All inspections: Southport and Ormskirk Hospital NHS Trust

Our rating of the trust stayed the same. We rated it as requires improvement because:

We rated safe, effective, responsive and well-led as requires improvement, and caring as good. At this inspection we inspected eight core services. We rated five of the trust’s services as good and three as requires improvement. In rating the trust, we took into account the current ratings of the four services not inspected this time. This means overall there are six services rated as requires improvement and six services with overall ratings of good.
We rated well-led for the trust overall as requires improvement.
We were concerned that issues raised at our previous inspection in relation to medical wards had not been effectively addressed and mitigated in a timely manner. Our concerns meant the rating for the well-led domain for medicine remained inadequate.
Across the trust we were concerned regarding the completion levels of mandatory training for resuscitation (61%).
At our last inspection we had concerns relating to the storage of hazardous materials. At this inspection we remained concerned.
We identified concerns during our last inspection as we found the use of bed rails was not consistent with the trust’s policy. Patients’ needs were not always assessed, which represented a patient safety risk. We found similar concerns at this inspection.
We were concerned regarding medicines, including medicines that were passed their expiry date and in relation to the way that controlled drugs were managed. We escalated this to the trust at the time of our inspection.
At our last inspection during our reviews of records we identified that staff had not completed documentation for Mental Capacity Act, Deprivation of Liberty safeguards and do not attempt cardiopulmonary resuscitation plans appropriately. This represented a patient safety risk. We had similar concerns at this inspection.
We were concerned regarding staff competencies including how they were evidenced. In relation to equipment, we were not assured that the trust had oversight as to whether staff were competent. We found gaps in records relating to competencies. Staff were also unclear regarding their roles and responsibilities in relation to capacity assessments.

However:

During this inspection we improved the overall rating of children and young people’s services and the rating for effective in end of life care to good. We improved the safe domain rating for urgent and emergency services to requires improvement. Our overall hospital rating for the well-led domain was improved to requires improvement.
Since our last inspection the trust had developed a strategy and a vision, which most staff were aware of.
Our full inspection report summarising what we found and the supporting Evidence appendix containing detailed evidence and data about the trust is available on our website – https://www.cqc.org.uk/provider/RVY/reports

Our rating of this service stayed the same. We rated it as good because:

The service provided mandatory training in key skills to all staff and made sure everyone completed it. The mandatory training was comprehensive and met the needs of patients and staff.
Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse, and they knew how to apply it.
The service controlled infection risk well. Staff used equipment and control measures to protect patients, themselves and others from infection. They kept equipment and the premises visibly clean.
The service provided care and treatment based on national guidance and evidence-based practice which was specific to sexual health and contraception services. Managers checked to make sure staff followed guidance. Staff had links with community mental health services so that adults and children could get their mental health needs addressed when and if issues arose.
Staff gave patients practical support and advice to lead healthier lives. We found the community outreach team to be responsive and creative in its practice with young people and vulnerable communities.
Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.
Staff supported and involved patients, families and carers to understand their condition and make decisions about their care and treatment. The service provided bespoke training to parents to enhance family conversations about sexual health
The service was inclusive and took account of patients’ individual needs and preferences. Staff made reasonable adjustments to help patients access services. They coordinated care with other services and providers.
Patients had a wide range of access points into the service when they needed care and treatment. However, the service sometimes had long waiting times of up to two hours at specific times during some of its walk-in clinics.
Leaders had the integrity, skills and abilities to run the service and this was being done whilst teams and the whole service were going through transitional changes, including job roles. They understood and managed the priorities and issues the service faced and sought support to enhance leadership by gaining additional support due to structural change.
The service had an evolving vision for what it wanted to achieve and a strategy to turn it into action, developed with all relevant stakeholders.
The vast majority of staff felt respected, supported and valued, however the service was going through structural change which impacted on some staff members. Despite these changes staff were focused on the needs of patients receiving care.
The service collected reliable data and analysed it. Staff could find the data they needed, in easily accessible formats, to understand performance, make decisions and improvements.
All staff were committed to continually learning and improving services. They had a good understanding of quality improvement methods and the skills to use them. Leaders encouraged innovation and participation in research.

However:

We found the majority of staff were competent for their roles and were supplied nationally accredited enhanced training. However, supervision rates and appraisal rates needed to improve in some staffing groups.

During our inspection we found areas of the surgical, medical and urgent and emergency care department at Southport hospital that weren’t visibly clean. This included equipment in wards. We escalated this to the trust at the time of our inspection.
In surgery, records we reviewed showed that not all theatre recovery staff had completed immediate or advanced life support training.
At Southport hospital in spinal injuries, medicine and surgery we found that patients with transmittable infections were not nursed in accordance with the trust’s policy or best practice guidance. This included staff not wearing suitable personal protection to minimise the spread of infection. We escalated this to the trust at the time of the inspection.
At Ormskirk hospital we found a fire exit that was propped open. This is not in accordance with the trust’s policy or legal requirements.
In the emergency department and surgical wards at Southport, hazardous substances were not securely stored in ward areas. This represented a patient safety risk.
In surgery we found that some medication, including oxygen, was not recorded when administered.
At Southport in surgery we found the use of bed rails was not consistent with the trust’s policy. Patients’ needs were not always assessed, which represented a patient safety risk. We escalated this to the trust at the time of our inspection.
In maternity, surgery, medicine and urgent and emergency care we found that thorough checks of emergency equipment, including resuscitation trolleys were not completed. During inspection we found out of date medications and missing equipment. We escalated this to the trust at the time of our inspection.
During the inspection we identified that records were not securely stored across most areas we inspected, excluding urgent and emergency care at Ormskirk. Staff were not following the trust’s policy. We escalated this to the trust at the time of our inspection.
Across medical and surgical wards we identified there were insufficient numbers of staff to assist with patients’ dietary needs.
During our reviews of records we identified that staff had not completed documentation for Mental Capacity Act, Deprivation of Liberty safeguards and do not attempt cardiopulmonary resuscitation plans appropriately. This represented a patient safety risk. We escalated this to the trust at the time of our inspection.
In the emergency department at Southport records did not evidence that patients received access to analgesia in timely manner. We escalated this to the trust at the time of our inspection and immediate action was taken.
In spinal injuries the overall security of the unit meant patients and their personal property and equipment were not sufficiently secure. We escalated this risk to the trust at the time of our inspection and they took immediate action.
At our last inspection we identified concerns regarding mandatory training completion rates at the trust. At this inspection we found that mandatory training levels had generally improved. However, there was still further progress to be made. The trust needed to ensure that sufficient priority continued to be given to mandatory training.
During our inspection, in urgent and emergency care and surgery at Southport, staff were using areas that were not suitable for the purpose they were being used. We escalated this to the trust at the time of our inspection and immediate action was taken.
In urgent and emergency care and spinal injuries patients were not consistently treated with dignity and their privacy was not consistently maintained.
Southport hospital continued to experience challenges in relation to patient flow. Bed occupancy, length of stay, and delayed transfers of care had an impact on the flow of patients throughout the hospital due to the demand for medical services. This impacted on urgent and emergency care where patients were still experiencing long and unacceptable waits for treatment.

