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Ormskirk District General hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 15 November 2016

We rated the hospital as requires improvement overall which is no change from the last inspection in November 2015.The same four of the fivedomains were judged to be requiring improvement with the caring domain rated as good. Urgent care and outpatient services remained at a rating of good. Surgery and children's services moved down from a good rating to requires improvement andmaternity services had improved moving from an overall rating of inadequate to requires improvement. End of life services were inspected and reported in the Southport and Formby DGH report as the service was delivered by the same team trust wide.

Our key findings since our last inspection were as follows:

  • Concerns raised regarding staffing in the paediatric emergency department (PED) had been addressed and staff were no longer pulled away from the department to undertake other duties. Work had been done to strengthen governance with regular meetings and risk registers were in place. We also found innovative work for orthopaedic care and goal directed therapy was undertaken in the PED.

  • In the medical service the RMO position was unchanged however a foundation year two doctor had been recruited to support them. There were concerns regarding the nurse staffing especially at night and the lack of seven day working across the therapy services was having a detrimental effect on patients rehabilitation particularly in regards to swallow assessments where patients could wait three days over a weekend for assessment. There also appeared to be a lack of documented oversight of the matrons in regard to regular reviews of infection control measures, equipment and records.

  • In the surgery services there remained a large number of staff vacancies in theatres and there was still no approved schedule for replacing older equipment. There were 10 vacancies in theatres and although it was reported that five new members of staff had been recruited, they had not commenced in post and no start date had been identified. The situation was unchanged from the last inspection. There remained no approved schedule for replacing older theatre equipment and there was no funding identified to address this. There was no clear vision for the future of surgical services at ODGH. There was extra capacity at the hospital, which contrasted sharply with the situation at Southport and Formby District General Hospital (SFDGH). We saw a business case for all urology procedures to be transferred to ODGH. We found that no decision had been made about the future, but could only be made as part of a decision in the wider healthcare economy.

  • Following a rating of inadequate in maternity services the Royal College of Obstetrics and Gynaecology (RCOG) completed a review commissioned by the trust in August 2015. As a result of this review 26 recommendations were made which included immediate changes to procedures to improve patient safety, review of staffing arrangements and improvements in governance. At this inspection we found managers and staff had accepted the outcome of that report, identified the changes required and implemented an improvement plan to change practices and develop the service. Whilst some of this work was on-going a vast majority had been completed and both midwifery and medical staff spoke about the positive changes which had taken place. There was acknowledgement that some changes were in their infancy and results could not yet be measured and others were still to be implemented. However there were examples of service improvements which had resulted in positive changes to patient care and improvements in staff culture.

  • In the Children’s and young people’s services safe, caring and well-led were rated as ‘good’ but it was deemed requires improvement in the effective and responsive domain because patient records were kept in unlocked trolleys across the service; paediatric policies, pathways and procedures were out of date or available and the dissemination of actions from complaints required strengthening as complaints were not addressed in a timely manner and there was no evidence of learning from them. The 2014 CQC inspection identified that the children and adolescence mental health service was limited, which often meant that children were not assessed during the weekend. CAHMS support from West Lancashire team out of hours for patients who presented with psychosis or severe intent to self-harm remained restricted due to financial provisions. The ward did not have an isolated room available for CAMHS patients but side rooms were used if available however, staff carried out risk assessment before patients were placed in rooms.

  • The rating remained the same for the outpatients and diagnostics departments who received a rating of ‘good’ for being safe, caring, responsive and well-led (effective is not rated under the current guidance). We found the hospital performed well against national targets. Waiting times for appointments were better than average. Radiology figures were excellent for both receiving appointments and results. In the last 12 months, less than 1% of patients waited six weeks for a radiology appointment. There were a large number of appointment cancellations that had a variety of causes including IT issues; patients received multiple appointments in error. However, managers were gathering evidence and had set improvement targets.

However, there were areas of poor practice where the trust needs to make improvements.

In surgery

  • The service must ensure that there are sufficient staff in theatre area.

  • The service must ensure that that there is a schedule for the replacement of old theatre equipment.

  • The service must ensure that the WHO checklist is completed in full on every occasion.

  • The service must take action to develop an action plan to reduce the high readmission rate in elective surgery.

  • The service must take action to ensure that mortality and morbidity events in surgical services are reported to the trust board.

In medicine

  • The service must take action to ensure that all staff have the up to date training they require to be able to safety care and treat patients in line with trust policy.

  • The service must ensure that all records relating to patients are kept securely.

  • The service must ensure that there are always sufficient numbers of qualified, competent staff on the ward and ensure there is adequate medical cover to provide the RMO with sufficient time off.

