review into the quality of care & treatment provided by 14

Report for North Cumbria University Hospitals NHS Trust

Review into the Quality of Care & Treatment provided by14 Hospital Trusts in England

RAPID RESPONSIVE REVIEW REPORT FOR RISK SUMMIT

June 2013

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Contents

1. Introduction 3

2. Background to the Trust 7

3. Key Lines of Enquiry 9

4. Review findings 10

Leadership and governance 15

Clinical and operational effectiveness 22

Patient experience 29

Workforce and safety 33

5. Conclusions and action plan 49

Appendices 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 bythose 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 thebasis that they have been outliers for the last two consecutive years on either the Summary Hospital-level Mortality Indicator (SHMI) or the Hospital Standardised MortalityRatio (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 andtreatment 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 thereview 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 thepatients 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 consideredindependent 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 theinterest 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 rapidresponsive 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:

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i. Whether existing action by these Trusts to improve quality is adequate and whether any additional steps should be taken.ii. Any additional external support that should be made available to these Trusts to help them improve.iii. 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 staffviews and feedback. The indicators for each trust were compared to appropriate benchmarks to identify any outliers for further investigation in the rapid responsive reviewstage 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-data-packs/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 observedthe hospital in action. This involved walking the wards and interviewing patients, trainees, staff and the senior executive team. This report contains the findings from thisstage 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, alongsideother 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 thehospitals 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 16May 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 multiplesources 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 theinterviews 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 arescheduled 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 trainingrecords 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 onpatients.

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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 9May, 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 morningof 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 mortalityscores 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 isa 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 Infirmaryin 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 one-on-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 qualityof 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 needsimproving 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 inWhitehaven. 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 careand 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 panelliststo 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 theannounced 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 identifiedto 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 arisingfrom 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 qualityand 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 thepreferred 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 CumbriaUniversity 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 wasduring 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 thepopulation 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 ishigher 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 groupswithin General Medicine which have higher than expected SHMI, including pneumonia (excluding that caused by tuberculosis or sexually transmitted disease) and congestiveheart 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 to114 in 2011/12. Specialty-level analysis of HSMR results indicate that the following areas have higher than expected HSMR: pneumonia, congestive heart failure (non-hypertensive), 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 thecancer 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 complaintsprocedure, 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

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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 frompatient incidents, harm for all four Safety Thermometer indicators (pressure ulcers, falls, urinary tract infections and venous-thromboembolism), pressureulcers, and clinical negligence scheme payments.

The Trust is ranked 7th

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 theTrust.

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 StaffSurvey, 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 patientsreceiving a foot risk assessment during their hospital stay and post-operative mortality for bowel cancer. The Trust performs more favourably in relation to measures ofoperational 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 breachedits 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 atarget 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 ofTransformation 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 September2012 and together with the Director of Transformation is seconded from Northumbria Healthcare NHS Foundation Trust, which is currently the preferred bidder to acquire theTrust.