During our inspection we identified that the trust’s internal escalation policies were not followed appropriately. Senior staff were aware there was deviation from the process and immediately addressed this.
Across the hospital we found a range of concerns relating to the systems and processes that should be in place to ensure the hospital runs effectively and efficiently. New systems and processes had recently been introduced to address this, but were not fully embedded to ensure all risks were identified and addressed.
The trust did not have a current strategy. As a result staff did not understand how their role contributed to achieving the organisation’s strategic goals.
The absence of a strategy meant services did not have meaningful and measurable plans in place in order to achieve strategic goals.
There was no credible statement of vision and staff awareness of the organisation’s values was limited.

However:

Safeguarding adults, children and young people at risk was given sufficient priority. Staff took a proactive approach to safeguarding and focused on early identification. They took steps to prevent abuse or discrimination that might cause avoidable harm, responded appropriately to any signs or allegations of abuse and worked effectively with others, including people using the service, to agree and implement protection plans. There was active and appropriate engagement in local safeguarding procedures and effective work with other relevant organisations, including when people experienced harassment or abuse in the community.
Since our last inspection mandatory training levels had improved across the trust. Whilst they were still below the trust’s target of 90%, they had significantly improved to average 78% across all areas.
Across most areas of the trust staffing levels and skill mix were planned, implemented and reviewed to keep people safe at all times. Where relevant, there were effective handovers and shift changes to ensure that staff could manage risks to people who used services.
In most areas of the trust people’s care and treatment was planned and delivered in line with current evidence-based guidance, standards, best practice, legislation and technologies.
People received coordinated care from a range of different staff, teams or services. All relevant staff, teams and services were involved in assessing, planning and delivering people’s care and treatment. Staff worked collaboratively to understand and meet the range and complexity of people’s needs.
Across most areas of the trust, people were supported, treated with dignity and respect, and were involved as partners in their care.
The majority of the trust was easily accessible for patients who required assistance with mobility, including patients who required the use of a wheelchair.

Southport and Ormskirk NHS Trust has two hospitals and a walk in centre and provides community services to a local population of 258,000 people across Southport, Formby, Sefton and West Lancashire. The health of people in Sefton is mainly worse compared with the England average. The trust is an integrated care organisation (ICO), delivering care in hospital and the community and employs approximately 3,242 staff of which 270 are medical, 1,052 are nursing and 1920 are other disciplines.

Acute care is provided at Southport and Formby District General Hospital and Ormskirk District General Hospital and had 23,084 admissions between September 2014 and August 2015. There are 497 beds, 455 General and acute, 27 Maternity and 15 Critical care.

We conducted a focussed follow up inspection of Southport and Ormskirk NHS Hospitals Trust between 8 and 11 April 2016. This was to review the progress of the trust following a previous inspection in November 2014 when concerns were raised. We visited Southport and Formby District General Hospital, Ormskirk District General Hospital and the Skelmersdale Walk in Centre. We also visited the community services for adults, end of life and children and young people’s sexual health services.

We reviewed all the services across the trust including all the areas of concern which were raised at the previous inspection in order to assess any changes.

Overall the trust has been rated as requires improvement with significant concern for safety identified in the Accident and Emergency Department and the surgical services at Southport and Formby District General Hospital. However, there was improvement noted in both the maternity services and the North West Regional Spinal Injuries Centre which both received inadequate ratings at the last inspection.

Our key findings were as follows:

Vision, Strategy and leadership

At the time of the inspection the trust had been led by an interim executive team with the exception of the Director of Nursing and the Medical Director. Interim management arrangements had been in place for the eight months prior to the inspection following the exclusion of three directors including the Chief Executive Officer. The Trust Development Agency (now NHS Improvement) had been and were continuing to support the trust through this challenging period.

The interim team had begun to explore and develop options for the future to in line with national and regional initiatives to change the healthcare landscape in terms of the development of sustainable services, however, at the time of our inspection definitive outcomes had yet to be determined. This limited the trusts ability to demonstrate a clear vision and strategy for the organisation going forward.

Staff engagement had been foremost and the interim executive team had made considerable efforts to engage and be visible to staff at a range of engagement meetings.

There were significant failings within the governance processes of the organisation including a lack of Board oversight of all risks and inconsistent use of the committee structures to provide board assurance. In addition, the pharmacy governance arrangements would not clearly support the principles of the medicines safety alert ‘Improving medication error incident reporting and learning, March 2014’ with regard to identifying, developing and promoting best practice for medication safety.

This was the case despite two never events occurring that related to appropriate medicines management. At the time of our inspection there was no designated committee to lead on the review of medication errors throughout the Trust, and in the absence of a champion, a pilot initiative to collect data for the NHS Medicines Safety Thermometer had been discontinued.

Access and flow

There were significant concerns regarding the management of flow through the hospital despite the trust taking action to promote discharges earlier in the day to allow for admissions from the emergency department.

