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Archived: Ormskirk District General hospital

Overall: Requires improvement read more about inspection ratings

Hilldale, Wigan Road, Ormskirk, Lancashire, L39 2JW (01704) 547471

Provided and run by:
Southport and Ormskirk Hospital NHS Trust

Important: The provider of this service changed. See new profile

All Inspections

09 July to 22 August 2019

During a routine inspection

Our overall inspection ratings take into consideration our findings from our last inspection in 2017.

At this inspection we rated effective, caring and responsive as good. We rated safe and well-led as requires improvement.

We rated three of the hospitals five core services as good. The other two services were rated as requires improvement.

During this inspection we improved the ratings of children and young people’s service to good and our overall hospital rating for the effective domain to good.

At this inspection we found:

  • At our last inspection we told the trust they must improve compliance with mandatory training. At this inspection we found that not all staff completed mandatory training. Whilst overall mandatory training compliance had improved since our last inspection, in 5/12 subjects, including resuscitation training, completion levels for nursing staff were still below the trust’s target. The target had not been met by medical staff in 7/10 subject areas, including resuscitation training, though compliance levels had improved.
  • Staff did not always take appropriate actions when recommended temperatures for the storage of medicines were exceeded.
  • In children and young people’s services not all of the medical staff had completed their mandatory training. Areas of poor compliance included resuscitation training.
  • In children and young people’s services there were issues with some equipment, in that regular and robust checks were not always completed.
  • In children and young people’s services we found evidence that there had been occasions when medical staff had not responded to nursing concerns, which led to avoidable harm occurring to two patients.
  • In children and young people’s services the service did not have enough medical staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment, particularly at consultant level, leaving pressure on junior doctors.
  • In outpatients cleaning checklists did not include specific prompts for the cleaning of children’s toys.
  • We were concerned in outpatients that the follow-up to new ratio for patient appointments was worse than the England average. The service did not routinely achieve the waiting time standard for cancer patients receiving their first treatment within 62 days of an urgent referral. There were delays in children seeing a paediatrician.
  • We noted that complaint responses were not always within trust targets.
  • In outpatients the number of staff who completed appraisals did not meet trust targets.

However:

  • Our overall rating of children and young people’s services improved to good.
  • Across both services staff understood how to protect patients from abuse. Staff controlled infection risk well. The services’ staff kept good care records. Safety incidents were managed well and lessons were learned from them. Staff collected safety information and used it to improve the services.
  • Staff provided good care and treatment, gave patients enough to eat and drink and offered pain relief when it was needed. Managers monitored the effectiveness of the service and made sure staff were competent. Most services were available seven days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people. The service took account of patients’ individual needs and made it easy for people to give feedback. People could access most of the services when they needed it.
  • Leaders supported staff to develop their skills. Most staff members that felt they were listened to by senior staff. The services were focused on the needs of patients’ receiving care. Staff were clear about their roles and accountabilities. The trust engaged with the patients and the community to plan and manage services. Staff were keen to learn and to develop the service.

12 - 15 April 2016

During an inspection looking at part of the service

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

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

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.

2 May 2012

During an inspection looking at part of the service

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.

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.

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.