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Ormskirk District General hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 13 March 2018

  • There was evidence of under reporting of incidents in surgery services. Staff did not always recognise incidents or report them appropriately. In maternity services, learning from incidents was not always disseminated in an effective way to staff.
  • Processes and procedures in relation to the duty of candour requirement were not fully embedded and staff did not fully understand and discharge their duties in relation to this requirement. (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).
  • The patient group directive (PGD) documents in urgent and emergency care services did not evidence regular review and approval since 2009. Whilst pharmacy had provided interim approval for the current use of paediatric PGDs, this was recorded as a risk on the directorate risk register.
  • The quality of documentation and approach to frequency of observations was inconsistent. In urgent and emergency care services, both issues were being addressed through repeated audit and the issue of a new protocol to standardise observations. However, in maternity services, staff did not complete Maternity Early Warning Scores (MEWS) assessments in accordance with trust policy in order to detect deterioration in a woman’s condition. Women did not always receive a medical review when their assessment identified this was required and the World Health Organisations’ surgical safety checklist was not always fully completed.
  • In urgent and emergency care services, documented evidence that staff offered food and fluids, where appropriate, to children during their stay in the department was inconsistent.
  • Records in maternity services were not always up to date. We saw examples of delay in scanning records onto the online system meaning there were gaps in women’s care records. Only one member of staff could open a particular patient record at a time which meant that records around caesarean sections were not always entered onto the system in a timely manner.
  • Care and treatment in surgery services was fully recorded. However, care records were kept in multiple locations and were difficult to follow. Staff also did not consistently print their name or document their designation when completing records, as per best practice guidance.
  • Staff in maternity services did not follow the trust’s schedule consistently for checking all equipment was present and in working order. This included the anaesthetic machine in theatre and resuscitation equipment available on the wards. Whilst staff in surgery services completed emergency equipment checklists, we found equipment inside resuscitation trolleys that was out of date or with damaged packaging.
  • In maternity services, we found that trust policies were not always reviewed in line with the schedule set out and there were some omissions within policies which made them difficult to follow. Staff were unaware if there was a review panel which had input into creating policies within the service.
  • Due to staff shortages in surgery services, urology and gynaecology patients were sometimes moved between the urology and gynaecology wards at short notice. As a result patients recovering from gynaecology surgery could be moved to the urology ward shortly after surgery and vice versa. This compromised patient privacy and dignity as it often led to mixed sex breaches.
  • In surgery services approximately one third of staff had not completed mandatory training and dashboards were not up to date and therefore did not reflect current completion rates. However, completion levels of mandatory training had improved since the last inspection.
  • Staff in surgery appraisals stated they had appraisals annually however dashboards we reviewed did not reflect this.
  • In surgery, unlocked doors to the dirty utility on all wards meant anyone could gain access. One ward had a fire door propped open on three consecutive days. Staff rectified this when highlighted by inspection staff.
  • There was no clear vision or strategy in place across all services and this hindered innovations and improvements within the services. A potential risk to leadership capacity was developing in urgent and emergency care services following the recent transfer of bed managers from the Ormskirk site to Southport by trust management. Senior nurses across the paediatric department were required to support bed management duties on the site.
  • Managers across maternity services did not always promote a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.

However:

  • 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. This has significantly improved since the last inspection. Safeguarding supervision had been made part of mandatory training for all midwives and staff reported receiving good support from the safeguarding midwife.
  • Mandatory training levels for nursing staff had improved since the last inspection. A practice development midwife had been appointed to ensure the training needs of midwifery staff were being met.
  • In surgery and urgent and emergency care, medicines were stored, administered and recorded in line with best practice guidelines.
  • The service had arrangements in place to recognise and respond appropriately to patient needs and risks.
  • Incidents in urgent and emergency care were reported and managed well.
  • Specialist midwives had been appointed since our last inspection to support midwives in the provision of care to women with complex needs.
  • Across the hospital staff were passionate about delivering patient centred care. In urgent and emergency care patients’ parents expressed that the hospital was their preferred emergency department.
  • Ward areas were visibly clean and tidy.
  • Facilities and premises were appropriate for the services delivered. In urgent and emergency care a new ‘quiet’ room had been constructed in the emergency department to strengthen their ability to meets the needs of children with mental health needs.
  • 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.
  • The paediatric urgent and emergency care department performed well against the national urgent care standards including the Department of Health standard (95%) for the percentage of patients admitted, transferred or discharged within four hours (monthly average 99% in 2017).
  • Staff in the paediatric urgent and emergency care department had clear roles and responsibilities to support the governance systems. Regular governance meetings took place at department and directorate level to monitor and review the quality of care and risk management. The service took complaints seriously and responded to lessons learned, for example staff developed a leaflet to improve parents’ understanding of the triggers for safeguarding referrals.
  • In the paediatric urgent and emergency care service there was strong leadership and a positive, supportive culture amongst medical and nursing staff. Nursing and medical leads worked together with a focus on continuous learning and improvement supported by annual training days, the local audit programme, the appraisal process and mentorship to achieve competencies.
Inspection areas

Safe

Requires improvement

Updated 13 March 2018

Effective

Good

Updated 13 March 2018

Caring

Good

Updated 13 March 2018

Responsive

Good

Updated 13 March 2018

Well-led

Requires improvement

Updated 13 March 2018

Checks on specific services

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 good rating across the domains. At this inspection, the rating remained the same and the outpatients and diagnostics departments received a rating of ‘good’ for being safe, caring, responsive and well-led (effective is not rated under the current guidance).

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

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

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

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

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

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

Maternity and gynaecology

Requires improvement

Updated 13 March 2018

  • Staff did not complete Maternity Early Warning Scores (MEWS) assessments in accordance with trust policy in order to detect deterioration in a woman’s condition. Women did not always receive a medical review when their assessment identified this was required.
  • The World Health Organisations’ surgical safety checklist was not always fully completed.
  • Staff did not follow the trust schedule consistently for checking all equipment was present and in working order. This included the anaesthetic machine in theatre and resuscitation equipment available on the wards.
  • Learning from incidents was not always disseminated in an effective way to staff. The trust reviewed every incident of postpartum haemorrhage from 1500mls and above but staff were unaware what learning had been gained from this.
  • Records were not always up to date. We saw examples of delay in scanning records onto the online system meaning there were gaps in women’s care records. Only one member of staff could open a particular patient record at a time which meant that records around caesarean sections were not always entered onto the system in a timely manner.
  • Trust policies were not always reviewed in line with the schedule set out and there were some omissions within policies which made them difficult to follow. Staff were unaware if there was a review panel which had input into creating policies within the service.
  • There was no vision and strategy for the service which impacted on staff morale and hindered innovation and improvements within the service.
  • Managers across the service did not always promote a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.

However:

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Safeguarding supervision had been made part of mandatory training for all midwives and staff reported receiving good support from the safeguarding midwife.
  • The service provided mandatory training in key skills to all staff and the majority had completed this. A practice development midwife had been appointed to ensure the training needs of staff were being met.
  • Specialist midwives had been appointed since our last inspection to support midwives in the provision of care to women with complex needs. This had been well received by the midwives we spoke with.
  • Staff we spoke with were passionate about providing good quality care to women and their families and some had been involved in initiatives to improve care.
  • We found evidence of service planning to meet the needs of the local population.