  • The service must take action to ensure that any patient who is deemed not to have capacity to consent to remain in hospital and does not wish to do so has a relevant and up to date deprivation of liberty safeguard in place. All actions taken in the patients best interests must be recorded.

In maternity and gynaecology

  • The service must take action to ensure that controlled drugs on the labour ward are correctly stored and staff do not have to leave the operating theatre to obtain controlled drugs.

  • The second obstetric theatre must be suitable for the purpose for which it is being used.

  • The administration area for the community midwives must be fit for the purpose for which it is being used, including provision for ensuring the privacy of a service user when speaking on the telephone and between professionals.

    In children’s

  • The service must ensure that all clinical pathways are up to date and reflect current standards and guidance.

  • The service must ensure complaints are dealt with robustly and in a timely manner.

In children’s

  • The service must ensure that all clinical pathways are up to date and reflect current standards and guidance.

  • The service must ensure complaints are dealt with robustly and in a timely manner.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 15 November 2016

Effective

Requires improvement

Updated 15 November 2016

Caring

Good

Updated 15 November 2016

Responsive

Requires improvement

Updated 15 November 2016

Well-led

Requires improvement

Updated 15 November 2016

Checks on specific services

Maternity and gynaecology

Requires improvement

Updated 15 November 2016

At the last inspection we found maternity and gynaecology services to be inadequate overall. They were rated inadequate in safe and well led, requires improvement in effective and responsive and good in caring. Improvements had been made and at this inspection we rated them as requires improvement in safe, effective, responsive and well led and good in caring.

In August 2015 the Royal College of Obstetrics and Gynaecology (RCOG) completed a review of the obstetric care provided. This was commissioned by the trust to “review the obstetric services at Ormskirk District General Hospital based on the findings of the CQC report dated November 2014 with an emphasis on patient safety and clinical governance”. As a result of this review 26 recommendations were made which included immediate changes to procedures to improve patient safety, review of staffing arrangements and improvements in governance.

At this inspection we found managers and staff had accepted the outcome of that report, identified the changes required and implemented an improvement plan to change practices and develop the service. Whilst some of this work was ongoing a vast majority had been completed and both midwifery and medical staff spoke about the positive changes which had taken place. There was acknowledgement that some changes were in their infancy and results could not yet be measured and others were still to be implemented. However there were examples of service improvements which had resulted in positive changes to patient care and improvements in staff culture.

Whilst improvements had been made to the investigation and system for learning from incidents there were some delays in the production of reports and sharing of information.

Some practices did not meet national or local policy guidance this included infection control practices, medicine management and checking of emergency equipment.

There were risks of safeguarding information not being shared due to issues with the new patient electronic record system.

There were environmental concerns with the second obstetric theatre and the administration area for community midwives in Southport and Formby District General Hospital.

Some of the risks to patients of not receiving blood products in a timely way remained the same as the last inspection.

The issues with access to the patient electronic record system for community midwives meant they could not easily access information for community visits they had to complete.

Not all patient outcomes were benchmarked against available national data.

84% of nursing and midwifery staff were up to date with their mandatory training which did not meet the trusts’ target of 90%. Appraisal rates for gynaecology nursing staff and midwives were below the trusts’ target.

There was a lack of understanding of the deprivation of liberty safeguards on the gynaecology ward.

The hospital scored worse than other trusts in three questions in the labour and birth section of the 2015 CQC survey of Women’s experiences of maternity services. An action plan was in place to address this.

Environmental constraints limited partners ability to be as involved as they would like during the hospital stay.

There was a lack of specialist midwives and a lack of facilities for bereaved parents.

However;

Changes to the risk assessments for patients at risk of a post-partum haemorrhage had been introduced with a process for meeting the RCOG recommendation of transferring those patients to other units.

Improvements had been made to mortality and morbidity reviews.

An electronic patient information system had been introduced although there were some issues with lack of compatibility with the other systems in use.

There was a full audit programme and changes were made as a result where necessary.

There were sufficient maternity, nursing and medical staff on duty.

Most guidelines were up to date and in line with relevant National guidance.

The referral to treatment times for gynaecology patients met the national recommendations.

Changes to the clinic environment meant gynaecology patients had a contained outpatient area.

Changes to the termination of pregnancy service meant those patients no longer came into contact with pregnant women.

A comprehensive information system for monitoring patient outcomes had been developed and monthly exception reports meant trends were identified, monitored and where necessary investigated.

There had been improvements in the training of midwives to assist in the operating theatres which increased their competence in this role.