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 ofoutcomes, 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 thatsignificant 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 includedin 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 filterdown 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 andpatient 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 staffwhilst 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 isalso 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 changewithin 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 anyfurther 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 preferredbidder 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 andpace of change has been insufficient to rectify all weaknesses in governance. There are identified weaknesses in clinical leadership, (which are now being addressed), andthe 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 ofthe 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 andcapability 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 increasedpartnership arrangements with Northumbria there is a requirement for further acceleration to enhance the pace of change. We witnessed at times a lack of attention tocompliance 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 patientsafety 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 RiskRegister (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 keystakeholders in the wider healthcare system is required, including, the NHS Trust Development Authority (NTDA) and Cumbria Clinical Commissioning Group (CCG). Therequirement for more support from partner agencies including primary care was stressed by many interviewed. There is a need for a full, independent quality governancereview to ensure that current gaps are addressed without delay. This will facilitate appropriate prioritisation of timing on the Board agenda and support the new leadershipteam 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 toestablish an appropriate middle management tier (General Managers, Matrons and operational managers) whose primary focus will be to support an enhanced clinicalmanagement 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 staffto 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 setcultural issues, such as apportionment of blame, which negatively impacts on learning. The recurrence of some types or categories of events, forexample, 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 eventoccurring 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 andhas 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 andis working in partnership with the CCG and the TDA to develop its serious incident investigations processes. This has commenced and the initial feedback demonstrates animproving trend since the senior management changes have taken place. This needs to be supported by a change in culture around serious incidents and improvedcommunications. 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 reviewof 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 acutemedicine 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 bymanagement. 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 oftime 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 leadershipchanges 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, professionaljudgement 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 alocum. At mid grade level this is particularly acute within Obstetrics and Gynaecology at West Cumberland and at Consultant level within General Medicine at WestCumberland. 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 theflexibility 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 bymanagement 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 patientsafety 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 inrelation 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 wardshave 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 patientstories 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 effectivecommunication. 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 middle-management 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 beaccessed 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 CEOhad ‘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 changesrequired 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 considerationshould 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 staffand 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 couldbe 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 notprovide evidence that other operating theatres had been adequately tested. Validation and verification reports for recent years were requested but were not available andwithout these no assurance can be provided of the environmental compliance for these areas. An urgent external review of the estates department is required to ascertaintheir competence and capability, and ensure that medical equipment maintenance is appropriately prioritised and undertaken. There was no evidence that this issue had beenescalated 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 currentarrangements. 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 servicestickers 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 theseissues 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 wasrequested by the panel. Senior staff in theatres at Cumberland Infirmary and West Cumberland Hospital were unaware of the planned preventative maintenance programmefor 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 equipmentregister 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 outsidetheir normally prescribed maintenance periods. Accordingly, the external review of estates should include a review of medical device management to ensure compliance withrelevant 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 nottime-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 programmeunderway 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 inendoscopy, the validation and verification documentation in respect of the endoscopy AER’s were not provided, prior reports were also requested butwere not forthcoming. The copies of the accreditation certifications for the SSD were requested and were not forthcoming, as were the validation documentation for thesterilisers 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 standardsrespectively, 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 thefuture.

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 urgentlygain 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 deep-clean 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 hadnot 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 theexpert 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 ofChair of the Infection Control Committee and there had been a recent change in DIPC. Cleaning products are under review. However, governance improvements have not yethad 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 resultswhich 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 theantibiotic 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 adoptedwith 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 tomanagement that all drug storage should be fully secured as we found examples of unlocked drug fridges. Additionally, the review team found drug fridges that containedfood 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 andensure improvement in the quality of care

High The Trust should develop a response and action plan for these recommendations toensure improvement in the quality of care

Medium The Trust should implement these recommendations to ensure ongoing improvementin 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 ofperformance information to drive improvements and the Trust’s use of information locally. They were based on the template KLOEs for governance and leadership andtailored to the Trust.

The panel sought to address the effectiveness of governance and leadership through reviewing documentation supporting key governance processes, interviews with keysenior managers. We also spoke to staff in different settings and observed conditions in clinical areas to understand whether improvements in governance reported bymanagement 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 includingevidence Planned improvements Recommended action

Priority – urgent, high ormedium

Capacity and Capability

A lack of capacity and capability of

senior and middle management to

The Trust is obtaining support from the

NTDA to speed up key appointments.

A leadership development plan was put in

Review the leadership structure to ensure the

capacity and capability gaps are filled.

Actively develop clinical and other managers,

Urgent

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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.

place in September 2012, recognising a

lack of organisational development in the

past. Staff appear committed to this

programme.

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.

and maintain this going forward.

Further enhance the development framework

for Board members, and cascade to middle

management and clinical leaders.

Clinical Leadership

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.

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

Consider more support from Northumbria and

the NTDA.

Develop critical audit progammes from Board

to Ward which are owned at local level and

have clear improvement trajectories

Urgent

Corporate Risk Register The Trust has an approved Annual Plan,and following a review of risks by the

Substantial review of the Trust’s CRR and

BAF document is required. The BAF is a key

High

17



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.

Executive Team (1 May 2013) the Trustplans to review its Assurance Framework(June) and Clinical Business Unit RiskRegisters (July).

It was also explained to the review teamhow this would be embedded from Board toward by adopting the UNIPART way (staffengagement in continuous learning basedon agreed corporate priorities). Thisinvolves each team with their strategicpurpose and their contribution to itssuccess with supporting real timemeasurement and support in the trainingand development of staff to focus oncontinuous improvement. This was the keymessage delivered to the staff road-showsin April 2013 and the first wards are due tocommence this from July 2013.

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.

Board Agenda

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.

High

Northumbria Acquisition

There is over-reliance on the

Northumbria acquisition being speedily

approved by Monitor. The Trust does

The Trust is working alongside the TDA toconsider its options.