Medical care (including older people’s care)

Requires improvement

Updated 15 November 2016

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

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

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

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

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

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

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

However,

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

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

Urgent and emergency services (A&E)

Good

Updated 13 March 2018

  • Patient safety and quality improvement were high priorities in the department. Management had identified lessons from incidents and the recent mortality review and were implementing changes to standardise nursing practice.
  • All staff were trained to level three in child safeguarding and were confident in dealing with safeguarding issues.
  • Mandatory training levels for nursing staff had improved since the last inspection
  • Facilities and premises were appropriate for the services delivered. A new ‘quiet’ room had recently been constructed in the emergency department to strengthen their ability to meet the needs of children with mental health needs.
  • Staff used evidence-based tools and the escalation process to manage clinical risk. They provided a consistent approach to frequent attenders with complex conditions by maintaining copies of their care plans for reference in the department.
  • Feedback from children and parents confirmed that staff treated them well. Parents we spoke with were happy with the service and three told us that they preferred this emergency department to others for their children.
  • The paediatric emergency department performed well against the national urgent care standards including the Department of Health standard (95%) for percentage of patients admitted, transferred or discharged within four hours (monthly average 99% in 2017).
  • Staff had clear roles and responsibilities to support the governance systems. Regular governance meetings took place at department and directorate level to monitor and review the quality of care and risk management. The service took complaints seriously and responded to lessons learned, for example staff developed a leaflet to improve parents’ understanding of the triggers for safeguarding referrals.
  • There was strong leadership and a positive, supportive culture amongst medical and nursing staff. Nursing and medical leads worked together with a focus on continuous learning and improvement supported by annual training days, the local audit programme, the appraisal process and mentorship to achieve competencies.

However:

  • The patient group directive (PGD) documents did not evidence regular review and approval since 2009. Whilst pharmacy had provided interim approval for the current use of paediatric PGDs, this was recorded as a risk on the directorate risk register.
  • The quality of documentation and approach to frequency of observations was inconsistent. Both issues were being addressed through repeated audit and the issue of a new protocol to standardise observations.
  • Documented evidence that staff offered food and fluids, where appropriate, to children during their stay in the department was inconsistent.
  • A potential risk to leadership capacity was developing following the recent transfer of bed managers from the Ormskirk site to Southport by trust management. Senior nurses across the paediatric department were required to support bed management duties on the site

Surgery

Requires improvement

Updated 13 March 2018

Surgical services had stayed the same since the last inspection. We rated it as requires improvement because:

  • Staff did not always recognise incidents or report them appropriately.
  • Staff were not clear about their role in relation to the 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).
  • Unlocked doors to the dirty utility on all wards meant anyone could gain access. One ward had a fire door propped open on three consecutive days. Staff rectified this when highlighted by inspection staff.
  • Due to staff shortages, urology and gynaecology patients were sometimes moved between the urology and gynaecology wards at short notice. This meant that patients recovering from gynaecology surgery could be moved to the urology ward shortly after treatment and vice versa.
  • Approximately one third of staff had not completed mandatory training and dashboards were not up to date and therefore did not reflect current completion rates. However, completion levels of mandatory training had improved since the last inspection.
  • Whilst staff completed emergency equipment checklists, we found equipment inside that was out of date or with damaged packaging.
  • Staff recorded care and treatment provided. However, this was in multiple locations and was difficult to follow. Staff also did not consistently print their name or document their designation when completing records, as per best practice guidance.
  • Surgical services had no current strategy in place and had several changes to senior managerial support.
  • Staff stated they had appraisals annually however dashboards we reviewed did not reflect this.

However:

  • The wards displayed the numbers of staff on duty and details of ward managers to show there were sufficient numbers of nursing staff to provide safe care and treatment.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.
  • Patients’ had their needs assessed including their physical, mental health and nutritional needs. Staff identified expected outcomes and reviewed and updated them.
  • 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. This had significantly improved since the last inspection.
  • Staff had infection control training and were aware of trust polices. Audits were completed and we observed appropriate hand washing and use of personal protective equipment (PPE).
  • Medicines were stored, administered and recorded in line with best practice guidelines. Staff checked these drugs as per trust guidelines and random checks found that these had been completed appropriately.
  • All areas we inspected appeared visibly clean and tidy. Wards displayed environmental audit results which were visible to staff, patients and visitors.

Services for children & young people

Requires improvement

Updated 15 November 2016

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

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

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

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

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

However,

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

End of life care

Good

Updated 13 May 2015

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

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

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