We observed staff in the maternity and gynaecology services to be kind, caring and respectful. The privacy and dignity of patients was protected.

Changes to the maternity admissions system meant improvements for patients through triage and induction of labour.

Since the last inspection there had been significant and numerous changes to the management of the maternity services. This included improvements in the governance, risk management systems, development and implementation of a maternity improvement plan and increased staff and public engagement. The sustainability of these improvements would be vital to the continued success of the service.

Medical care (including older people’s care)

Requires improvement

Updated 15 November 2016

At the last inspection in November 2014, we rated medical services at Ormskirk district general hospital as requires improvement overall. The service required improvement in the safe, effective and responsive domains and was rated good in the caring and well-led domains.

At this inspection we rated medical services at Ormskirk district hospital as requires improvement because;

A Resident Medical Officer (RMO) was employed to provide medical cover 9am to 5pm through the day and on call through the night for a whole two week period without a rest break. There was also a junior doctor who worked Monday to Friday 8am to 6pm. The RMO also covered other wards at Ormskirk hospital. This risked that if the RMO was called out that they would not receive adequate breaks leaving them overworked and exhausted.

Overnight there were two qualified staff and no regular unqualified staff. Staff reported that this caused some difficulties as it often meant having to stop giving medication and attend to personal care tasks. It also meant that if trained nurses were attending to deteriorating patients then there were no staff to support patients with their personal care needs.

The service was not equitable across the week. There was no routine medical cover on H ward at weekends to see and treat any patients that required medical attention.A junior doctor on the ward worked Monday to Friday 8am to 6pm and any medical cover outside of this time was provided by the RMO on call. The therapy team worked Monday to Friday 8.30am to 4.30pm and there was no routine cover for patients to receive therapy over the weekend this included swallow assessment and patients that were nil by mouth on a Friday would need to remain nil by mouth over a weekend  This risked vulnerable patients who were already malnourished without access to diet and fluids over a weekend.

Records on the ward were not stored securely in a lockable trolley on the ward next to the nursing station and nursing assessments were stored in a plastic box under the desk. This did not provide the security required to ensure the confidentiality of patient records.

Compliance with core competency training was variable. There were no formal cleaning rotas in place but it was evident  that the ward was being cleaned. We also found that matron checklists had not been completed formally since July 2015. The checklist ensures that ward quality is maintained and evidence that wards are compliant with all policy and procedures.

However,

Medical care services were delivered by hardworking, caring and compassionate staff who treated patients with dignity and respect. Local leadership was good, and staff felt supported by their immediate managers. All patients we spoke with were positive about their interactions with staff. They told us that the staff were kind, polite and respectful, and they were happy with the care they received.

The percentage of patients who returned back to their usual residence following rehabilitation was 77% and the average length of stay was17.3 days on the ward before being discharged. Discharge was supported by good communication and co-operation between the hospital staff and local community teams from both the NHS and local authority, which enabled safe, timely and effective discharge of patients.

Urgent and emergency services (A&E)

Good

Updated 15 November 2016

Following previous concerns about staffing in the paediatric emergency department (PED), we saw practice had changed to ensure staff were not routinely undertaking duties which pulled them away from the department (such as on call bed management duties).

There was a culture of reporting and learning from incidents. Areas we inspected were visibly clean and tidy and staff responsible for cleaning followed protocols which helped control infection. The infrastructure was fit for purpose and equipment, medicines and controlled drugs were stored appropriately.Records were stored securely with legible, relevant information recorded.

Processes, guidelines and pathways supported staff reporting safeguarding concerns, ensured staff maintained compliance with training and helped staff manage potential risks to patients. Some local audits were done to measure outcomes.

Staff worked together to provide care for patients. Where services were not available 24 hours per day, processes were in place to ensure care could still be provided. Pain was appropriately monitored, with pain relief provided if necessary.

Patients and carers felt happy with the care provided, and felt that treatment was fully explained in a way they could understand. We observed compassionate care being provided by staff who were mindful of privacy and dignity when moving between areas. Bereavement support was available for those who had lost someone.

Waiting areas catered for the needs of patients. Translation was available for patients whose first language was not English. A hearing loop and sign language facilities were also available. Specialist nurses provided specific care for certain ailments.

Wait times were not excessive and department of health targets were being met.

Low levels of complaints were received and findings were disseminated to staff to promote learning.

Staff had visions of how services could be improved for patients. Work had been done to strengthen governance since our last inspection with regular meetings and risk registers in place.

We saw examples of managers engaging with staff. Staff told us they felt happy to work for the trust and proud of the teams they worked with. Engagement with the public also took place to help educate and familiarise them with the service.

