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Southport & Formby District General Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 13 March 2018

  • Across the hospital patients’ records were not securely stored. In spinal injuries, surgery and medical wards we found nursing, medical and notes from teams who supported patients were kept in different places. This presented a risk that staff did not have access to all a patient’s records when making decisions. We escalated this issue to the trust at the time of our inspection and immediate action was taken.
  • In urgent and emergency care, surgical wards and the spinal injuries unit, patients’ risk assessments were not consistently completed. This meant the hospital’s staff were not assessing all the risks to health and safety for patients and doing all that was reasonably practicable to minimise these risks. We escalated this issue to the trust at the time of our inspection.
  • Across the hospital staff did not follow the trust’s infection control policy in relation to nursing patients with communicable diseases. Patients were not barrier nursed, side room doors where isolated patients were located were open and appropriate signage was not consistently used. This represented an infection control risk, which we escalated at the time of our inspection.
  • At the time of our inspection areas within the hospital were not visibly clean. This included areas within spinal injuries, urgent and emergency care, surgery and medical wards.
  • In urgent and emergency care and surgery, care provided was not always person centred. Areas used by the hospital’s staff to provide care for patients did not consistently allow staff to make reasonable adjustments to meet people’s needs or ensure their privacy and dignity was maintained. We escalated this to the trust at the time of our inspection and immediate action was taken.
  • In the emergency department and some surgical wards resuscitation equipment was not all in date including medicines.
  • Investigation of incidents and learning from them was not consistent and comprehensive. This meant that opportunities to improve services were missed.
  • Staff in medicine and surgery told us that although they were aware what constituted an incident, they did not consistently report them. This issue was also identified at our last inspection.
  • In urgent and emergency care and surgery, staff did not manage medicines consistently and safely at all times. We found medicines were not consistently stored, oxygen was not consistently prescribed and there were omissions in procedures for checking and signing for controlled drugs. We escalated this to the trust at the time of our inspection.
  • Staff in some areas where mandatory training completion was low reported that they had not been able to attend training. Across medicine and surgery not all staff had received an annual personal development review. We identified similar issues at our last inspection.
  • Across the hospital staff did not consistently apply the principles outlined in the Mental Capacity Act 2005. We found delays in assessment of patients’ mental capacity. There was a lack of consistency in how people’s mental capacity was assessed and not all decision-making was informed or in line with guidance and legislation.
  • In spinal injuries there was open access to the unit including wards where high risk patients were nursed. We escalated this at the time of our inspection and the trust took immediate action.
  • In some areas of the hospital outcomes for people who used services were below expectations compared with similar services.
  • In urgent and emergency care there were times when people did not feel well supported or cared for and their dignity was not consistently maintained.
  • The 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.
  • There was limited personalisation of care plans in the records we reviewed. Plans were largely in the form of standardised templates, which identified risks, but lacked clarity relating to the specific needs and wishes of the patient.
  • Across surgery and medicine we found risks that had previously been identified at the last inspection. There was insufficient progress to improve these areas and/or improvement was not sustained.
  • 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 were not aware of or did not understand the organisation’s values.

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 out last inspection mandatory training levels had improved across the hospital. 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 hospital 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 can manage risks to people who use services.
  • People’s care and treatment was planned and delivered in line with current evidence-based guidance, standards, best practice 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 hospital, people were supported, treated with dignity and respect, and were involved as partners in their care.
  • The majority of the hospital was easily accessible for patients who required assistance with mobility, including patients who required the use of a wheelchair.
Inspection areas

Safe

Requires improvement

Updated 13 March 2018

Effective

Requires improvement

Updated 13 March 2018

Caring

Good

Updated 13 March 2018

Responsive

Requires improvement

Updated 13 March 2018

Well-led

Inadequate

Updated 13 March 2018

Checks on specific services

Medical care (including older people’s care)

Inadequate

Updated 13 March 2018

Our overall rating of this service stayed the same. We rated it as requires improvement because:

