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Provider: Southport and Ormskirk Hospital NHS Trust Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 13 March 2018

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 During inspection we found out of date medications and missing equipment.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

 

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

 

However:

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

 

 

Inspection areas

Safe

Requires improvement

Updated 13 March 2018

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

  • Systems, processes and standard operating procedures were not always reliable or appropriate to keep people safe.
  • Monitoring whether safety systems were implemented was not robust. There were some concerns about the consistency of understanding and the number of staff who were aware of them.
  • In medical wards we found there were periods of understaffing or inappropriate skill mix, which were not addressed quickly.
  • Across most areas of the trust that we inspected, risks to people who used services were not consistently assessed, monitored and managed on a day-to-day basis. These included signs of deteriorating health and completion of risk assessments. We found risks assessments were not consistently in place or reviewed regularly.
  • Across medical and surgical wards and the spinal injuries unit, systems to manage and share care records and information were uncoordinated. Staff did not always have the complete information they needed before providing care, treatment and support because records from different professionals were stored in different places.
  • In surgical areas staff did not consistently meet good practice standards in relation to controlled drugs. Records did not consistently have two signatures and wastage records were not consistently completed.
  • Across some areas of the trust, there was limited use of systems to record and report safety concerns, incidents and near misses. When things went wrong, reviews and investigations were not always sufficiently thorough. Necessary improvements were not always made when things went wrong. Learning from incidents was not consistently shared across the trust to prevent recurrence of incidents. However, the number of reported incidents had increased since out last inspection.
  • Since our last inspection our rating for safe for the spinal injuries unit went down due to concerns about access to the unit, infection control and relating to completion of risk assessments for patients.

However,

  • Since our last inspection, we noted improvement in safety in surgery services at Southport.
  • Across the trust patients were safeguarded from abuse and staff knew when and how to use local safeguarding procedures whenever necessary. Since our last inspection there was significant improvement in safeguarding training completion levels.
  • Safeguarding adults, children and young people at risk was given sufficient priority. Staff took a proactive approach to safeguarding and focus on early identification. They took steps to prevent abuse or discrimination that might cause avoidable harm, responded appropriately to any signs or allegations of abuse and worked effectively with others, including people using the service, to agree and implement protection plans. There was active and appropriate engagement in local safeguarding procedures and effective work with other relevant organisations.
  • Across most areas, staffing levels and skill mix were planned, implemented and reviewed to keep people safe at all times. Most staff shortages were responded to quickly and adequately. Where relevant, there were effective handovers and shift changes to ensure that staff could manage risks to people who use services.
  • Across most areas, staff met good practice standards described in relevant national guidance, including in relation to non-prescribed medicines. People received their medicines as prescribed. Staff managed medicines consistently and safely. Medicines were stored correctly, and disposed of safely. Staff kept accurate records of medicines.
  • Openness and transparency about safety was encouraged. Staff understood their responsibilities to raise concerns and report incidents and near misses.

Effective

Requires improvement

Updated 13 March 2018

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

  • People did not consistently have comprehensive assessments of their needs, which included consideration of clinical needs (including pain relief), physical health and wellbeing, mental health and patients’ needs when being moved.
  • Outcomes for people who used services were below expectations compared with similar services.
  • The results of monitoring were not always used effectively to improve quality.
  • The learning needs of staff were not consistently identified and training was not consistently provided to meet these needs. There was not a clear approach for supporting and managing staff when their performance was poor or variable. This meant poor performance was not dealt with in a timely or effective way.
  • There was a lack of consistency in how people’s mental capacity was assessed and not all decision-making was informed or in line with guidance and legislation. Decision-makers did not always make decisions in the best interests of people who lacked the mental capacity to make decisions for themselves, in accordance with legislation. Restraint (where relevant) was not always recognised, or less restrictive options used where possible.
  • Applications to authorise a deprivation of liberty using the Deprivation of Liberty safeguards were not always made appropriately or in a timely way.

However,

  • People’s care and treatment was planned and delivered in line with current evidence-based guidance, standards, best practice, legislation and technologies.
  • Information about people’s care and treatment, and their outcomes, was routinely collected and monitored.
  • Most staff were qualified and had the skills they needed to carry out their roles effectively and in line with best practice. Most staff were supported to deliver effective care and treatment, including through meaningful and timely supervision. Where relevant, staff were supported through the process of revalidation.
  • When people received care from a range of different staff, teams or services, it was coordinated. All relevant staff, teams and services were involved in assessing, planning and delivering people’s care and treatment. Staff worked collaboratively to understand and meet the range and complexity of people’s needs.
  • Across most areas, consent to care and treatment was obtained in line with legislation and guidance.

Caring

Good

Updated 13 March 2018

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

  • Feedback from people who used the service and those who are close to them was mainly positive about the way staff treated people. Across most areas we observed that patients were treated with dignity, respect and kindness during their interactions with staff. Relationships with staff were mainly positive. People told us that they felt supported and said staff cared about them.
  • Across most areas, staff responded compassionately when people needed help and they supported them to meet their basic personal needs as and when required. . Staff supported people and those close to them to manage their emotional response to their care and treatment. People’s personal, cultural, social and religious needs were understood.
  • During our inspection we observed that people who used services, carers and family members were involved and encouraged to be partners in their care and in making decisions, and received support they needed. Staff communicated with people and provided information in a way that they could understand it. People understood their condition and their care, treatment and advice. People and staff worked together to plan care and in most areas there was shared decision making about care and treatment.
  • People who used services, those close to them and most staff understood the expectations of the service around privacy and dignity. Most staff recognised the importance of people’s privacy and dignity and respected it at all times. Staff developed trusting relationships with people.