Innovative work for orthopaedic care and goal directed therapy was undertaken in the PED.

Surgery

Requires improvement

Updated 15 November 2016

The previous inspection in November 2014 found all domains of surgical services at ODGH to be good apart from safe. Safe was found to require improvement because of the large number of vacancies in theatres, the lack of approved schedule for replacing older equipment used in theatres and that the only medical cover was provided by a resident medical officer (RMO).

This inspection identified that surgical services still required improvement in safe.We also found that it required improvement in well-led. For effective, caring and responsive we rated it as good.

There were still a large number of staff vacancies in theatres and there was still no approved schedule for replacing older equipment. There were 10 vacancies in theatres and although it was reported that five new members of staff had been recruited, they had not commenced in post and no start date had been identified. The situation was not very different from the last inspection.

There was still no approved schedule for replacing older theatre equipment. The issue appeared on the risk register of the planned care division, but there was no funding attached to it and it was clear that it would not be addressed until funding was identified.

In well-led, the situation had deteriorated from the last inspection because there was no clear vision for the future of surgical services at ODGH. There was extra capacity at the hospital, which contrasted sharply with the situation at Southport and Formby District General Hospital (SFDGH). We saw a business case for all urology procedures to be transferred to ODGH.We found that no decision had been made about the future, but could only be made as part of a decision in the wider healthcare economy.

Morale was poor amongst significant sections of clinical staff. Staff reported concern about the length of time that disciplinary investigations took and that clinical staff were suspended for lengthy periods of time. Staff reported that this approach created a culture of fear. There were high rates of sickness in some important areas of the service. Staff based at ODGH felt isolated from the rest of the trust and reported that they did not see executive directors.

However;

Since the last inspection a foundation year two doctor had been recruited to support the RMO at ODGH.

The standard of documentation was good, with evidence of all risk assessments being carried out and reviewed. Services were effective, implementing national and local guidelines. There were planned pre-operative assessments taking place.

Services were also responsive, in that they were planned to meet the needs of the local population and took into account the complex needs of individual patients.

Services for children & young people

Requires improvement

Updated 15 November 2016

The hospital was previously inspected by the Care Quality Commission in November 2014 and Children’s and Young people’s service received a good rating across the all domains. During this inspection, the Children’s and young people’s services received a rating of ‘good’ for being safe, caring and well-led however the overall rating was deemed requires improvement because the effective and responsive domain was rated as requires improvement.

  • Although Staff knew what constituted as an incident and regularly reported them in categories of; no harm caused, low harm, moderate short term harm need further treatment / procedure or severe harm caused, we found 57 incidents relating to medication during February 2015 – January 2016. Discrepancies relating to medicine management had been addressed and involvement from the pharmacist was sought to improve practice.
  • Patient records on the ward and neonatal unit were kept in unlocked trolleys across the service; this meant that they were accessible to visitors.
  • There was no robust major incident planning, staff were not aware of their roles and responsibilities if a major incident was declared.
  • Policies, pathways and procedures were out of date or available. This meant they did not reflect current guidelines and best practice. Reviewed pathways used by staff on a day to day basis were not referenced and therefore we could not determine which guidance they were taken from.
  • Multidisciplinary team working was evident during ward rounds and handovers. However there was a lack of communication across other services such as theatres. Children attended pre op clinics alongside adults without informing clinical leads of the children’s and young people’s service.

  • The public, parents of children and babies using the services were not involved in developing the service, however diabetes patients were offered meetings to share experiences and learn how to self-care for their condition.

  • Dissemination of actions from complaints required to being more robust, complaints were not addressed in a timely manner and there was no evidence of learning from complaints.

  • Leaflets were not responsive to the needs of children’s visiting the ward. Information was available in English but was not available in different languages. Patient information was not in a child friendly format, leaflets contained long descriptions of conditions such as bronchiolitis or febrile convulsion.
  • The 2014 CQC inspection identified that the children and adolescence mental health service was limited, which often meant that children were not assessed during the weekend. CAHMS support from West Lancashire team out of hours for patients who presented with psychosis or severe intent to self-harm was restricted due to financial provisions. The ward did not have an isolated room available for CAMHS patients but side rooms were used if available. Staff carried out risk assessment before patients were placed in rooms. . However senior managers were aware, side rooms were not always available when the ward was busy and patients would be placed with other patients.
  • Senior managers did not involve children and their families to develop and plan the children, and young people’s,
  • The service did not have an executive or non-executive lead, and therefore was not represented at board level.

