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Ormskirk District General hospital Requires improvement

Reports


Inspection carried out on 20 November 2017

During a routine inspection

  • 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 carried out on 12 - 15 April 2016

During an inspection to make sure that the improvements required had been made

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

Our key findings since our last inspection were as follows:

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

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

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

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

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

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

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

In surgery

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

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

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

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

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

In medicine

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

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

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

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

In maternity and gynaecology

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

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

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

    In children’s

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

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

In children’s

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

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

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 12-14 and 20 November 2014

During a routine inspection

The comprehensive inspection at Ormskirk District General Hospital was conducted between 12 and 14 November 2014 and an unannounced inspection was carried out on 20 November 2014 between 10pm and 1am.

This inspection was conducted under the new model of inspection as part of the inspection of Southport and Ormskirk NHS Trust. 

Overall the hospital was rated as requiring improvement but the safe domain was rated requires improvement or inadequate in five of the seven services.  In maternity services the well-led domain was also rated as inadequate. The concerns in this hospital were discussed with the trust at the end of the inspection.

Our key findings were as follows:

Safe

Ormskirk Hospital requires improvements in the safe domain as staffing levels were not always deemed sufficient to meet patients’ needs at times when senior staff were utilised as the designated on call person for the site. The trust were made aware and have made changes since the inspection.

Patients were supported with the right equipment; however there was no approved schedule for replacing older equipment used in the theatres. The staffing levels in the theatres were not sufficient, but the theatres department had plans in place to address this. There was a potential risk of unsafe care because the arrangements for medical cover on the wards were not sufficient. There was one resident medical officer who worked 24 hours per day continuously over a two week period.

The safety of people using the maternity service was compromised due to the reduced numbers of experienced midwives employed, a lack of learning from incidents and adverse clinical data and inadequate and out of date staff training. There were risks of patients whose condition deteriorated experiencing delays in receiving blood transfusions and inadequately trained staff assisting in the obstetric theatre. Whilst the service had recognised some of these risks they had not taken sufficient actions to mitigate them.

There were a higher than average number of deliveries using forceps and of peripartum hysterectomies (Peripartum hysterectomy is a major operation and is invariably performed in the presence of life threatening haemorrhage during or immediately after abdominal or vaginal deliveries). There were no plans in place to reduce these. There was a lack of monitoring of the quality of the service with resulting plans for improvement and change.

Effective

There were insufficient medical and nursing staff with the appropriate skills and experience to provide safe and effective care to patients outside of normal working hours.

However, 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 majority of patients had a positive outcome, however, the number of patients that underwent elective trauma and orthopaedic surgery and were readmitted to hospital following discharge was higher (worse) than the England average. The average number of days patients stayed at the hospital was better than the England average across all the elective specialties at the hospital.

Safeguarding measures were understood by staff and escalation processes were well managed. Staff understood the legal requirements of the Mental Capacity Act 2005 and deprivation of liberties safeguards.

In outpatients information had been used to make improvements including improving the waiting rooms for patients and staff; the privacy and dignity for bedded patients in diagnostics department; introduction of children’s activity boards and the production of a video to show young children or patients with a learning disability what it would be like when they attend the department. Additional services had been created, such as the ‘dressings’ clinics which had freed-up consultants time and reduced delays in fracture and orthopaedic clinics. Reviews were conducted into clinics which consistently ran late to identify blocks in patient flow.

Caring

Care was delivered by hardworking, caring and compassionate staff who treated patients with dignity and respect. Patients spoke positively about their care and treatment. Patients and their relatives were involved in care and supported with their emotional needs and there were bereavement and counselling services in place.

Responsive

The hospital had done a significant amount of work to tackle the capacity and patient flow challenges that had affected its performance. Ormskirk Hospital met its target to admit or discharge 95% of patients within 4 hours of arrival at A&E between April 2014 and September 2014.

Services provided on H ward were generally responsive to people's needs, but there was no adequate provision for patients who needed a blood transfusion without transferring them out of the hospital.

The number of cancelled elective operations was better than the England average, and there had been improvements in performance against 18 week referral to treatment standards. There were plans in place to improve theatre efficiency.

Children's services were provided in a child friendly environment by a workforce with a range of specific skills, competencies and training relating to children. All staff had relevant professional registration and were encouraged to be up to date with required training programmes.

Well-led

The organisation’s vision and strategy had been cascaded and staff were proud of the work they did. The overall ethos was centred around the quality of care patients received. Key risks and performance data were monitored. There was clearly defined and visible leadership, and staff felt free to challenge any staff members who were seen to be unsupportive or inappropriate in carrying out their duties.

H ward was well-led, although there was a disconnection between the staff providing hands-on care and the executive team. The system in place to communicate risks and changes in practice to nursing staff required improvement.

However, Midwives described a culture which was not open and transparent and where the leadership was inconsistent resulting in staff feeling they could not easily raise issues or concerns. There were a high number of newly qualified midwives employed which resulted in inexperienced staff fulfilling roles for which they lacked experience and competence.

We saw several areas of outstanding practice including:

  • 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.
  • The work of the children’s community nursing outreach team had been further recognised by the successful publication in the British Journal of Nursing (“Paediatric community home nursing, acute paediatric care” British Journal of Nursing 2014, vol 23, No. 4).
  • 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.
  • The trust paediatric diabetes service was peer reviewed in July 2014. Multidisciplinary team work scored 90% and hospital measures scored 100%. Some good practice was recorded, including having a support group.
  • The trust and hospital proactively implemented the ‘New priorities for care of those thought to be dying’, before the compulsory withdrawal of all references to the Liverpool care pathway. This had been supported by a robust training programme.
  • Patients at the end of life and their relatives were supported by the palliative care team to plan for their future, and a national system was in place to identify them when accessing emergency care in order to speed up admission and discharge.
  • 85% of patients who had a documented preferred place of death died where they chose to, facilitated by an effective end of life rapid transfer programme.
  • The mortuary team was outstanding in its responsiveness and its innovative approach to caring for the patients and relatives who used their services.