There continued to be very poor performance regarding patients being seen within four hours in the A&E department with extensive waits for patients who remained in the supervision of the ambulance service for up to 11 hours. Percentage compliance rate against the 4 hour A&E wait differed between the two hospital sites with Ormskirk delivering at high percentages but the Southport site was performing at much lower levels. Over January 2016 Southport performed between 51% and 75% against the Ormskirk site performance between 99% and 100%. This meant that the trust wide performance was between 80% and 89% masking the very poor performance at the Southport site. Year-to-date performance at February 2016 was 92.9%, driven primarily by performance of 60.4% at Southport. February 2016 performance was 84.5% (53.7% in Southport).

The Trust continued to breach the ambulance handover target and performance remained poor with significant breaches in December 2015 and January 2016 (203 '30 minute', 271 '60 minute' up on December's 142 & 159).

We found elements of care for patients with sepsis that were worse than the regional average and in at least one case where the patients care had been poor. We also found that the recording and governance of this patients care was poor.

Other contributing factors included lack of bed space for planned admissions and a lack of escalation facilities at times of high demand. This meant that patients were often placed in areas unsuited to their needs or remaining in the A&E department for long periods of time.

We found that staff did not always assess monitor or manage risks to people who use the services and opportunities to prevent or minimise harm were missed. Medically deteriorating patients were not always identified promptly and when they were identified through the electronic EWS it was reported that out of hours there could be a delay before medical assessment was undertaken. We also saw evidence of a delay in the response time of the critical care outreach team to a patient with a high early warning score. We found that nutritional risk assessments were not always completed for patients who were clearly vulnerable. In addition fluid balance charts were not consistently kept updated on all wards.

The GP assessment area was used as an escalation area for medical patients and consequently there was underutilisation of ambulatory care. There were surgical patients waiting in the emergency department for assessment causing additional 4 hour breaches.

Patients on the acute wards waited for rehabilitation beds at Ormskirk DGH and there were delayed discharges of medically fit patients.

Nurse and midwifery staffing

The nursing and midwifery teams were positive about the impact of the Director of Nursing in terms of support and service improvement, however it was acknowledged that there was still much to do in terms of recruiting suitable and sufficient numbers of staff within both disciplines.

Recruitment and retention of nursing and midwifery staff was a long standing challenge for the trust and although some progress had been made there were still significant numbers of vacancies, 5% in senior nurses; 7% for nurses below band 7 and 5% in non-clinical staff.

Medical staffing

The recruitment of suitable and sufficient numbers of medical staff was also a managerial challenge at the time of our inspection there remained a 9% medical staff vacancy rate across the trust with 12% vacancy rate within consultants; 11% in other medical grades. We found that medical rotas were not well managed and governed. There was a reactive approach to completing rotas often at the last minute and a lack of oversight by senior staff.

There were ongoing concerns regarding the trusts approach and ability to recruit and retain medical staff.

Mortality and morbidity

The 12 month HSMR to October 2015 was 101.7 (as expected) and was on a downward trajectory reaching 95.2 to November 2015. However mortality due to pneumonia remained high with the report commissioned from Dr Foster in March 2016 showing the HSMR for 12 months to November 2015 as 122.6 and the SHMI for 12 months to June 2015 as 116.8.

There was a lack of consistency to the application and evaluation of the trusts mortality and morbidity review. This meant there may have been missed opportunities for learning and improvement in some services where the process was not appropriately applied of monitored.

Incident reporting

At the time of the inspection he trust was ranked 87 of 137 similar sized organisations for the reporting of incidents The senior team acknowledged the need to increase the reporting of incidents including near misses so that potential risks could be mitigated and opportunities for learning and improvement applied.

There was a lack of risk awareness across the trust and new incident reporting systems within the policy were not fully embedded or understood.

There had been two Never Events reported in the last 12 months both related to medicines management but our review demonstrated that learning had been shared following investigation.

Environment and equipment

The management and replacement of equipment was better managed than at our previous inspection in November 2014 although there remained some areas of concern. In maternity one of the rooms used as a theatre was found not to be fit for purpose and has since been removed from use. Additionally the rehabilitation ward at Ormskirk was unsuitable for the safe and appropriate observation of patients this ward has since moved to an alternative more suitable location.

There were also concerns around the use of the theatre recovery area as an escalation area. This did not meet the needs of the patients and was a potential safety risk. Since our inspection, the trust has ceased this practice.

Mandatory Training

Mandatory training did not meet the trusts targets in 13 of 14 key areas. There was little improvement on the situation as it was in February 2015. The trust target for mandatory training was 90% but in many areas across all disciplines uptake was as low as 30% in some topic areas. In January 2016 Fire training uptake was 67% against a target of 90%; Basic resuscitation training uptake was 76% against a target of 90%; Infection control training uptake was 76% against a 100% target.

Patient Outcomes

There were concerns regarding the assessment and timely care to patients within the emergency department and the monitoring, escalation and treatment for patients whose condition deteriorated whilst they were in the trust in line with the introduction of an electronic EWS. We found examples in the surgical services were nursing staff had not completed the patient observations as per the policy and also had not escalated deteriorating patients to the medical team in a timely way. We raised this with the trust and these incidents were investigated. We were informed that there were some concerns regarding the electronic systems reliability and this was being investigated further.

Safeguarding

Safeguarding had been identified by the trust as an area requiring improvement but actions were on hold pending the results of a second service review. A new appointment to the leadership of the safeguarding service had been made but it was recent and too early to determine the impact on practice. Safeguarding training uptake was good across all disciplines except for administrative staff where it was reported as 0% in the urgent care service.

Fit and Proper Persons Regulation (FPPR)

The trust included the FPPR within the trusts recruitment and selection policy and the procedure was initiated in March 2015. The procedure met the requirements with the exception of the reviews for non-executive directors.

The interim executive’s files were being held centrally by NHS Improvement at the time of the inspection as they held the responsibility for recruitment. However of the seven files of executive and non-executive appointments since November 2014 that were available for review, none contained all the information mandated within the trust policy.

