Westmorland General Hospital, Kendal

General Services Information

Hospital Questions

• How many single rooms are available to NHS patients at this hospital: 19

• Of these how many have an ensuite toilet: 8

• Of these how many have an ensuite toilet and shower or bath: 0

• Does this hospital operate an accident and emergency unit: There is a Primary Care Access unit at this site manged by Primary Care

• How many specialist palliative care beds are available at this hospital: 0

• Does this hospital have a named private unit/service:

Trust Questions

• Does the Trust treat private patients:

Patient Safety

Trust Questions

• Is there a system for recording operations that resulted in a foreign body being left post surgery:

• What is the reporting system for a foreign body being left post surgery: Safeguard Risk Management System These events would also be coded and a CHKS report would flag them up which would allow us to check whether the incident had already been reported on safeguard or allow us to input it retrospectively if it had not been. These events would also be reported to the PCT via StEIS

• Is there a system for recording operations that were cancelled due to missing notes:

• What is the reporting system for operations that were cancelled due to missing notes: Safeguard Risk Management System

• Is there a system for recording operations that resulted in wrong site surgery taking place:

• During the period 01 April 2010 - 31 March 2011, how many operations resulted in a foreign body being left post surgery: 0

• During the period 01 April 2010 - 31 March 2011, how many operations were cancelled due to missing notes: 12

• During the period 01 April 2010 - 31 March 2011, how many operations resulted in wrong site surgery taking place: 0

• How many incident investigations using a full Root Cause Analysis did were carried out in 2010/11: 18

• What percentage of patient safety incidents resulting in severe harm or death had a full RCA initiated/completed: 0-30%

• What percentage of patients are risk assessed for venous thromboembolism on admission: 91-99%

• Compliant with all relevant NPSA safety alerts issues in 2010/11 (you can find a full list of alerts issued at http://www.nrls.npsa.nhs.uk/resources/?p=3). :

• Alerts where not expected to be compliant by 1st December 2011 and when expected to be compliant. : We expect to be compliant for all the above by December 2011.

• Does the Trust have a policy for providing educational programmes on using and interpreting clinical indicators: CHKS training

• Does the Trust have a designated member of staff who supports teams in locating and analysing safety and quality data? (support): Integrated Risk Team

• Is safety and quality data available on a central platform and actively disseminated to users: the central platform is Safeguard and the dissemination is through the monthly reports to ward/department managers, divisional governance groups and the quarterly analysis report to the Integrated Risk Sub-Committee

Infection Control

Trust Questions

• Does the Trust employ an antibiotic pharmacist:

• Does the Trust operate a pre-admission assessment clinic or equivalent system where patients are screened and results returned in advance of the day of admission:

• Elective patient groups screened at the pre-op assessment clinic: All elective other Elective surgical * Orthopaedics

• Are all oncology patients screened at the pre-op assessment clinic: YES within clinics

• Are all chemotherapy patients screened at the pre-op assessment clinic: YES within clinics

• Are all elective neurosurgery patients screened at the pre-op assessment clinic: Not Applicable

• Are all patients with past history of MRSA screened at the pre-op assessment clinic:

• What method of MRSA screening is used when screening at admission: Culture based in 48-72hrs

• On admission, does topical suppression take place immediately:

• Does the Trust have at least one accident and emergency unit:

• Are all patients admitted through A&E screened:

• Is screening done according to individual risk assessment:

• Does the Trust have a dedicated isolation ward:

• Protocol for isolating patients with infections: if admitted with diarrhoea and vomiting go to single room, if high risk MRSA carriage go to single room, all others treat when results are known

• Does the Trust have an isolation policy:

• Where medically appropriate, are patients with C Diff isolated in single rooms as a matter of priority:

• Does the Trust have a policy to guide the use of metronidazole and vancomycin for C.difficile infected patients:

• Does the Trust routinely isolate all patients with diarrhoea:

Stroke Medicine

Hospital Questions

• Does the hsopital have a specialist stroke unit:

Trust Questions

• Does the Trust have a specialist stroke unit or units:

• Is the Trust part of a stroke care network:

• Details: Cumbria & Lancashire Stroke Network

• How many emergency admissions with a primary diagnosis of stroke (ICD10 codes I60 - I64) did the Trust receive in the financial year (period 01 April 2010 - 31 March 2011): 669

• Of these, what was the number of patients given a Computerised Tomography (CT) scan within 24 hrs of admission: 365

• Is thrombolysis for stroke patients provided 24 hours per day and 7 days a week :

• Are there any formal arrangements with neighbouring hospitals for the emergency transfer of stroke patients who would benefit from thrombolytic treatment: We have the ability to provide thrombolysis on each of our sites.