Signage was amended in the A&E

Improvement plans need to be developed

immediately including contingency plans

should the acquisition not go ahead.

Undertake a review of signage in all areas of

High

18



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

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.

Development and support of Clinical

Business Unit (CBU) Directors and senior

nursing staff to take the lead on clinical

governance.

Development of Terms of Reference for

CBU Director’s meeting.

Implement appropriate performance

management systems to monitor performance

at CBU level with clear lines of accountability

High

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.

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.

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

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?

19


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 Recommended actionPriority – urgent,high or medium

Board Business Intelligence

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.

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.

Board reporting has not supported a robust review and challenge of

management and performance by the Board.

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.

Non-Executive Directors taking on

more of a “challenge role” including

representation on the Quality

Governance Committee.

Obtain independent review of

the quality governance

framework to assess all gaps

and implement quality reporting.

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.

High

Incident reporting

Detailed reports on individual incident investigations revealed delays

in reporting and investigating, poor quality documentation, and lack

More staff were being trained to

undertake Root Cause Analysis to

support improved turnaround.

Documents supporting executive

overview of serious incidents,

never events and infection

control, such as C. difficile and

Urgent

20


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.

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.

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.

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.

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.

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.

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.

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.

Urgent

Manual Systems

Manual systems are “creating work” and do not provide good data,

Adoption of Northumbria IT system

post-acquisition.

Improve communication and

engagement with staff.

Medium

21


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.

Other options should be

considered to reduce the burden

of manual working.

22

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 clinicaleffectiveness 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?


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.

23

Outstanding concerns including evidence Planned improvements Recommended actionPriority – urgent, highor medium

Limited learning from clinical audits

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.

The Trust has approved a clinical audit plan but the

panel were not persuaded this clearly incorporated

mortality review.

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.

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.

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.

High

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.

The Trust should consider the

provision of services across its

two sites (including pharmacy,

High

24

Outstanding concerns including evidence Planned improvements Recommended actionPriority – urgent, highor medium

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.

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.

physiotherapy and dietetics) to

ensure that there is sufficient

provision of services to allow

timely discharge.

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 arelisted below. We recommend that the Trust reviews these matters further:

25

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?


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 actionPriority(urgent, high or medium)

Quality of review of all deaths in financial year 2011/12

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.

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

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.

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.

High

26

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?


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 actionPriority – urgent, high ormedium

Lack of staff confidence in the introduction of the

National Early Warning System (NEWS)

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.

NEWS training continues across theTrust to improve engagement, skillsand buy-in. Monthly audits of theuse of NEWS have been reported tothe Trust Board since April 2013;and further training of doctorsinitiated as a result.

All relevant staff who have not

received training on NEWS should

receive this training as a matter of

urgency.

The ongoing appraisal and

supervision processes should be

used to identify staff lacking

Urgent

27


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.

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.

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.

A Deterioration group met in April.

The planned improvementsexpected of the consultants and theward managers were set out in aletter by the Medical Director andthe Director of Nursing.

confidence in using NEWS, who

should be provided with further

training and development

opportunities.

Measure number of patients being

admitted to intensive care from ward

and the reason for the transfer to

inform outreach team

Ventilator acquired pneumonia

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.

Compliance with the VAP care

bundle should be prioritised, and

compliance monitored.

Urgent

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

28


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.

The Trust may not have the capacity to make changes at the

pace required to improve patient safety.

Group. timeframe.

Purchased equipment is not used to improve patient care

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.

None identified.

During our review we recommended

that management immediately

implement the blood gas analyser in

A&E and check for other missing

equipment.

Urgent



There is a lack of an epidural service at Carlisle, although this is in place at Whitehaven.

29

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 byspeaking 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?


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.



Poor Communication

A recurring theme from engagement

Following a serious complaint with thistheme at the centre of the complaint, theTrust Board and the Clinical Business Unit

Identify leads to address issues with

communication to patients.

High

30



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.

During the review, there was evidenceof excellent staff communication aroundmoving trauma, vascular and electiveorthopaedics.

Directors agreed with the complainant toproduce a DVD of the story and share thiswith staff via the staff road-shows, cascadeto every ward and service managementmeeting and report feedback and actionthat they were taking to the Trust Board inJune 2013. It was arranged for the clinicalteam to have time out in April to considerthe experience of the patient and whatsystems, processes and behavioursneeded to be improved to affect a betteroutcome and experience. It is planned topresent this to the Trust Board in May.