It was evident from our review of records and incidents that although the trust was aware of its obligations in terms of the fit and proper person regulation, a robust process had not been robustly or consistently applied.

Duty of Candour

The duty of candour is a regulatory duty that relates to openness and transparency and requires providers of health and social care services to notify patients (or other relevant persons) of certain ‘notifiable safety incidents’ and provide reasonable support to that person.

Duty of candour was not fully reflected in the trusts DOC guidance, policies were not cross referenced and the description of incidents that require DOC consideration did not include those incidents where moderate/severe harm was identified within a complaint and so were not consistently applied. Assurance processes were not robust and failed to identify all cases where the regulation must be applied due to a lack of a mandatory field within the electronic incident management system in regards to DOC. Staff knowledge and understanding of the DOC regulations was understood at department level however there were limited examples of the Doc being robustly applied.

Workplace Race Equality Standards

The trust was not compliant with Public Sector Equality Duty, which requires objectives to be reviewed annually and published every four years which has not happened and the cycle for 2016-17 was not under way. The contractual requirement for trusts to publish their results for the Workforce Race Equality Standard had not been met as neither had been produced nor published.

The BME consultant focus group recognised improvements since the interim board appointments had been made but still reported perceived discriminatory behaviour towards senior consultants specifically relating to inappropriate practices during recruitment processes and inappropriate use of MHPS and disciplinary processes.

The trust had instigated an independent investigation into these concerns following the previous inspection; however, a number of senior consultants considered opportunities were missed in terms of the scope of the review.

In addition, clinicians felt there was a lack of engagement in terms of their inclusion in service planning and future provision. There was no current clinical strategy and the review of the 2012-15 clinical strategy had not yet commenced.

They had subsequently made the interim Chief Executive and Chair aware of their concerns at an MSC meeting in October 2015. Since then, the Chair of that group had been given assurances that MHPS procedures would be better supervised and used appropriately.

However, a number of consultants continued to feel that further changes were required as they felt that there was very limited engagement and opportunities for inclusion.

However;

We saw significant improvements across all aspects of patient care and treatment at the North West Regional Spinal Injuries Unit that was rated as inadequate for safety at the last inspection. It is now rated as Good with some aspects of outstanding care practice.

We also saw improvement within the maternity service which was also rated as inadequate in the safety and well led domains at the last inspection. This rating has improved to requires improvement in both domains.

The new DON was having a positive impact in relation to the nursing agenda and nursing staff engagement.

We also found a lack of pace to the implementation of required improvements and a number of the improvements required at our last inspection were still to be implemented.

We saw several areas of outstanding practice including:

The NWRSIC service had developed improvement in information for healthcare professionals. For example, following assessment, the outreach team had produced a document with written advice and instructions. This document had been developed by the NWRSIC by taking into account standards and protocols for SCI management practised nationally. This document has also been developed in co-operation and discussion with the outreach team at the Midlands Spinal Injuries Centre at Oswestry.
The centre has been pivotal in providing training to other Spinal and Rehabilitation Centre’s for the development of intrathecal baclofen pump services.
The additional capacity the outreach service has brought to the centre had enabled patients referred to the centre from major trauma centres to be admitted faster. The length of referral to admission is now reducing ensuring patients are able to commence their rehabilitation sooner. However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

Assess, monitor and act on the serious concerns raised regarding both the emergency department and surgical services. Particularly around EWS and sepsis management.
Ensure that the governance mechanisms are robust enough to ensure the Board has clear oversight of all risks within the organisation.
Ensure that all executive and non-executive appointees since November 2014 have been reviewed and documentation is held in line with the trusts policy for recruitment and selection in regards to the Fit and Proper person regulation.
Improve the management of risk including the embedding of the revised processes for serious incident reviews including the use of RCA by trained staff and meet the timescales of their policy for Board oversight.
Improve the adherence to the use of and escalation resulting from the use of the Early Warning Score electronic system.
Improve the rigor of the Duty of Candour application.
Improve the consistency and learning from mortality review processes.
Ensure that they address all the actions detailed within the location reports.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Community health services for adults in Southport & Ormskirk were last inspected in November 2015. The service received an overall rating of Requires Improvement although the caring domain was rated as Good. We found staffing numbers to be low and inadequate, particularly in district nursing services. It was felt there was a lack of senior management attention. An action plan was introduced to remedy the situation which we have monitored.

It should be noted that;

At the time of our inspection in April 2016, the service was going through a procurement process in both its commissioned areas of activity.
The trust were not successful in the tender process for the community adult services in West Lancashire and its current adult services would be transferred to a new provider shortly.
The remaining services in Sefton were in the process of being tendered at the time of inspection and the Trust was hopeful of retaining the services commissioned in that area.
It was recognised that the procurement process had an effect on the services ability to proactively develop the shape of its services and may have caused some issues around the recruitment and retention of staff in the period between our inspections.
Whilst we found a certain level of anxiety in the staff group and its managers because of the procurement process, we also found them to be resilient and motivated. The staff had put enormous effort into stabilising the service and were on an upward trajectory to making the service good, despite a number of setbacks.

At this inspection we rated the service as Requiring Improvement because:

Although we saw significant improvement from our last inspection it was from a low base. The service had improved its rating in two areas in both the Responsiveness and the Well Led domains. The Caring domain continued to be good. Safety and Effectiveness were still seen as requiring improvement although improvement had been seen.
Some of the areas of concern which we found in this inspection had been highlighted in our last visit in 2015.
The service had an over reliance on agency staff to cover vacancies. At times agency staffing reached 50% of the workforce, especially in some district nursing teams. The service itself had recognised that this over reliance on agency staff was a risk. Time and energy was targeted towards filling in gaps through the use of agency staffing on a weekly basis. The reliance on agency staffing led to teams having limited time to reflect on future planning of care and reviewing the effectiveness of what they did.
The community health services for adults were unable to show us how they shaped service delivery. The managers in community health services for adults noted that information systems were slow and hard to make sense of both in interview and on the local management log. We felt the service needed to improve at showing how they made patients’ lives better and healthier with hard evidence.
Despite improvements in staffing numbers a legacy still existed of some teams having not undertaken staff meetings or supervision.
Mandatory training rates and personal development plans (PDPs) were below what was expected by the Trusts own standards in a number of community teams.A direct correlation existed between high use of agency staffing and the lack of personal development plans and mandatory training. The numbers of staff in community health services who had been appraised were below the numbers expected in the trusts own performance targets. In some district nursing teams the lack of appraisal was concerning.

