Serious staff shortages and coronavirus pressures are behind a warning over ‘patient and staff safety’ given to north Cumbria’s NHS trust, after a new report found that some Carlisle hospital patients were being given ‘one-to-one’ care by porters and security guards.

The Care Quality Commission (CQC) has now served a warning notice to the North Cumbria Integrated Care NHS Trust (NCIC), ordering that it must make immediate improvements “to keep people safe” at both the Cumberland Infirmary and the West Cumberland Hospital.

The CQC’s latest inspections were carried out in August and September in light of “emerging concerns” about “risks to patient and staff safety”, and as a result has issued a list of 51 actions the trust must undertake in order to comply with its legal obligation on the care it provides, alongside further recommendations.

As a focused inspection, the CQC was looking exclusively at the safety and responsiveness of emergency and urgent care, medicine, end of life care and community adults’ services across the trust. Therefore, the trust’s current rating of “requires improvement” remains unchanged, though it was issued before the merger of the North Cumbria University Hospitals Trust and the Cumbria Partnership Foundation Trust in October last year.

Published today, the report highlights a number of concerns, including seven “serious incidents” between January and August this year in the Cumberland Infirmary’s emergency department.

Professor Ted Baker, the CQC’s chief inspector of hospitals, said that the trust “has been very responsive” to the improvement requirements.

“I feel assured that they are taking steps to address these issues, working closely with NHS England and NHS Improvement,” he said.

The central theme highlighted by the CQC’s report is the staff shortages facing the trust, particularly in the Cumberland Infirmary’s emergency department.

Concerns over staffing levels were first raised by the CQC in February. Inspectors returned in August, following the receipt of information from whistleblowers and “concerned members of the public”.

“When we returned in August 2020 the department still had significant staffing problems with little sign of an improved situation,” the report explains.

An internal assessment of staffing levels suggested it needed “ approximately 50 per cent” more staff “to ensure patients were safe and received their care and treatment appropriately”, the report details.

“Evidence sent by the trust showed 28 per cent of shifts were covered by agency and bank staff in June 2020, 46 per cent in July 2020 and 65 per cent in August 2020.

“This raised concerns about consistency of care, competencies and training of staff and there was an increased risk to patients that they may not receive care and treatment in line with departmental policies and procedures.”

This is an issue trust bosses say is being tackled as a priority, with 37 new nurses recruited from overseas set to join the wards in March, and through its 100-strong nursing apprenticeship programme.

Perhaps the most stark example of the staffing issues been faced by the trust is the revelation that that porters and security guards at the Cumberland Infirmary had been used to monitor patients one-to-one, “when patients were restless and wouldn’t stay in bed for their own safety”.

Addressing this issue with the trust in February, the CQC was assured this would no longer take place.

“Our staff survey asked staff across the trust if, after May 2020, they had witnessed security guards or porters giving one-to-one care to patients.

“At Carlisle Hospital, 36 per cent of staff said they had witnessed security guards or porters giving one-to-one care.

“Of the 177 responses to this question, 38 related to [emergency departments] across the trust and of these 38, 33 related specifically to Carlisle Hospital [emergency department].

“We had concerns about how some vulnerable people such as those living with dementia were supported within the department,” the CQC report explained.

“This was because the people delivering one-to-one care had not received the correct training to be able to manage such patients appropriately. There was a risk that patients could experience suboptimal care or come to harm due to this lack of training.”

The report also highlighted concerns over staffing levels at the West Cumberland Hospital, which at the time of inspection had 188 registered nursing vacancies in the emergency and medicine care group.

“The leadership team for medicine at the site were clear that nursing staffing could be challenging,” the report stated.

“This was echoed by staff we spoke with. For instance, one staff member reported being on their own for six hours with 15 patients. Whilst this was escalated, on the day in question, there was no staff available to offer support.”

Trust medical director and consultant anaesthetist, Rod Harpin, stressed that these staff members were not providing clinical care.

“It was to assist our clinical teams to provide care to the patients,” he said.

He explained that the trust has now put in place “clinically-led enhanced care teams,” providing “individuals who are clinically trained to assist the lead clinicians in that context”.

Dr Harpin added that “challenging” patients are “now under enhanced supervision”.

“This is about ensuring all staff understand restraints, that patients are reviewed by the consultants in charge of their care, and that there is record-keeping and completion of the Mental Capacity Act, and what we term deprivation of liberty,” he said.

“That’s basically making an assessment of a patient’s ability to understand what’s been done to them, and the consent that those restraint measures require.

“Those checklists are monitored by our matrons.”

Another area of concern highlighted by the report was the use of the Cumberland Infirmary’s atrium for the holding of patients when the emergency department was full.

Dr Harpin described this as a “short-term, few hours manoeuvre to assist the safety of our patients by offloading patients from the ambulances.

“This relates to the ambulance handover delays, and the potential for patient harm in that context.

“It was used for a few hours, and taken down after that used.

“It hasn’t been used since, and we’ve responded to the concerns of the CQC by considering other areas of absorb the surge in patient numbers.”

The handover of patients from ambulances to the infirmary’s emergency department was another issue causing concern to the CQC, with inspectors being told by ambulance staff of long delays in the process.

Dr Harpin said that addressing these delays was one of the immediate actions taken by the trust following the CQC inspection.

“We made improvements in triage and ambulance handover times. I want to emphasize that the numbers of ambulance handover times exceeding 15 minutes have halved since October,” he said.

Dr Harpin added that the CQC report should not cast any doubt over the dedication and commitment of the trust’s staff, who he emphasized have worked tirelessly in the face of the pressures brought by Covid-19.

“I really do want to acknowledge our staff, across all areas of our trust, not just clinical-facing staff but all the staff who have supported us through the pandemic.

Lyn Simpson, who was appointed as chief executive earlier this year, said that the CQC report shows that the plans the trust has in place are “the right ones”, but the pace of change has been “too slow”.

“We are a relatively new organisation coming together at a time of global pandemic but the bravery and hard work of all our staff, and the efforts and sacrifices of our communities, require that services for patients emerge stronger from Covid-19.

“Importantly, we have already taken swift action to deliver rapid improvements in patient safety.

The inspection in the summer enabled us to identify immediate actions we needed to take to ensure patients can access appropriate care and treatment in a more timely way.”

Anna Stabler, the trust’s chief nurse, added that there have been plans put in place to “significantly” improve the trust’s staffing levels since December 2019.

“We have put in place plans to significantly improve our staffing, and have brought in over 100 agency nurses to give us additional capacity while longer term plans are put in place.

“We are making good progress on international recruitment with 37 nurses due to be live on the wards by the end of March, and have focussed on growing our own by supporting over 100 people on our apprentice nurse programmes.

“We are also implementing a more sustainable plan for clinical staffing and have approved and advertised for additional clinical staffing in the emergency departments.”

She added that work has also been carried out by the trust since the inspection on improving triage and ambulance handover times, another area of concern highlighted in the CQC’s report, “particularly ensuring clinical oversight where we do experience delays”, she said.

“We are also taking action to improve the flow of patients within the hospital and improve the quality of record keeping.”