detailed or robust enough to ensure the improvements were sustainable and embedded, and more should have been done.


The Trust’s response to the urology report at the time of the publication can be found on our website.