However ;

The services staffing numbers were on an upward trend but still required improvement and this had an impact on how well it performed in the area of safety. In February 2015 the teams collectively had 53% of the staff they required to deliver its services. As of January 2016, this figure had risen to over 86% of required staff.
Considerable improvement had been made in leadership. The staff told us that they were listened to by managers and in most cases found that change had occurred after our last inspection.
The responsiveness of staff to patient need was seen as good with appropriate facilities, delivering planned care, in a way that suited individual’s needs.
Whilst teams focused on patient care, staff also told us they were unsure about where they would be employed in the future. Planning for changes in services was on hold until the completion of the final tender bid.
Community health services for adults had developed a reporting tool, which gave senior managers real time updates on staff numbers and enabled them to make high level decisions about filling staff vacancies quickly.
The service had made a concerted effort to fill its vacant staffing positions but this was, mainly by the use of employing agency staff in its teams.
Managers advertised posts based on established staffing levels and used agency to achieve safe levels of care. t all levels managed risk positively and responsively and reacted when needed. Senior managers showed flexibility and pragmatism in allowing the use of agency staff or allowing advertisement of posts due to service need.
We found that the majority of staff were happy about the progress made by the service in terms of staffing and they were appreciative of being listened to and had noticed positive change.
Good processes were in place to reduce the risk of abuse and avoidable harm to patients. Training was on offer so that teams could identify concerns regarding Adult abuse or Child abuse. Systems were in place to report and record concerns about patients who were in the services care.
The data we gathered provided us with evidence that incidents of harm to patients was relatively low when compared to the rest of the Trust.
We were told by staff that teams had an open culture, where they felt free to disclose concerns and report issues as they occurred. The managers showed us that they took those concerns on board by making changes when staff voiced an issue about potential patient safety.
Patients told us they felt safe and “in good hands”, whilst in the care of the community health services for adults.
The service and its teams were seen as providing good care and were person centred and committed. The staff showed empathy and concern for people they treated. We observed staff giving good care to patients in their homes and in clinic treatment rooms.
We found that staff were responsive to patient need and were good and competent at their job. The teams provided care to patients in different ways depending on circumstance.
The patients we talked to valued what the staff did for them and felt Involved in their treatment. The staff talked to them and their families about treatment and placed patients and carers at ease.
We saw a workforce who obviously supported each other and who were resilient and vocal about health care.
We found examples of good leadership across the individual services. The recruitment of some new staff has enabled managers to start to have some space to think about leading rather than covering gaps in their own services because of lack of staff.
We found on the whole that managers were visible in services. The staff noted how managers up to district level were available and supportive, often coming to services to see how staff were coping. Staff members talked of managers helping out at the shop floor when needed and they clearly had a fondness and respect for them.
Despite uncertainty in their future employment staff were positive about their role and told us they concentrated on patient care first before anything else.

Overall rating for this core service Requires Improvement

We found the overall rating for this service as requires improvement because:

The computer system did not consistently flag up patients with safeguarding concerns. Systems in place to address this were not robust across the service’s different clinics.
The number of staff that were up to date with their statutory and mandatory training were below the trust’s target.
The lack of an electronic patient record presented risk of patients attending multiple clinics unknown to staff.
Patients were turned away from clinics which could not meet the demand and 168 clinics were cancelled in the 12 months to January 2016.
The management team did not document, monitor or manage the numbers of patients turned away from clinics or the cancellation of clinics when the service was not always meeting the demand for the service. However they told us that they were in consultation with the commissioners regarding the increased demand.

However,

There was a good incident reporting culture. Feedback was provided and staff met regularly to address how services could be improved.
The service followed British Association for Sexual Health and HIV (BASHH) Guidance and service audits demonstrated compliance with BASHH guidelines.
The Faculty of Sexual and Reproductive Health CEU clinical guidelines are accredited by NICE and the service was compliant with these guidelines.
Staff demonstrated a good understanding of people’s needs, ensured they maintained privacy and dignity and took extra time to support people.
The service worked closely with commissioners to ensure they were targeting local service users; needs.
The service regularly reviewed the provision it made with other stakeholders to ensure the needs of the community were addressed.
The service had created multi-agency relationships which ensured service leaders and those within the team were aware of current health economy factors.

Overall we have rated urgent and emergency services at the Skelmersdale walk in centre as requires improvement.

This is because:

We were concerned that the process of reviewing and approving Patient Group Directives (used to enable some registered health professionals to provide certain medicines to a pre-defined group of patients, without them having to see a doctor), was not robust. We saw that the anti-microbial guidelines (2015) contained dosing information that differed from the PGD relating to the treatment of urinary tract infections which was out of date.
Processes to manage patient risk were in place but not used routinely. When processes (such as triage, including the measurement of clinical observations) were used they were not undertaken by registered healthcare professionals. This was not in line with a Triage Position Statement written collaboratively by the College of Emergency Medicine, Emergency Nurse Consultant Association, Faculty of Emergency Nursing and Royal College of Nursing (2011)
Not enough staff were up to date with statutory training topics such as duty of candour and consent.
Patient outcomes and adherence to local care pathways had not been routinely measured by the department. For example, the urgent care directorate contributed to national audits run by the College of Emergency Medicine (CEM), the walk in centre was not listed as contributing data to them. Despite this, we saw evidence that managers were starting to focus on this with some local audits recently commenced or planned for the future. However, the lack of completed audits reaffirmed our concerns that measuring outcomes or adherence to pathways was not an embedded process.
Access to information gathered during previous attendances such as allergies, was limited by the lack of electronic records and reliance on paper records which were not scanned onto systems.
Although efforts were made to encourage the public to rate services, the response rate was very low and therefore not a robust measure. Nevertheless the results produced gave an average score of only 44%.
Managers did not have a regular presence at the centre as they were based at another location. Staff meetings were not held regularly. We were concerned that opportunities to relay important information such as outcomes following incident investigation might be missed because of this.
Managers were limited in what changes they could make whilst involved in a tender process which would not be complete until September 2016. However this was not something that the department or the trust could control.