Trauma & Orthopaedics

Trust Questions

• Does the Trust offer a trauma service:

• Does the Trust have a dedicated trauma list available 24 hours a day for the duration of the week, (Sunday to Sunday):

• Does the Trust offer an orthopaedics service:

• Do all the Trust's orthopaedic ward/team have a linked geriatric team with whom they have regular meetings at least once a week:

• Does the Trust run a pre-operative patient education session/class for patients to attend prior to Total Knee Replacement (TKR) and Total Hip Replacement (THR)? : FGH & RLI only

• Not able to put a figure on the percentage of all patients that attend the class prior to surgery:

• Does the Trust have a standardised anaesthetic protocol for Total Knee Replacement (TKR) and Total Hip Replacement (THR) patients:

• Audited percentage of the Trusts total knee replacement (TKR) and total hip replacement (THR) patients walk within 24 hours of surgery: 99 FGH only

• Estimated percentage of the Trusts total knee replacement (TKR) and total hip replacement (THR) patients walk within 24 hours of surgery: 80 RLI & WGH

• Does the Trust have a specialist orthopaedic physiotherapy service which is available 7 days a week: available 5 days a week

• How many patients' discharge's delayed due to lack of physiotherapy services at weekends - estimated figure: 20 percentage

• Are patients for total knee replacement (TKR) and total hip replacement (THR) admitted prior to the day of surgery: unless medical condition determines this

• Are patient records routinely recorded using a specific multi-disciplinary team THR/TKR pathway document:

• Is this data used to monitor compliance with the agreed pathway:

• Is criteria-based discharge used:

• Are patients routinely phoned in the first 48 hours after discharge to check on their progress:

Paediatrics

Hospital Questions

• Does the hospital have a paediatrics service: Outpatients only

Trust Questions

• Is the Trust's elective paediatric surgery carried out only by designated surgeons with at least six months training in a specialist unit:

• Do the Trust's anaesthetists with responsibility for paediatric anaesthesia participate in at least one paediatric list per week:

• Is a paediatrician on site (SpR or higher) 24 hours per day, 7 days per week:

• Are at least two registered children's nurses on duty 24hours per day in each children's ward:

• Is there a designated facility on site for parents or guardians to stay overnight:

Palliative Care

Trust Questions

• Does the Trust provide a palliative care service:

• How is specialist palliative care delivered at the hospital: Other (please specify) Yes we provide a palliative care service at FGH and RLI. At RLI we have sessions of consultant time in palliative medicine. At RLI and FGH we have palliative care nurses Counsellors are available via CancerCare, a local cancer charity but not based in house. admin support is provided for the MDT at RLI.

• Does the hospital's specialist palliative team includes: A consultant in palliative medicine,A palliative care nurse,Counsellor(s) Yes we provide a palliative care service at FGH and RLI. At RLI we have sessions of consultant time in palliative medicine. At RLI and FGH we have palliative care nurses Counsellors are available via CancerCare, a local cancer charity but not based in house. admin support is provided for the MDT at RLI.

• Is the Trust's specialist palliative care team available 24 hrs a day seven days a week: There is a 24 hour specialist palliative care telephone advice service from St John's hospice but no, the Trust's specialist palliative care service is not available 24/7

• Are facilities provided to support relatives and carers who wish to stay with a patient in hospital: Yes, facilities are usually available to support relative and carers who wish to stay with a patient in hospital (but this is usually a campbed in the patients room (if the patient is in a single room))

• Does the Trust routinely survey and evaluate the views of patients and bereaved relatives and carers regarding the delivery of care on the end of life programme: ,we review complaints and carry out a rolling audit of care at end of life, results of which are presented to the Trust End of Life Group. A ward based nursing training needs analysis has been completed the results of which will provide the focus area for the training programme to be developed.