Further enhance communications team,

potentially with support from Northumbria.

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

High

Ward Environment

The environment at Whitehaven (in The Trust plans to implement the “15 steps” Rectify major issues and quick wins (for

Medium

31



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.

methodology on ward visits – this is

something that Northumbria has

undertaken.

example, de-cluttering wards) ahead of

completion of the redevelopment at

Whitehaven.

Implement focused deep clean and ward

maintenance programme annually.



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 homemedications.

Duty of candour

KLOE 8: How is the Board responding to the challenges relating to the duty of candour?


None identified.



Transparency

There is a lack of openness from the

Trust in its communications to patients

None identified. The Trust should review how it is fulfilling its

duty to demonstrate candour.

Quality performance metrics should be re-

Medium

32



and the public as evidenced through

the patient public listening events.

developed and displayed within ward areas,

with staff fully engaged and owning

improvement.

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.

None identified. Compare complaints, incidents and litigation,

to identify themes and/or common problem

areas on an on-going basis.

All complaints should be responded to within

the 25 day target.

High


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 arelisted 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 commonpractice in many organisations to have a Whiteboard with any current delays in outpatient clinics shown in real time to inform patients of likely delays.

33

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 mixon 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 maintenanceduring 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.

34

Outstanding Concerns including evidence Planned improvements Recommended Action

Priority –urgent, highor medium

Staffing Levels

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 on-

site (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 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.

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’.

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.

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 non-

qualified. This needs to be done in light of the Francis

report and the overall quality agenda.

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.

Urgent

Over-reliance on Locum Staff

There is an over-reliance on locum appointments at middlegrade 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 appropriateinduction needs to be given in consultation with thewider health economy and stakeholders.

Urgent

35



on locums and feedback from staff.

General Medicine and Acute General Medicine atWhitehaven Hospital are a particular and relatively urgentcause for concern. There is a high dependence on locum,very few substantive posts and the existing substantive staffhave concerns regarding proposed arrangements for cross-cover from Carlisle. All of the medical registrars working outof hours at the Whitehaven hospital are reported to belocums.

There is poor evidence of adequate locum induction, trainingand appraisal.High locum dependency can have a negative impact on thequality of patient care, is costly and likely to prolongadmissions, further aggravating problems with patient flowmost particularly at Whitehaven.

The review team note actions by the Deanery to addresscomplaints around lack of supervision have meant juniorstaff were removed in some areas. This has exacerbated themedical staffing problem.

drive and help deliver financial

savings.

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,

Mandatory Training

Several staff at each site reported that they do not havesufficient time to complete mandatory training – this isconfirmed by the low compliance with mandatory trainingshown in a quality report to the Board – meaning thatstaffing shortfalls are having a compounding effect on risksto patient safety. Staff also feel that they have lost access toimportant face-to-face training, which can be more effectivethan e-learning. For example, fire safety training isperformed via e-learning, meaning staff do not have theopportunity to practice evacuating patients.

Adopting Northumbria

recruitment process which

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.

The Trust should urgently address these trainingshortfalls and reconsider its methods for the deliveryof training.

Urgent

36



Training in other staff groups such as estates and medicalengineering is lacking (for example, no-one is qualified toundertake revalidation of medical equipment) and staff onwards have reported no formal training on medicalequipment, for example, renal dialysis.

Appraisal Compliance

Appraisal rates are variable. Although this has beenrecognised as a high priority by the Interim Chief Executive.Clinical Business Unit Directors and Deputy Directorsconfirmed their trajectories; staff reported that appraisalswere not being done properly, but rather as a tick-boxexercise to get the numbers up.

None identified Appraisals are an important part of staff developmentand should be meaningfully undertaken by all grades.The Trust should endeavour to measure the quality ofappraisals alongside actual rates undertaken.

High

Staff Support

Openness and support needs to be driven from senior andmiddle management. Discussions with staff suggest thatthey do not feel supported, and in many cases, intimidatedand bullied (the Trust was in the worst 20% for staff bullyingaccording to the latest staff survey); nor do they seem to bereceiving effective communication.Bullying and harassment is also referred to repeatedly in aDeanery report of Feb 2013.

The review team were also provided with evidence of threestaff allegations around potential racism.

At both sites, some staff requested we shut windows whentalking to them in private drop-in sessions – suggesting fearin speaking openly about issues. Others were visibly upset.