However:

Incidents were reported and learning was shared following investigation. Most incidents reported resulted in low or no harm to patients. Equipment was properly maintained and medicines were stored and checked correctly.
Staffing was adequate and sickness levels were lower (better) than average.
Major incident policies were in place which included information about pandemics.
Despite pockets of low compliance in statutory training, staff were up to date with mandatory training topics.
Efforts were made to maintain privacy and dignity for patients. Chaperones were available if required. Patients and visitors told us they were happy with the care and advice provided.
We saw staff interacting with patients. They were polite, respectful and compassionate in their approach and people said they would come back to the centre if they needed medical attention again in the future.
Leaflets were available with information for people to take away with them about a range of conditions such as sore throats.
Staff were familiar with their local population and the centre provided free car parking, adequate seating and unisex toilet and baby changing facilities.
Translation and sign language services were available if required and staff described how they adjusted their communication style to cater for patients with complex needs or learning disabilities.
Complaints were rare; however, staff explained how they managed verbal complaints before escalating to the trust’s patient advice and liaison service (PALS) if issues could not be resolved. Learning was shared following complaints to limit recurrence.
The centre managed risk through a risk register. Governance reports were generated on a monthly basis which detailed a number of items such as training and infection control.
Senior staff told us their line managers were approachable.

Southport and Ormskirk NHS Trust has two hospitals and a walk in centre and provides community services to a local population of 258,000 people across Southport, Formby and West Lancashire. The trust is not a foundation trust, but aspires to achieve foundation trust status. In 2011 following merger with community services the Trust registered as an integrated care organisation.

Southport and Formby District General Hospital provides emergency services, medical and surgical services and outpatient services which are fully supported by on site critical care services and diagnostic services. The North West Regional Spinal Injuries Centre is also located at Southport and Formby District General Hospital.

Ormskirk District General Hospital (eight miles away) provides the maternity services for the Southport and Ormskirk area as well as services for children including a specialist children's emergency department. They also provide some medical and surgical services and an outpatient facility. There are no critical care services on site and pathology support is provided out of hours from Southport and Formby.

Adult community services include community nursing (including out of hours), community matrons, community emergency response team (CERT), therapies, leg ulcer, podiatry and continence management.

Children and Young Adults community services consisted solely of sexual health services.

We undertook an announced inspection of the trust between 12 and 14 November 2014, and an unannounced inspection at both hospitals on 20 November 2014 between 10pm and 1am.

Overall the provider trust is rated as requires improvement. For safety both acute hospital sites and community services were rated as requires improvement. For effectiveness acute and community services were rated as requires improvement. Caring was rated as good for acute and community services. Responsiveness was rated as requires improvement for acute and community services. Well Led was rated requires improvement for acute and community services.

Our key findings were as follows:

SAFE

Staffing levels in the North West Regional Spinal Injuries Centre were significantly below benchmarked levels.
Facilities were clean and well maintained with infection control policies, procedures and protective equipment in place.
Staff knew how to report incidents, however staff did not always receive feedback or opportunity to learn from incidents. This was particularly notable in Maternity services and Emergency Care.
District nursing staffing levels had stagnated despite a significant increase in workload.
Health records were largely recorded appropriately and securely stored.
That out of hours arrangements with regard to medical, nursing and support service cover at Ormskirk Hospital led to significant safety risks in maternity, emergency, medical and surgical services when staff were moved to provide cover to areas under pressure.
Safety data was demonstrated to be in use in departments, however it was of concern that Maternity services were not using such data to identify risks or service improvements.
Although the RMO model for medical cover employed at Ormskirk District General is accepted, the level of exhaustion described, poor rest facilities, working hours and reports from staff regarding competency gave cause for concern.
Access to diagnostics and multidisciplinary working was good with the major exception being access to Blood Transfusion laboratory support to Maternity services. This service is provided from Southport and Formby District General Hospital between the hours of 22.00 and 08.00. The potential for delayed treatment for deteriorating patients was confirmed by a reported incident of delay.
Although equipment was largely clean with documentation demonstrating appropriate maintenance, we saw and heard concerns from staff regarding an aging equipment fleet with no trust wide strategic replacement plan.
A mandatory training programme and a number of staff indicated the provision of the opportunity to develop. In Maternity services the low numbers of medical staff who had completed training in maternal resuscitation and the management of severe pre eclampsia was of concern.
The surgical theatres used appropriately trained staff and maintained levels with the use of both bank and agency staff. However, in obstetric theatres midwives were deployed without appropriate training and with no competency assessment, contravening recognised guidelines.

EFFECTIVE

National guidelines were in use throughout services and audit was encouraged.
The end of life care team had successfully implemented an individual plan of care for those thought likely to be dying to replace the Liverpool Care Pathway.
The trust was an outlier for a number of national indicators including SHMI, Sentinel Stroke Audit and cerebrovascular mortality but had sought external support to develop improvement plans.

CARING

Across the Trust we saw many examples that evidenced that staff were caring, compassionate and treated patients with dignity. We have however highlighted issues relating to caring on the North West Regional Spinal Centre.
Patients we spoke to felt they had been given sufficient information and had been involved in decisions surrounding their care.