Maternity Care

Maternity Sites

• Royal Lancaster Infirmary - Midwife Led

• How many women gave birth in the unit during the year? (not including home births): 800

• How many babies were born in the unit during the year? (not including home births): 800

• How many women were booked for a home birth: 21

• How many women had a home birth? (not including births at home by accident): 21

• Number of antenatal rooms: 0

• Total antenatal beds: 0

• Number of assessment area rooms (for monitoring and / or induction): 0

• Total assessment area beds: 0

• Number of delivery rooms: 0

• Total delivery beds: 24

• Number of postnatal rooms: 24

• Total postnatal beds: 24

• Number of rooms in obstetric high dependency unit: 0

• Total obstetric high dependency beds: 0

• Number of single rooms used for both delivery and postnatal care (labour, delivery, recovery and postnatal, or LDRP, rooms): 0

• Amenity rooms; Are women able to book a single room in advance of their birth:

• If women can pay for a single room what is the average cost per night (GBP): 0

• Does the maternity unit have a neonatal intensive care unit:

• Does the maternity unit have a neonatal high dependency unit:

• Does the maternity unit have a special care baby unit:

• Security measures - ankle bands for the baby:

• Security measures - cot alarms:

• Security measures - CCTV:

• Security measures - restricted access:

• Other security measures: 0

• Pain relief available - bath or shower: Provided by unit

• Pain relief available - birthing pool: Provided by unit

• Pain relief available - birth ball: Provided by unit

• Pain relief available - Massage: Not available

• Pain relief available - Aromatherapy: Not available

• Pain relief available - TENS: Not available

• Pain relief available - Epidural: Provided by unit

• Pain relief available - Mobile epidural: Provided by unit

• Pain relief available - Entonox (gas and air): Provided by unit

• Pain relief available - Intramuscular injection: Provided by unit

• Other pain relief: 0

• Total number of WTE midwives at the unit in your funded establishment, including vacant posts: 77.63

• Total number of WTE midwives at the unit as staff in post, including agency and bank staff: 77.63

• Does the unit have midwives available to provide one-to-one care available 24 hours a day, 7 days a week: On site

• Does the unit have midwives available for home births available 24 hours a day, 7 days a week: On call

• Does the unit have midwives trained and experienced in water birth available 24 hours a day, 7 days a week: On site

• Does the unit have a paediatrician available 24 hours a day, 7 days a week: On site

• Does the unit have an obstetrician available 24 hours a day, 7 days a week: On site

• Does the unit have an anaesthetist available 24 hours a day, 7 days a week: On site

• Does the unit have a dedicated obstetric anaesthetist available 24 hours a day, 7 days a week: On site

• Westmorland General Hospital - Midwife Led

• How many women gave birth in the unit during the year? (not including home births): 259

• How many babies were born in the unit during the year? (not including home births): 259

• How many women were booked for a home birth: 6

• How many women had a home birth? (not including births at home by accident): 6

• Number of antenatal rooms: 0

• Total antenatal beds: 0

• Number of assessment area rooms (for monitoring and / or induction): 0

• Total assessment area beds: 0

• Number of delivery rooms: 0

• Total delivery beds: 6

• Number of postnatal rooms: 6

• Total postnatal beds: 6

• Number of rooms in obstetric high dependency unit: 0

• Total obstetric high dependency beds: 0

• Number of single rooms used for both delivery and postnatal care (labour, delivery, recovery and postnatal, or LDRP, rooms): 0

• Amenity rooms; Are women able to book a single room in advance of their birth:

• If women can pay for a single room what is the average cost per night (GBP): 0

• Does the maternity unit have a neonatal intensive care unit:

• Does the maternity unit have a neonatal high dependency unit:

• Does the maternity unit have a special care baby unit:

• Security measures - ankle bands for the baby:

• Security measures - cot alarms:

• Security measures - CCTV:

• Security measures - restricted access:

• Other security measures: 0

• Pain relief available - bath or shower: Provided by unit

• Pain relief available - birthing pool: Provided by unit

• Pain relief available - birth ball: Provided by unit

• Pain relief available - Massage: Not available

• Pain relief available - Aromatherapy: Not available

• Pain relief available - TENS: Not available

• Pain relief available - Epidural: Not available

• Pain relief available - Mobile epidural: Not available

• Pain relief available - Entonox (gas and air): Provided by unit

• Pain relief available - Intramuscular injection: Provided by unit

• Other pain relief: 0

• Total number of WTE midwives at the unit in your funded establishment, including vacant posts: 15.5

• Total number of WTE midwives at the unit as staff in post, including agency and bank staff: 15.5

• Does the unit have midwives available to provide one-to-one care available 24 hours a day, 7 days a week: On site