Nurses reported they are struggling to escalate acute

The Trust is currently consulting

on a revised strengthened

management structure which

includes operational managers

and matrons

Serious concerns around bullying and potential racismneed to be addressed through implementation ofdiversity type training.

Communication between all levels of staff needs to beimproved and the Trust should explore otheropportunities for communication such as “screensaver” message boards and directed newsletters if notalready doing so.

Although staff recognise the potential benefits of theimpending acquisition by Northumbria, the reviewteam detected some sceptism, and it will be extremelyimportant not to let staff feel disengaged anddisempowered in the process. Due considerationshould be given to different models and ways ofworking, whether the Northumbria way or somethingelse.

Urgent

37



staffing shortfalls – a number of staff reported they weredirected by the bed management team to find staffthemselves to close the gaps, but this meant that more timewas taken away from patient care.

Staff Identity

There was inconsistency in the wearing of nursing uniformsleading to a lack of clarity of “who was who” on wards.

None identified The review team recommend standardising uniformswithin and between hospitals to help create a commonidentity for staff.

Workforce strategy

KLOE 10: Describe the Trust’s workforce strategy


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.


Nursing 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

The Nurse Director is now working

closely with the TDA to undertake a

refreshed staffing review.

In light of the Francis

Report, the Trust needs to

urgently review the nursing

workforce strategy in line

with patient acuity

Urgent

38


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.

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?


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.



CIPs

A review of the Trust’s informationindicates that significant cost savingswere being made at the Trust partlythrough consolidating locum costs into

Business case presented to Board on e-

rostering to improve the safe management

of rotas.

The Board considered the CIP in March

and views of the Medical Director and

The Implementation of a robust PMO

arrangement to oversee the Trust’s CIP plan

needs to retain its high priority.

High

39

substantive posts. Consequently, thereshould be no impact on front-line staff.However, recruitment of staff is anissue which may adversely impact onthese planned savings.

A PMO has been in place for eighteenmonths 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


Priority – urgent,high or medium

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.

Two UCV operating theatres at Whitehaven

were closed by the Trust during the review,

and an urgent, independent review

performed of all others.

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 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).

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.

Urgent

Planned Preventative Maintenance The Trust has seconded a member of stafffrom Northumbria as Interim Director of

An urgent external review of the estatesdepartment should be undertaken to ascertain theirprofessional, management and technical competence and

Urgent

40



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 astatutory 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

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.

Accenture appointed to explore cost

investment opportunities.

The Trust should undertake an in depth review todevelop and or validate a risk based medical devicemanagement system and replacement programme, toinclude a review of compliance with MRHA DB 2006(05), (note: it is likely that this will be replaced in replacedin Jun 13 with a suite similar to CFPP fordecontamination) and MDD 93/42 EEC.

High

Fire Safety

There are fire safety concernsexpressed by staff at the renal ward inCarlisle – apart from there being only e-learning on fire evacuation training,

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

41



there is a fire hazard from clutter andstaff are unsure of how to get a beddownstairs. General concerns wereraised within the Corporate RiskRegister which states no fire safetyofficer in post on one site and noevacuation training.


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 arelisted 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.

42

Infection and prevention control practices


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.


IPC Training

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.

A new DIPC has been

appointed (but this is not a

member of the Board). All

processes and policies are

planned to be reviewed.

Terms of reference for the

IPC committee have been

drafted and this will be

chaired by the CEO to add

drive.

The Trust has received

support from the TDA to fast-

track these improvements.

Training on infection and prevention control

should be undertaking supported by an

awareness campaign throughout the Trust.

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.

High

Deep Cleaning

Whilst the panel were informed there is a deep cleaning team inplace, including a rapid response team with a rolling deep-cleaning programme, there was both ingrained dirt and dust onsurfaces in the wards and corridors the review team visited atthe Whitehaven site. The review team observed numerouscluttered wards e.g. Elm and Beech Wards which would makeproper cleaning difficult.

Whilst the panel acknowledge that there is currently a

None identified. A further review needs to be performed by aspecialist in healthcare cleaning, supported bya decontamination expert and ICT nursespecialist, with a view to developing a formal,annual deep-clean programme supported byinput from the IPC team and estates.

Given the amount of redevelopment going onat the site, the estates team should review theasperguillus policy and managementarrangements and agree with the DIPC a new

High

43


redevelopment programme underway at the site, the reviewteam note that there are compromised surfaces which couldnegatively impact on the prevention and control of infection.

policy.