RESPONSIVE

Patient flow was challenging on the Southport and Formby site leading to difficulties in maintaining emergency access targets, with patients being moved on numerous occasions during their stay and issues with the tracking of medical outliers.
Following the decision to close the breast service, communications employed did not provide assurance to staff and patients about transition of care into the new model.
The end of life care team was seen to be highly responsive to the needs of patients under their care, whilst the mortuary team also demonstrated a highly responsive approach to supporting relatives.
The trust had a clear process for the management of complaints, responding in an appropriate timescale. Teams discussed complaints at team meetings using the information for service development. However, this was not the case within the Maternity service.
Children's services and pathways had been well developed to meet the needs of patients

WELL LED

The trust had augmented experienced and well established members of the executive with recently appointed Chair, Director of Nursing and Executive Medical Director.
The trust is an integrated care organisation and has developed with stakeholder involvement, a corporate strategy that provides a high level framework until 2020. There was concern about the lack of clarity as to how this translates to a sustainability plan that meets the aspirations of Foundation Trust status, financial balance, estate rationalisation and clinical strategy. The trust is developing with external support and with local stakeholders a sustainability plan.
The trust acknowledged the staff engagement challenge that staff survey results indicated and had initiated a canon of approaches to meet this, however recent evidence presented to the board indicated that large numbers of staff remain with a feeling of not being valued.
Our interviews and focus groups with staff detected the feeling of a hierarchy of importance within the trust headed by the Southport and Formby site, followed by Ormskirk and then Community Services.
Extreme risks had been identified relating to staffing in the North West Regional Spinal Injuries Centre and District Nursing without clear mitigation and resolution actions.
The trust had introduced a detailed performance management structure which was still in the process of becoming fully embedded in practice.
Communication from our BME focus group and from consultants in writing indicated that these groups were not engaged with the Trust executive, leading to suggestions of behaviour that may constitute bullying and harassment. As a result of the allegations the CQC initiated a regulatory challenge relating to Fit and Proper Person Regulation. In response the Trust commissioned an independent, external investigation the final report of which has been received by the Trust Board. The investigation found no evidence or grounds for the allegations. The CQC has reviewed the report viewing it as thorough and comprehensive whilst also noting the supported actions of:-
- establish a BME Network Group to inform the Workforce Committee on relevant issues.
- enhance the workforce dashboard that informs the Workforce Committee to include analysis of the BME workforce indicators such as turnover and grievances, and recommendations from the BME Network Group.
- review the membership of the Equality Assurance Group and seek a nomination from the medical staff group via the JMSNC

The Trust has yet to complete and communicate an action plan relating to the investigation

We saw several areas of outstanding practice including:

The development of the CERT (Community Emergency Response Team).

A very responsive end of life care team who had ensured that 85% of patients who had a documented preferred place of death, died where they chose to.
The consideration and care that Mortuary staff have taken to deliver an excellent service that takes due consideration of cultural and religious beliefs of deceased patients and their relatives.
Compassionate improvements and re-design of the outpatients departments to reduce anxiety for young children and patients with a learning disability. Child friendly activity boards are being erected. An access film showing the experience of a child attending an outpatient department is being posted on the Trust website. This will allow parents of young children or carers of patients with learning difficulties to view the film with them and explain the process and what to expect before they attend for their own appointment.
Specialist paediatric nurses were employed to support children with diabetes and respiratory conditions. They held specialist multidisciplinary clinics on a regular basis. We heard of exemplary good practice such as specialist nurses visiting schools to give support and training to teaching staff.

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

Importantly, the trust must:

Southport and Formby District General Hospital

Ensure adequate nurse staffing levels and an appropriate skill mix in all areas but notably the emergency department.
Ensure equipment used in the theatres is fit for purpose and older equipment is replaced under a planned replacement schedule.
Ensure medicines management meets national standards in the critical care unit and in the emergency department.
Improve infection prevention and control processes within the medical directorate.
Ensure that there are suitably qualified, skilled and experienced staff to meet the needs of the patients in the North West Regional Spinal Injuries Centre.
The trust must ensure adequate senior nursing management is afforded to the North West Regional Spinal Injuries Centre.
Ensure the equipment used is fit for purpose and older equipment is replaced under a planned replacement schedule.

Ormskirk District General Hospital

Ensure adequate medical and nursing staffing levels and an appropriate skill mix in all areas notably maternity.
Ensure medical and senior nurse cover out of hours is safe and fit for purpose.
Ensure consent for obstetric procedures is recorded appropriately.
Ensure all staff working in obstetric theatres are appropriately trained and experienced to provide safe care.
Review the incidence of peripartum hysterectomies and the use of forceps delivery to ensure they are appropriate and safe.
Ensure all newly qualified midwives receive support and supervision as per their perceptorship guidance, taking into account the number of experienced midwives working with them on any shift.
Ensure the leadership of the maternity services encourages and enables an open and transparent culture.
Ensure the equipment used in the theatres is fit for purpose and older equipment is replaced under a planned replacement schedule.

Community Adult Services

Complete the staffing review for district nursing and establish a clear plan for the management of increasing workloads.

In addition the trust should:

Southport and Formby District General Hospital

Medicine

Take immediate action to prevent the sharing of computer passwords between medical staff.
Improve storage on medical wards for essential pieces of equipment and staffs' personal clothing and belongings.
Improve feedback and learning from incidents.
Increase 7 day working for all disciplines across the medical directorate.
Improve the flow of medical patients within the hospital.
Improve learning from complaints.
Improve the way risks are communicated to nursing staff within the medical directorate.
Improve the storage facilities for patients' clothes and belongings in the North West Regional Spinal Injuries Centre.

Surgery

Reduce clutter in the theatres.
Improve compliance with the national hip fracture audit.
Reduce the number of patients that are readmitted to hospital after having elective urology and general surgery.
Improve performance relating to the patient length of stay at the hospital.
Reduce delays to admitted patients awaiting surgery in the theatres.
Improve bed capacity on the surgical wards.

Urgent and emergency services

Continue to ensure that all staff complete their mandatory training in a timely manner.
Have a list of appropriate staff that have been trained with the required scene safety and awareness training.
Ensure the environment in the triage area can allow patient conversations to be private.
Ensure that all items of equipment have a record of being serviced or calibrated and that the service is in date.
Ensure that two members of staff check controlled drugs during dispensation and as part of the daily stock check.
Designate a lead for education in the department.
Look to improve the location target to treat 95% of patients within 4 hours.
Tackle the issue of junior medical staff who felt bullied by senior staff

Outpatients

Ensure concerns raised about outpatient services are addressed appropriately and in a timely manner

Ormskirk District General Hospital

Urgent and emergency care

Keep a list of appropriate staff that have had the required scene safety and awareness training.
Ensure sufficient numbers of staff are recruited.
Ensure the department is safely staffed when staff are called away from the A&E department to assist in other duties such as covering the bed management and being the designated on call person for the site.