  • Staff did not consistently follow the trust’s Mental Capacity and Deprivation of Liberty safeguards operational procedure. Staff we spoke with did not have a clear understanding on how to assess patients’ capacity to make decisions about their care. Staff training relating to the Mental Capacity Act 2005, and Deprivation of Liberty safeguards, was not fully embedded.
  • The medical care services had failed to make significant improvements in relation to staff training. With training falling below 60% in areas such as resuscitation, infection prevention [level 2], hand hygiene and manual handling.
  • The service had not made sure staff were competent for their roles. Managers had not appraised all staff’s work performance.
  • At the last inspection we found staff in medical care services did not always wear suitable personal protective equipment to minimise the spread of infection. At this inspection we found the service still did not control infection risk well. They did not always use control measures effectively to prevent the spread of infection.
  • Not all of the wards and corridors we inspected were clean and well maintained. Wards and corridors were cluttered with equipment, some of which was in front of fire escapes. Some of the ward floors were not clean and some ward storage areas were not well kept. Patient records were not always stored securely. We also found that computers were not always locked to prevent data from being seen by unauthorised personnel.
  • Services were not always provided seven days a week. This was because Allied Health Professionals such as dieticians and speech and language therapists were unable to provide a full seven day service across all medical wards.
  • The service did not always have enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment. Qualified nurse staffing remained an ongoing challenge and an identified risk.
  • There were pockets of low morale amongst staff who told us they felt pressured to compromise their standards and the care delivered to patients due to reduced staffing numbers and issues with the environment in which care was provided.
  • The service had significant issues with the access and flow through the medical wards and departments.
  • The use of escalation areas meant that issues with staffing and the environment impacted on patients receiving the appropriate care they required. There were high numbers of delayed discharges and high numbers of medically fit patients occupying beds on medical wards.

However:

  • The service had arrangements in place to assess and respond to patient risk. Arrangements to recognise the development of sepsis known as the “sepsis 6 bundle” were implemented in April 2017 to assist in recognising changes in patients’ conditions.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff knew how to recognise and report abuse.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness. In the main, managers checked to make sure staff followed guidance. Medical services participated in all relevant national audits they were eligible to complete.
  • Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
  • The majority of patients and relatives stated they were happy with their care and that staff worked hard and were kind and caring.

Critical care

Good

Updated 15 November 2016

We gave the critical care services at Southport and Formby District General Hospital an overall rating of ‘good’. However, we rated the services as ‘Requires Improvement’ for responsive.

This was because: -

  • Patient safety was monitored and incidents were investigated to assist learning and improve care. Patients received care in safe, clean and suitably maintained premises. Patients were supported with the right equipment. There were systems in place to manage resource and capacity risks and to manage patients whose condition was deteriorating.
  • The staffing levels and skills mix was sufficient to meet patients’ needs and staff assessed and responded to patient’s risks. The consultants covering the critical care unit during out of hours were also responsible for other areas, such as providing anaesthetic cover for the surgical and maternity services. However, there was a second on-call consultant to provide additional cover and support.
  • Patients received care and treatment by multidisciplinary staff that worked well as a team. A consultant-led ward round took place twice a day on the critical care unit. Staff carried out a daily assessment of delirium (acute confusion) in patients using the ‘Confusion Assessment Method for intensive care’ (CAM-ICU) guidelines.
  • The services provided care and treatment that followed national clinical guidelines and staff used care pathways effectively. The services performed in line with expected levels for most performance measures in the Intensive Care National Audit and Research Centre (ICNARC) audit.
  • Patient’s relatives spoke positively about the care and treatment they received. They were supported with their emotional and spiritual needs. Feedback from surveys showed patient’s relatives were positive about the services. There were systems in place to support vulnerable patients.
  • There was effective teamwork and clearly visible leadership within the services. Most staff were positive about the culture within the critical care services and the level of support they received from their managers. Key risks to the services, audit findings and quality and performance was monitored though routine departmental and divisional quality and governance meetings.