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

Importantly, the trust must:

  • Ensure adequate medical and nurse staffing levels and appropriate skill mix.
  • Ensure medical and senior nurse cover out of hours is safe and fit for purpose.
  • Ensure consent for obstetric operations is recorded accurately.
  • Ensure all staff working in obstetric theatres are appropriately trained and experienced to ensure safe care.
  • Review the incident of peripartum hysterectomies and the use of forceps for delivery are appropriate and safe.
  • Ensure all newly qualified midwives receive support and supervision, as per their preceptorship 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 equipment used in the theatres is fit for purpose and older equipment is replaced under a planned replacement schedule.

In addition the trust should:

In 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.

In 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.

In 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.

In 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.

In 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

Inspection carried out on 30 August 2013

During a routine inspection

During our inspection we visited two inpatient wards, the day ward and an operating theatre. We spent time with 17 patients and two relatives and invited them to share with us their experience and views of care and treatment at the hospital. Some of their comments included:

“My whole experience was of a dedicated professional team who made me feel very relaxed”, “Everything is explained really well and is very clear”, “Very impressed with the staff. Nothing is too much trouble”, “I can wash but the staff will help me if I need it” and “The staff make sure I am doing my exercises and not getting sore.”

Patients told us staff were responsive and attentive to their requests, with nurse call bells responded to in a timely way. Most of the patients we spoke with received support to order their meals via the TV screen. However one patient said, “I only had the scraps to eat as they (staff) didn’t come and tell me what to do.”

We observed the staff draw curtains around patients’ beds when attending to them and lowered their voices when they spoke to patients, to ensure their privacy.

Patients were aware of their plan of care and felt they had received adequate information to understand their condition and treatment. The health care records we looked at showed that care and treatment was planned and delivered in a way that ensured patient safety and welfare. Patients who were attending for an operation told us they felt reassured by the information provided to them about their procedure.

Inspection carried out on 2 May 2012

During an inspection to make sure that the improvements required had been made

During our visit we were able to speak with seven patients and a few visiting relatives. Six patients gave us positive feedback for the outcomes we reviewed during this visit. We were told that they understood the care and treatment choices available to them. We heard they felt involved in making decisions about their care and treatment. Mostly patients told us their privacy, dignity and independence were respected. Comments we heard that reflected our overall view of the service included ‘Staff are very polite……... staff approach is pleasant, I feel reassured. Staff are smashing 100%..........staff very polite, can’t fault them. Very attentive and explain everything, particularly therapy staff.’

Other positive comments included patients telling us ‘Care was very good, can’t fault it. Everything is always explained.’ A few patients told us that staff give good explanations about their exercise and treatment programme and goals were set daily by the multi disciplinary team (MDT). This is a team involving all professionals including nursing/medical staff, physiotherapy and occupational therapy staff. One patient told us they ‘Feel well cared for and safe and was very impressed by the standard of care’. Relating to diet and nutritional support the six patients spoke positively and made comments such as ‘The food is good……drinks were always available….I had a daily menu to choose from…..good choices available’.

However these positive views were not expressed by one patient and their family. When we spoke they raised their concerns that they did not consider that care had been respectful and given with dignity at all times. They told us they had a lack of confidence in the ward staffs ability to support their parent at meal times and because of this they attended daily. This was reported immediately to the unit Matron.

Inspection carried out on 20 March 2012

During a themed inspection looking at Termination of Pregnancy Services

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

Inspection carried out on 23 March 2011

During a themed inspection looking at Dignity and Nutrition

We carried out a site visit at the service and reviewed the care on two of the wards over the period of a day. We spoke with a total of 14 patients across the two wards. We asked them their views specifically about their experiences of how the service involved them and kept them informed. We were also able to make general observations of people’s wellbeing as further evidence of inclusion. All but one person spoken with said that they felt like they were encouraged to express their views openly and that they were kept fully informed about their care and any decisions made. They were of the opinion that any views they had were being taken into account by staff in the decision making for the care and treatment they received. One patient said ‘the staff are excellent, from doctors through to nursing staff they keep me fully informed and explain everything’. Patients talked about some of the difficulties with being in hospital but said that staff were always patient and reassuring.

Although the findings above were generally the case and many expressed the view that they felt like they were treated with respect and dignity, we did find some inconsistencies in the different areas we reviewed and in the care of patients with higher levels of dependency. Some patients for example reported having to wait for long periods for attention [on one ward]. We also saw call bells out of reach for at least half the patients in two of the bays [on one ward]. One patient told us he has to ‘shout for staff to come’. We also made some observations that were a concern and evidence that there may be some patients who are not being monitored appropriately with respect to their privacy and dignity.

People we spoke with were positive about the food provided and said that there was choice made available on a daily basis. People said that dietary choices and requirements were discussed either prior to or during the admission process. Over all the comments we received were very positive and evidenced that most people were satisfied with the food in the hospital.

As with issues around privacy and dignity, we did find some inconsistencies with the monitoring of dietary intake for more vulnerable people and these are discussed in the body of the report.