Medicine

Improve feedback and learning from incidents.
Increase seven day working for all disciplines across the medical directorate.
Improve the way risks are communicated to nursing staff within the medical directorate.
Improve access to blood transfusions for medical patients.

Surgery

Ensure there is suitable medical staffing cover on the orthopaedic surgical ward.
Ensure there are sufficient numbers of trained staff in the theatres department.
Improve the completion of the WHO Safer Surgery procedure.
Improve performance relating to patients having elective trauma and orthopaedic surgery who are readmitted to hospital.

Maternity

The records in the maternity services should be stored securely at all times.
Staff in the maternity services should be aware of their role within the major incident plans.
The layout of the waiting areas for patients in the termination of pregnancy outpatients area should be separated from the ante-natal and fertility clinic.
Ensure all staff receive information of lessons learnt following incidents.

Outpatients

Ensure that people are protected from the risks associated with unsafe use and management of medicines. This is something that is required as part of Regulation 13 of the Health and Social Care Act 2008 (Regulated activities) Regulations 2010, in relation to the management of medicines. However it was considered that it would not be proportionate for that one finding to result in a judgement of a breach of the Regulation overall at the location.
The trust should consider the process for formalising team and multidisciplinary team meetings in order increase understanding and information flow.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Community nurse staff numbers were mainly historical, despite an increase in community nursing referrals. A need to review the equity of caseloads by the trust had been identified, although this was to be met within the existing community staffing budget. Staffing concerns regarding the size of caseloads in some district nursing teams had been raised on a number of risk registers since January 2013 and remained an identified high risk.

The provision of new therapy services within the trust had adversely affected community GP therapy provision. Patients with complex needs were supported by community matrons and specialist nursing teams including Palliative Care.

Patients told us that they felt safe using the community services provided by the trust. The trust had mechanisms in place to report and record safety incidents, concerns, near misses, allegations of abuse and to audit the quality of treatment. Staff said that they were confident to report incidents and usually received feedback on the incidents and concerns they had reported. Incident reporting within the trust was in the lowest 20% compared to other trusts; most incidents reported were low or no harm although reporting in the business unit was increasing.

Community nursing teams, therapists and staff in clinics were skilled and appropriately qualified. However there was a need that the trust ensured that staff and particularly community nurses received appropriate professional development training in areas such as prescribing. Therapy staff received regular clinical supervision although there were no similar arrangements for community nurses. Staff followed up to date nationally agreed guidelines and procedures for treating patients that were within trust policy. Patient’s needs were assessed; they were involved in their care planning and provided with the equipment they needed to support their care and independence.

Patients told us that the staff were kind and caring, supporting them with their needs. They were pleased with the care and treatment provided by Southport and Ormskirk Hospital NHS Trust.

Some services were working to improve access such as running clinics in the evening, so that working age people could more easily attend. Most patients did not have to wait long once they arrived for their appointments but waiting times for first and follow up appointments varied between clinics. Patients being discharged from hospitals were usually seen by the community nursing service either on the same day or the next day. There was a need to ensure that arrangements were improved to ensure that timely prescriptions required by community nursing patients were available.

Patients who received care in their own home had information in their records about how to raise concerns, although not all patients were aware of this. There was generally a lack of information for patients in community clinics about raising concerns about the service.

Leadership arrangements required improvement and particularly by senior managers from outside the local teams. Staff spoke positively of the contribution they made to patient care. There was some engagement with staff although many staff felt community services were the ‘poor relation’ compared to acute services and that issues that affected the community were not seen as a priority.

There were notable examples of innovation including the Community Emergency Response Team (CERT) team and the impact it had on avoided hospital admission and shorter lengths of stay.

We spoke with approximately 53 patients, 9 carers or relatives and 55 staff across a range of roles within the trust.

We found the overall rating for this service as good. Systems to safeguard vulnerable young people and relevant escalation processes were in place. Health promotion teams educated young people and supported them in outreach teams. Appointment advice and relevant leaflets were available and staff offered good emotional support. The teams had won two best practice awards, for developing practice nurses (2011) and improving sexual health for vulnerable groups (2014).

Contracting reorganisation had resulted in limited community services being offered to children, young people and families by the Trust. Paediatric community service in West Lancashire and sexual health being the only community service offered to children, young people and families by Southport and Ormskirk NHS Trust.

Integrated Sexual Health in Sefton (ISIS) delivered community sexual health support across Sefton and West Lancashire. The clinics were confidential and offered a range of options such as drop-ins, appointment only and ‘under 25 years of age only’ sessions. These were for STI screening and treatment, contraception clinics were run from other venues in West Lancashire.

We met and spoke with a health promotion specialist, a sexual health practitioner, an advanced nurse practitioner, the service manager and members of the team. We spoke with eight patients.

These reports look at how NHS hospital trusts use resources, and give recommendations for improvement where needed. They are based on assessments carried out by NHS Improvement, alongside scheduled inspections led by CQC. We’re currently piloting how we work together to confirm the findings of these assessments and present the reports and ratings alongside our other inspection information. The Use of Resources reports include a ‘shadow’ (indicative) rating for the trust’s use of resources.

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up. Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.

We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.

All Inspections

Professor Sir Mike Richards

Importantly, the trust must:

Southport and Formby District General Hospital

Ormskirk District General Hospital

Community Adult Services

In addition the trust should:

Southport and Formby District General Hospital

Medicine

Surgery

Urgent and emergency services

Outpatients

Ormskirk District General Hospital

Urgent and emergency care

Medicine

Surgery

Maternity

Outpatients

Professor Sir Mike Richards