However, we also found that: -

  • The critical care services were previously rated as ‘requires improvement’ for responsive following our last inspection because we had concerns around delayed discharges and the provision of single sex accommodation.
  • During this inspection, we found that significant improvements had been made to reduce the number of delayed discharges. However, further improvements were still needed to ensure patients received appropriate care.
  • The number of patients with delayed discharges had improved from 487 during 2014 to 294 during 2015. However, recent capacity issues across the hospital meant there was a worsening trend and there had been 111 delayed discharges between January 2016 and March 2016. There were 86 ‘mixed sex’ breaches on the unit between April 2015 and March 2016.
  • This meant a significant number of patients were still affected by delayed discharges and patient’s privacy and dignity was affected as a result of ‘mixed sex’ breaches.
  • The majority of staff had completed their mandatory training and appraisals. However, this was below the hospital’s target of 90% training completion.
  • There was one speech and language therapist across the hospital during weekdays. This meant staff on the unit occasionally experienced a delayed response after referring patients for this service.

End of life care

Good

Updated 15 November 2016

At the last inspection in November 2014 we found EOL services to be good in all five domains of Safe, Effective, Caring, Responsive and Well Led. At this inspection we found good EOL services across all the domains with the exception of Effective which we found requires improvement. They were rated as good overall because;

  • Incident reporting systems were in place and actions were followed up following investigation.

  • Anticipatory EOL care medication was prescribed appropriately in hospital and in the community. Hospital staff were knowledgeable about responding to deteriorating patients and hospital care records reflected this with appropriate evidence or establishment of ceilings of care documented. There was evidence of the service delivering treatment and care in line with best practice, including the individual plan of care (IPOC) of those thought likely to be dying which was well embedded in community services. EOL services were adequately staffed and as well as the SPC team which was clinically led by a consultant in palliative medicine, there was a Transform team which promoted advance care planning, the amber care bundle and provided EOLC training.

  • The delivery of EOLC was planned in accordance with the Priorities for Care of the Dying Person set out by the Leadership Alliance for the Care of Dying People including the introduction of the IPOC. Actions were being taken to meet the national framework, Ambitions for Palliative and End of Life Care, including cross boundary working to coordinate care and the generation of data via national and local audits to review and improve services. Patients had comprehensive assessments of their needs which included pain assessments and in hospital, nutrition and hydration assessments. There was good evidence of multidisciplinary team working and seven day services were in place. There was a rapid transfer process in place which the team were working to improve.

  • EOL care services were provided by compassionate, caring staff who were sensitive to the needs of seriously ill patients. The service was delivered by staff who were committed to providing a good service and there was good clinical leadership from a consultant in palliative medicine. Community services in particular, were highly regarded by patients and families. In the hospital staff were mindful of prioritising EOL patients for side rooms when the situation allowed and the Oasis unit provided space for relatives to stay. Accommodating people’s preferred place of care (PPC) was important to staff and their success rate at achieving this was over 80% in the year to December 2015. There was a clear strategy in place and all the EOL and palliative care staff we spoke with understood what the service was setting out to achieve and how their role fitted in. Staff were positive about EOL care and felt well supported.

However there were areas for improvement:

  • Conversations between district nurses and GPs around the commencement of the IPOC to support patients at the end of life were not always documented. The service should ensure that all GP involvement is documented in the IPOC when the decision is made for this to be commenced.

  • Completion of mental capacity assessments was not consistent, even when indicated on the DNACPR. The trust was not using the unified DNACPR process and hospital DNACPR forms did not travel with the patient when they left hospital. There was no audit of DNACPR forms or decisions despite the system for reviewing these forms being identified as an area for improvement in the last CQC inspection in 2014.
  • The complaints process and governance processes around monitoring incidents required improvement. The trust should ensure the new incident monitoring system includes dissemination of feedback and lessons learned to all relevant areas, including the mortuary.
  • Syringe drivers were not being checked four hourly in line with hospital standards. The service should continue to educate and audit this process.

  • Prior to our inspection there had been no-one actively taking the part of executive lead for EOLC and there was no non-executive director with responsibility for EOLC.

Outpatients and diagnostic imaging

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 rating of ‘requires improvement’ for safe and good for the other domains of caring, responsive and well-led.

At this inspection, we gave the outpatient and diagnostic services a rating of ‘good’ overall, however we rated the services as ‘requires improvement’ for safe. This was because:

The previous ‘requires improvement’ rating was due to safety incidents not being communicated with the trust board. This has since been addressed, however other issues of concern were found.