An urgent de-clutter amnesty needs to begranted followed by a monthly refresh.

HPV Fogging

HPV Fogging is not used in a structured and coordinated way.

None identified. The Trust should review the operational policyfor HPV fogging and agree with the DIPC adeployment process and trigger point. TheTrust should focus this deployment, in acareful and structured way to optimise thebenefit against cost.

High

Compliance with Policies and Procedures

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.

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.

None identified Compliance reviews of all Trust policies shouldbe undertaken by an independent body e.g.,internal audit.

The antibiotic policy needs strengthening andre-launching with clear audit of compliance andaccountability frameworks

Medium

Bed Proximity

There are beds that are too proximate in wards at the Carlislesite, especially the stroke unit (Elm A).

None identified Review of beds on all wards should beundertaken to ensure patient dignity andeffective space utilisation/reconfiguration.

Medium

44


IPC Learning

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.

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.

A review of infection control practices shouldbe undertaken and a more multi-disciplinaryapproach needs to be adopted including moreinvolvement from estates.

High

45

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 fromNorthumbria University Hospitals NHS FT in September 2012, a Director of Transformation also seconded from Northumbria University Hospitals NHS FT, and an interimDirector 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 patientsafety 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 ongoingperiod 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 theuse 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 increasedfocus 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 furtherimpetus 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 qualityand safety of patient care and urgent attention is needed to readdress the impact of these programmes and where necessary reverse decisions around capital expenditureand investment in the sites. The Trust have embarked on a major redevelopment of the West Cumberland Hospital site but there are immediate concerns over themaintenance 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 doin 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 ofenquiry. 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’sdesire for progress and improvement, however, there remain a significant number of areas where improvements need to be made. Some of these require support and advicefrom the wider health economy including stakeholders such as the TDA, CCG and CQC. Further recommended action for each area has been included and prioritised asurgent, high, medium or lower priority.

46

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.


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.


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

culture throughout the Trust.

b. Introduce a development programme for senior and

middle management.


47

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.


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.


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 notto 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 orsomething 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.

48

Appendices

49

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 wouldexpect. 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 thehospital. 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 acase-mix of: age band, sex, deprivation, interaction between age band and co-morbidities, month of admission, admission method, source of admission, the presence ofpalliative 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 ifvariation 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 havebeen 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 SHMIfollows 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 forpotential 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

50

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 HSMR SHMI

Are all hospital deaths included? No, around 80% of in hospital deaths are included,which varies significantly dependent upon theservices provided by each hospital

Yes all deaths are included

When a patient dies how many times is this counted? If a patient is transferred between hospitals within 2days the death is counted multiple times

1 death is counted once, and if the patient istransferred the death is attached to the lastacute/secondary care provider

Does the use of the palliative care code reduce therelative impact of a death on the indicator?

Yes No

Does the indicator consider where deaths occur? Only considers in hospital deaths Considers in hospital deaths but also those up to 30days post discharge anywhere too.

Is this applied to all health care providers? Yes No, does not apply to specialist hospitals

51

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

52

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

53

Item Location Date

Surgery WCH - Whitehaven 8 May

General Medicine WCH - Whitehaven 8 May

54

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

55

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

56

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

57

SUI report for 2012/30218


SUI report for 2013/1683 (never event)


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

58

Appendix V: Agenda for unannounced visit

Item Location Date

Accident & Emergency CIC – Carlisle 16th

May

Emergency Assessment Unit CIC – Carlisle 16th

May

Beech C&D – Surgery CIC – Carlisle 16th

May

Larch C – Medicine CIC – Carlisle 16th

May

Theatres CIC – Carlisle 17th

May

Renal Dialysis CIC – Carlisle 17th

May

Elm A – Stroke CIC – Carlisle 17th

May

Endoscopy suite CIC – Carlisle 17th

May

Accident & Emergency WCH – Whitehaven 16th

May

Emergency Assessment Unit WCH – Whitehaven 16th

May

Surgery ward WCH – Whitehaven 16th

May

59

Item Location Date

Trauma & Orthopedics WCH – Whitehaven 16th

May

Obstetrics WCH – Whitehaven 16th

May

Theatres WCH – Whitehaven 17th

May

Endoscopy WCH – Whitehaven 17th

May

Honister WCH - Whitehaven 17th

May

ITU WCH – Whitehaven 17th

May