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CQC Inspections

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

The areas the CQC said we must or should work on can be grouped into a number of topics. We have already begun working to address these issues:

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

As a result of the current financial challenges (both local and national) NHS Improvement rated us as Inadequate for Use of Resources – contributing to the overall Trust rating. But I am keen to point out to our partners across the area that our hospitals have not been sufficiently invested in over recent decades, resulting in buildings which are inefficient, overly costly to run and in some parts just not good enough for our patients or staff to have a consistently positive experience.

You all make the very best of it;  we’ve seen some phenomenal results of improvements in services delivered without any additional funding, done by working innovatively in partnership with our commissioners and other providers, such as GPs and community teams to reduce demand through schemes like our Patient Initiated Follow Up initiative;  improved staffing through our nurse apprenticeship scheme or delivering our annual cost improvement plans each year; but to deliver further improvements and the efficiencies required over this next period we are looking to secure much needed capital investment.

That said, there is now clear evidence of areas we can be more productive in – such as our operating theatres and outpatient clinics – and we are committed to improving those services.

In terms of the good news, I am proud to see that across the board, every area of the Trust has been rated as “Good” for the care provided for our patients. This has been the highest priority for the Trust on its improvement journey to this point and will continue to be as we seek to improve further and address the issues highlighted in the report. It was also great to see some areas of outstanding practice highlighted.

These included:

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

Once again, I would like to thank you all - colleagues, volunteers, governors, patients, partners and our local communities for your continued help and support.   We are a great team at the Trust and I know that we will all work hard to implement the report’s recommendations so that we are providing the best possible treatment and care that we can to our patients.

The full Inspection reports for the Trust will be able to be found on the CQC website (

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

The CQC has now published its inspection report on our Trust, and has rated the Trust as “Requires Improvement”.

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

Trust has now produced an Improvement Plan which sets out how we will successfully address these actions.

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

To support the plan, all actions are aligned to an Executive lead, and associated assurance committees, with clear accountability and sight through to the Trust Board.

It is important that we continue to engage with colleagues throughout and ensure that everyone remains updated on the progress we are making together. To support this, each month we will publish a copy of the action plan and a summary of the improvements on our website.

Additionally, we will also write to all of our colleagues, partners, governors, volunteers and other stakeholders to ensure they also know where we are up to.

Thank you for your continued support;  we look forward to continuing to work with you in support of the delivery of the improvements identified.

Our improvement plan is available here (live document)

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

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

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

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

RLI final report:
FGH final report:
Action Plan

How can staff find out more?

Further information about the inspection can be found on the CQC website, or by speaking to your line manager, senior nurse or Clinical Director.