We had a control of infection issue in the eye clinic that was raised during the inspection. The trust responded quickly and an action plan to improve was put in place; however, some issues were not addressed.

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 and patients receiving 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.

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.

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.

Spinal Injuries Centre

Requires improvement

Updated 13 March 2018

We visited the unit as part of our unannounced inspection on 27 and 28 November 2017. Our inspection was unannounced (staff did not know we were coming) to enable us to observe routine activity.

Before the inspection visit, we reviewed information that we held about these services and information requested from the trust. During the inspection visit, the inspection team:

  • Reviewed the environment and staffing levels.
  • Looked at 10 sets of patient notes.
  • Spoke with 10 patients and two relatives.
  • Spoke with 27 staff of different grades, including nurses, health care assistants, doctors and consultants, physiotherapists, psychotherapists, case managers and senior managers who were responsible for the regional spinal injuries unit.
  • Observed a goal planning meeting involving a patient and their relative and an admission planning meeting involving 14 staff from different professions.
  • Observed daily practice and reviewed management arrangements.

Our overall rating of this service went down. We rated it as requires improvement because:

  • Nursing staff were not meeting trust targets for a number of mandatory training modules.
  • The service was failing to minimise the risk of the spread of infections in the ward areas.
  • There was a lack of security throughout the unit. People who had no business in the unit could freely gain access to all areas and this did not ensure that people were kept safe and personal property and equipment was kept protected at all times.
  • Patient records were not always stored securely in locked trolleys and during inspection we saw patient details were left open on computer screens.
  • Not all patient risk assessments were being completed fully and appropriately.
  • Patient records were not stored centrally and were split into medical, nursing, therapy, case management and psychology notes and stored in separate places around the unit. This meant there was a risk that the full picture of a patient was not known when decisions were being made.
  • In one instance, the decision to not resuscitate a patient in the event of a cardiac arrest had not been properly reviewed. The “Do not attempt resuscitation” documentation was not discontinued, despite the fact that the patient had regained capacity and this was against their wishes.
  • There was only one isolation room. This meant that patients with existing infections could not be admitted to the unit in a timely way if this room was already in use.
  • Patients’ privacy and dignity was put at risk when they were receiving treatment or therapy in the gym because the area was overlooked from above and the gym was also used by members of the public.
  • Procedures and documentation for assessing patients who lacked capacity were inconsistently recorded.
  • Trust leadership was new and local governance systems were not embedded. There was a lack of oversight of some key risks in the unit.
  • Staff expressed the view that they often felt separate from the trust as a whole and there was a need to keep reinforcing the work of the unit within the organisation.

However,

  • Staff understood how to protect patients from abuse and the service planned for emergencies.
  • Equipment was looked after well and medicines were stored and prescribed appropriately.
  • Care and treatment was based on national guidance and evidence of its effectiveness was monitored.
  • Patients were supported to be self –managing for their care needs and families were educated in how to assist patients in this approach.
  • Patients received adequate pain relief, nutrition and hydration.
  • Patients reported that they were treated with dignity and respect. They were very positive about staff and the care that they received and told us that nurses went the extra mile to ensure that their needs were met.
  • The spinal injuries unit team was strongly person centred in its approach to patient care. Patients’ individual needs were considered as a priority and assessed on a case by case basis, with appropriate support available.
  • Staff received appraisals and at 30 June 2017 the appraisal rates for staff on the ward areas of the unit were only marginally below the trust target of 90%. All staff in administration and the allied health professionals in the case management team had received an appraisal.
  • Staff received adequate training and competencies were assessed.
  • Patients were admitted to the unit in a timely way and all referred patients were assessed for suitability to be admitted to the unit within five working days.
  • There were very few complaints against the unit (four in the year from July 2016 to June 2017). Complaints were treated seriously, investigated and lessons learned were shared.
  • There was a set of vision and values local to the unit and the service had a work plan in draft for service improvements from 2017 to 2019.
  • Information was collected, analysed and managed to support activities and make improvements.
  • The unit led and participated in spinal injuries research and development activities, involved in regional and national specialist networks.
  • There was wide engagement activity with patients, staff and different community groups related to spinal injuries care.
  • Staff spoke highly of the unit management team and told us that they were very supportive and responsive to new ideas to improve the service. Managers were knowledgeable, competent and communicated well with staff at all levels.