However,

  • The service actively audited hand hygiene practice and environmental checks were regularly recoded. Hand gels were readily available across the ward and neonatal unit.
  • Safeguarding referrals were appropriately escalated, clinicians, nursing and social services staff met regularly to discuss concerns.
  • Mandatory training arrangements were in place; staff who had not attended mandatory training were identified and given protected time to complete.
  • We reviewed a sample of staffing rotas between January – April 2016 whilst on inspection. Staffing reflected the British Association of Perinatal Medicine (BAPM) on the neonatal unit and the Royal College of Nursing (RCN) standards on the ward.
  • Pain and nutritional and hydration needs of children was routinely assessed. The ward used the paediatric early warning score system to assess poorly children. A pain rating scale was used to help children communicate information about pain alongside assessments and observations. Fluid charts contained the weight and the child’s age so that staff could calculate the appropriate levels of fluids
  • The service participated in local and national audits; we found that staff actively reviewed patient outcomes to improve their service. Actions from audits were documented and timescales were set appropriately. The neonatal unit actively collected data for the Bliss audit and were awarded a prize of monetary value which was used to furnish the parent’s room.
  • Staff were competent in their roles and given opportunities to upskill themselves. We saw a number of competency frameworks to support staff when staff were rotated across the service or sent to help busy areas such as a paediatric nurse sent to alleviate staffing pressures on the neonatal unit. Annual appraisals were regularly completed and personal development opportunities were identified and supported.
  • The transition pathway was clear and supported by a three step guide to transitioning children. Children and their families were supported by clinicians and nursing staff, who coordinated care.
  • Staff sought appropriate consent from patients and those close to them before delivering care and treatment. Gillick competency guidelines were used to decide whether a child or young person had the mental capacity to understand information about their care and treatment.
  • Staff delivered compassionate care to children, the privacy; dignity was respected and maintained when care was provided. Families were informed about their child’s care and actively participated in developing their child’s care plan. Staff recognised when children and their families required additional support such as the need for an interpreter. Staff demonstrated an empathetic and considerate attitude towards children and their families.
  • The local leadership on the ward and unit was visible and leaders were approachable.
  • Staff received information about changes to practice and policies through staff meetings and emails. The trust wide newsletter was sent to staff, this announced achievements to other services.
  • Senior managers recognised the need to consider innovative ways to develop their service. Senior managers had written a business case to employ two more Advanced Paediatric Nurse Practitioners to increase the workforce because the senior managers believed there would be a shortage of junior doctors in the future.

End of life care

Good

Updated 13 May 2015

We found that the end of life/palliative care services at Ormskirk Hospital were generally good, and were supported by a robust training programme and adherence to national guidelines.

Staff from both the general wards displayed enthusiasm to provide safe, effective and compassionate care to patients reaching the end of their life. The multidisciplinary team worked well together to achieve this. This enthusiasm and desire to maintain competencies was particularly commendable considering the small number of patients at the end of life that the staff came into contact with.

The mortuary and bereavement service was focused on making its environment and interaction with patients and relatives as minimally distressing as possible, and displayed excellent, innovative care.

Outpatients

Good

Updated 15 November 2016

The hospital was previously inspected by the Care Quality Commission in November 2014 and outpatients and diagnostic imaging received a good rating across the domains. At this inspection, the rating remained the same and the outpatients and diagnostics departments received a rating of ‘good’ for being safe, caring, responsive and well-led (effective is not rated under the current guidance).

At this inspection, we found the hospital performed well against national targets. Waiting times for appointments were better than average with 50% of patients receiving an appointment within five weeks of referral. Radiology figures were excellent for both receiving appointments and results. In the last 12 months, less than 1% of patients waited six weeks for a radiology appointment. There were a large number of appointment cancellations that had a variety of causes including IT issues, patients received multiple appointments in error. However, managers were gathering evidence and had set improvement targets.

A large number of audits were performed to ensure patients received treatment in line with best practice guidance and there was evidence of collaborative working with neighbourhood trusts.

Staff were positively encouraged to further their education and gave us examples of courses and qualifications gained within their speciality. Some areas of mandatory training showed poor results and managers acknowledged that work was needed.

When something went wrong, the outpatients and diagnostic departments responded well to patients and investigated the causes to make sure errors did not reoccur.

Patients had positive opinions about the hospital and a recent survey of 86 people gave the hospital an overall rating of 4.4 out of 5.

The outpatient improvement project was still progressing from 2014; changes had been made to the environment, clinical coding and staffing ratios. Phase four had been suspended due to staffing issues, which was to address the high cancellation numbers.