• Does the unit have midwives available for home births available 24 hours a day, 7 days a week: On call

• Does the unit have midwives trained and experienced in water birth available 24 hours a day, 7 days a week: On site

• Does the unit have a paediatrician available 24 hours a day, 7 days a week: On site

• Does the unit have an obstetrician available 24 hours a day, 7 days a week:

• Does the unit have an anaesthetist available 24 hours a day, 7 days a week:

• Does the unit have a dedicated obstetric anaesthetist available 24 hours a day, 7 days a week:

• Furness General Hospital - Midwife Led

• How many women gave birth in the unit during the year? (not including home births): 446

• How many babies were born in the unit during the year? (not including home births): 446

• How many women were booked for a home birth: 12

• How many women had a home birth? (not including births at home by accident): 12

• Number of antenatal rooms: 0

• Total antenatal beds: 0

• Number of assessment area rooms (for monitoring and / or induction): 0

• Total assessment area beds: 0

• Number of delivery rooms: 0

• Total delivery beds: 20

• Number of postnatal rooms: 20

• Total postnatal beds: 20

• Number of rooms in obstetric high dependency unit: 0 beds shared between Midwives and Consultant as needed

• Total obstetric high dependency beds: 0

• Number of single rooms used for both delivery and postnatal care (labour, delivery, recovery and postnatal, or LDRP, rooms): 0

• Amenity rooms; Are women able to book a single room in advance of their birth:

• If women can pay for a single room what is the average cost per night (GBP): 0

• Does the maternity unit have a neonatal intensive care unit:

• Does the maternity unit have a neonatal high dependency unit:

• Does the maternity unit have a special care baby unit:

• Security measures - ankle bands for the baby:

• Security measures - cot alarms:

• Security measures - CCTV:

• Security measures - restricted access:

• Other security measures: 0

• Pain relief available - bath or shower: Provided by unit

• Pain relief available - birthing pool: Provided by unit

• Pain relief available - birth ball: Provided by unit

• Pain relief available - Massage: Not available

• Pain relief available - Aromatherapy: Not available

• Pain relief available - TENS: Not available

• Pain relief available - Epidural: Provided by unit

• Pain relief available - Mobile epidural: Provided by unit

• Pain relief available - Entonox (gas and air): Provided by unit

• Pain relief available - Intramuscular injection: Provided by unit

• Other pain relief: 0

• Total number of WTE midwives at the unit in your funded establishment, including vacant posts: 39.91

• Total number of WTE midwives at the unit as staff in post, including agency and bank staff: 39.91

• Does the unit have midwives available to provide one-to-one care available 24 hours a day, 7 days a week: On site

• Does the unit have midwives available for home births available 24 hours a day, 7 days a week: On call

• Does the unit have midwives trained and experienced in water birth available 24 hours a day, 7 days a week: On site

• Does the unit have a paediatrician available 24 hours a day, 7 days a week: On site

• Does the unit have an obstetrician available 24 hours a day, 7 days a week: On site

• Does the unit have an anaesthetist available 24 hours a day, 7 days a week: On site

• Does the unit have a dedicated obstetric anaesthetist available 24 hours a day, 7 days a week:

• Royal Lancaster Infirmary - Consultant Led

• How many women gave birth in the unit during the year? (not including home births): 1400

• How many babies were born in the unit during the year? (not including home births): 1400

• How many women were booked for a home birth: 0

• How many women had a home birth? (not including births at home by accident): 0

• Number of antenatal rooms: 0

• Total antenatal beds: 0

• Number of assessment area rooms (for monitoring and / or induction): 0

• Total assessment area beds: 0

• Number of delivery rooms: 0

• Total delivery beds: 0

• Number of postnatal rooms: 0

• Total postnatal beds: 0

• Number of rooms in obstetric high dependency unit: 0

• Total obstetric high dependency beds: 0

• Number of single rooms used for both delivery and postnatal care (labour, delivery, recovery and postnatal, or LDRP, rooms): 0

• Amenity rooms; Are women able to book a single room in advance of their birth:

• If women can pay for a single room what is the average cost per night (GBP): 0

• Does the maternity unit have a neonatal intensive care unit:

• Does the maternity unit have a neonatal high dependency unit:

• Does the maternity unit have a special care baby unit:

• Security measures - ankle bands for the baby:

• Security measures - cot alarms:

• Security measures - CCTV:

• Security measures - restricted access:

• Other security measures: 0

• Pain relief available - bath or shower: Provided by unit

• Pain relief available - birthing pool: Provided by unit

• Pain relief available - birth ball: Provided by unit

• Pain relief available - Massage: Not available

• Pain relief available - Aromatherapy: Not available

• Pain relief available - TENS: Not available

• Pain relief available - Epidural: Provided by unit

• Pain relief available - Mobile epidural: Provided by unit

• Pain relief available - Entonox (gas and air): Provided by unit

• Pain relief available - Intramuscular injection: Provided by unit

• Other pain relief: 0

• Does the unit have midwives available to provide one-to-one care available 24 hours a day, 7 days a week: On site

• Does the unit have midwives available for home births available 24 hours a day, 7 days a week: On call

• Does the unit have midwives trained and experienced in water birth available 24 hours a day, 7 days a week: On site

• Does the unit have a paediatrician available 24 hours a day, 7 days a week: On site

• Does the unit have an obstetrician available 24 hours a day, 7 days a week: On site

• Does the unit have an anaesthetist available 24 hours a day, 7 days a week: On site

• Does the unit have a dedicated obstetric anaesthetist available 24 hours a day, 7 days a week: On site

• Furness General Hospital - Consultant Led

• How many women gave birth in the unit during the year? (not including home births): 764

• How many babies were born in the unit during the year? (not including home births): 764

• How many women were booked for a home birth: 0

• How many women had a home birth? (not including births at home by accident): 0

• Number of antenatal rooms: 0

• Total antenatal beds: 0

• Number of assessment area rooms (for monitoring and / or induction): 0

• Total assessment area beds: 0

• Number of delivery rooms: 0

• Total delivery beds: 0

• Number of postnatal rooms: 0

• Total postnatal beds: 0

• Number of rooms in obstetric high dependency unit: 0

• Total obstetric high dependency beds: 0

• Number of single rooms used for both delivery and postnatal care (labour, delivery, recovery and postnatal, or LDRP, rooms): 0

• Amenity rooms; Are women able to book a single room in advance of their birth:

• If women can pay for a single room what is the average cost per night (GBP): 0

• Does the maternity unit have a neonatal intensive care unit:

• Does the maternity unit have a neonatal high dependency unit:

• Does the maternity unit have a special care baby unit:

• Security measures - ankle bands for the baby:

• Security measures - cot alarms:

• Security measures - CCTV:

• Security measures - restricted access:

• Other security measures: 0

• Pain relief available - bath or shower: Provided by unit

• Pain relief available - birthing pool: Provided by unit

• Pain relief available - birth ball: Provided by unit

• Pain relief available - Massage: Not available

• Pain relief available - Aromatherapy: Not available

• Pain relief available - TENS: Not available

• Pain relief available - Epidural: Provided by unit

• Pain relief available - Mobile epidural: Provided by unit

• Pain relief available - Entonox (gas and air): Provided by unit

• Pain relief available - Intramuscular injection: Provided by unit

• Other pain relief: 0

• Does the unit have midwives available to provide one-to-one care available 24 hours a day, 7 days a week: On site

• Does the unit have midwives available for home births available 24 hours a day, 7 days a week: On call

• Does the unit have midwives trained and experienced in water birth available 24 hours a day, 7 days a week: On site

• Does the unit have a paediatrician available 24 hours a day, 7 days a week: On site

• Does the unit have an obstetrician available 24 hours a day, 7 days a week: On site

• Does the unit have an anaesthetist available 24 hours a day, 7 days a week: On site

• Does the unit have a dedicated obstetric anaesthetist available 24 hours a day, 7 days a week:

Trust Questions

• Do all women have a choice about where they receive their antenatal appointments (i.e. at hospital or local health centre):

• Are NHS antenatal classes available (e.g. Parentcraft):

• Available during the daytime (until 5pm):

• Available in the evenings (after 5pm):

• Available at weekends (Saturday and/or Sunday): unit tours

• Available for women only groups: woudl be arranged on one to one basis as required

• Available for other groups:

• Are all women routinely offered ultrasound scans:

• Scan 1 available between: around 12 weeks

• Scan 2 available between: around 20 weeks

Trust Statistics

Trust Questions

• You can view various measures relating to the Trust's performance by clicking the following link: University Hospitals of Morecambe Bay NHS Foundation Trust