Surgery

Requires improvement

Updated 13 March 2018

Surgical services had improved from inadequate since the last inspection. We rated it as requires improvement because:

  • Not all staff had received mandatory training updates and there was no evidence that staff in theatre were trained in immediate or advanced life support.
  • Staff we spoke with did not always recognise incidents or report them when required. Staff were not clear about 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).
  • Monitoring equipment was dusty and doors to the side rooms of patients with infections were left open.
  • Routine checks of emergency equipment were not carried out appropriately on the wards.
  • Fridge temperatures were not always checked and there were some omissions in the administration and disposal of controlled drugs in theatres.
  • Care of patients was recorded in multiple locations and difficult to follow. Paper records were not always stored securely and electronic records were visible to all visitors to wards.
  • On wards where patients required assistance with meals, there were not always enough staff available to provide support during mealtimes.
  • Information from the provider showed that compliance with appraisal rates was below the trust target.
  • Staff did not always understand the requirements of the Mental Health Act 1983, the Mental Capacity Act 2005 and Deprivation of Liberties safeguards and their application to patients.
  • Surgical services were organised across two hospitals. Patients assessed as higher risk were care and treated at Southport. This meant that there may be no choice of location for certain patients.
  • We did not see any leaflets or posters on the wards, for patients to share their experiences and the response rate to the NHS friends and families test was low.
  • There was no strategy currently in place for surgical services and there had been a number of changes in senior leadership.

However:

  • The service displayed details about safety information for staff, patients and visitors to view on the wards.
  • Staff we spoke with 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 wards displayed numbers of staff and details of ward managers to show that there were sufficient numbers of nursing staff, trained and health care assistants to provide care and treatment.
  • The service planned for emergencies and staff we spoke with were clear about how to respond.
  • The service based care and treatment on national guidance and submitted data for internal and external audits in order to benchmark performance.
  • There was a multi-disciplinary approach to care on the wards with doctors, nurses and allied health professionals very visible.
  • Patients told us that staff took account of their individual needs and provided us with positive feedback about care and treatment.
  • Managers we spoke with promoted a positive culture that supported and valued staff.
  • The surgical service was committed to improving care and treatment for the local population.

Urgent and emergency services

Updated 18 September 2018

We did not re-rate urgent and emergency care at the time of this inspection. We found the following areas for improvement:

  • We had concerns about the safety of patients in the department. This was for a number of reasons. The department did not have enough capacity to accommodate all the patients requiring treatment.
  • Patients waited a long time to receive medicines such as pain relief. Handover, initial assessment and responsibility for patients was not happening in a timely manner. Ambulance staff were waiting with patients for excessively long times in the department.
  • Records were not completed in a comprehensive way and risk assessments were not documented as being carried out.
  • Infection prevention and control practices were not following national guidance: staff were not always washing their hands, using gloves appropriately or arms bare below the elbow. The department was not always as clean as it should be with dirty rooms and smears of bodily fluids on walls.
  • There were insufficient staff deployed to the department and from the evidence we looked at, this had been a long-term issue.
  • Staff were not up to date with their mandatory training.
  • We had concerns about the responsiveness of the department. It was not able to meet the demand from the number of patients attending. The department had severe problems with capacity.
  • The hospital was also full to capacity and as a result, emergency department patients were waiting for long periods of time in corridors before being admitted to wards. There was poor flow through the department on to wards and from wards home. From what we saw and what staff told us, the whole flow of the system did not appear to be working well.
  • The department was performing poorly against national government performance indicators such as waiting time targets. This meant patients did not have access to treatment and care in a timely manner.
  • There was no system of data validation in place to ensure waiting time information was accurately reflecting the time patients spent in the department.
  • Escalation processes in place were not effective and patients were waiting excessive time in the department as a result.

However:

  • Staff were working extremely hard to deliver care that was caring and compassionate under very difficult circumstances.
  • We observed staff helping patients and supporting them as best they could.
  • Nursing and medical staff worked well together and were doing the best they could for patients.