However,

  • In the urgent care service at Southport there were times when people did not feel well-supported or cared for or their dignity was not maintained.
  • People were sometimes not treated with kindness or respect when receiving care and treatment or during other interactions with staff.
  • Across several areas of the trust, people’s confidentiality was not respected at all times. This meant that legal requirements about data protection were not consistently met.

Responsive

Requires improvement

Updated 13 March 2018

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

  • At the trust Ormskirk District General Hospital was rated as good overall for responsive and Southport and Formby District Hospital were rated as requiring improvement.
  • At Southport the hospital continued to experience challenges in relation to patient flow. Bed occupancy, length of stay, and delayed transfers of care had an impact on the flow of patients throughout the hospital due to the demand for medical services. This impacted on urgent and emergency care where patients were still experiencing long and unacceptable waits for treatment.

 

  • At our last inspection we told the trust it must improve patient flow in medical services at the hospital to ensure patients are cared for on wards appropriate for their needs. At this inspection we found that the trust had not reduced the numbers of patients being cared for in non-speciality beds which may not be best suited to meet their needs (also known as outliers).
  • The Ambulatory Care Unit was being used as a bedded area for four patients due to the high demand for hospital beds. The patients in those beds had access to a toilet situated at each end of the unit, however did not have direct access to shower facilities.
  • Passport documents were used for patients with dementia and patients with learning disabilities to identify additional support needs, communication methods, likes and dislikes. However we noted that these were not always completed.
  • Medical patients who were being cared for and treated on surgical wards were not seen by the therapy team covering the surgical ward. This meant there was a risk that these patients did not receive the therapy they required whilst on a surgical ward.
  • Average length of stay was longer for general surgery and trauma and orthopaedics for elective and non – elective procedures when compared to the England average. Average stay for urology patients was higher for non-elective surgery.
  • There was limited personalisation of care plans in the records we reviewed. Plans were largely in the form of standardised templates, which identified risks, but lacked clarity relating to the specific needs and wishes of the patient.

 

However,

  • Facilities and premises were appropriate for the services being delivered.
  • The needs and preferences of different people were taken into account when delivering and coordinating services, including those with protected characteristics under the Equality Act, people who may be approaching the end of their life and people who were in vulnerable circumstances or who had complex needs. Across most services, care and treatment was coordinated with other services and other providers. This included liaising with families and carers and ensuring that all services are informed of any diverse needs that need to be addressed.
  • People could access the service when they needed it. In surgery waiting times for treatment were and arrangements to admit treat and discharge patients were in line with good practice.
  • The trust’s staff had worked to improve their handling of complaints. Complaints were responded to in a shorter time frame and the trust were meeting their legal requirements under the NHS complaints regulations.

Well-led

Inadequate

Updated 13 March 2018

Our rating of well-led went down. We rated it as inadequate because:

  • There was no stable leadership team, with high unplanned turnover and vacancies across a range of areas within the trust.
  • The need to develop leaders was not always identified and action was not always taken to address this.
  • There was no current strategy. As a result staff did not understand how their role contributed to achieving the organisation’s strategic goals. There was no credible statement of vision.
  • The trust had systems for identifying risks. However; not all ward managers we spoke with were aware of risks identified on the risk register.
  • Across most areas, the trust did not engage well with patients, staff, the public and local organisations to plan and manage appropriate services, or collaborate with partner organisations effectively. The trust was beginning to address this but plans were in their infancy.
  • The trust collected, analysed, managed but did not use information well to support all its activities.
  • The trust did not use a systematic approach to continually improving the quality of its services. Focus for improvement was on external reports including CQC’s previous inspection report rather than a proactive internal approach to sustainable improvement.
  • Across the hospital we found a range of concerns relating to the systems and processes that should be in place to ensure the hospital runs effectively and efficiently. New systems and processes had recently been introduced to address this, but were not fully embedded to ensure all risks were identified and addressed.

 

 

However,

  • Clinical business unit leaders had the experience, capacity, capability and integrity to ensure that a strategy can be delivered and risks to performance addressed.
  • The trust was transparent and open with all relevant stakeholders about performance and the challenges to the system, in order to meet the needs of the population.
  • The trust had managers at all levels with the right skills and abilities to run the service providing high-quality sustainable care.
  • Staff we interviewed told us that managers across the trust promoted a positive culture that supported and valued staff and they tried to create a sense of common purpose based on shared values.
Checks on specific services

Community health services for adults

Requires improvement

Updated 15 November 2016

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

It should be noted that;

  • At the time of our inspection in April 2016, the service was going through a procurement process in both its commissioned areas of activity.

  • The trust were not successful in the tender process for the community adult services in West Lancashire and its current adult services would be transferred to a new provider shortly.

  • The remaining services in Sefton were in the process of being tendered at the time of inspection and the Trust was hopeful of retaining the services commissioned in that area.

  • It was recognised that the procurement process had an effect on the services ability to proactively develop the shape of its services and may have caused some issues around the recruitment and retention of staff in the period between our inspections.

  • Whilst we found a certain level of anxiety in the staff group and its managers because of the procurement process, we also found them to be resilient and motivated. The staff had put enormous effort into stabilising the service and were on an upward trajectory to making the service good, despite a number of setbacks.

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

  • Although we saw significant improvement from our last inspection it was from a low base. The service had improved its rating in two areas in both the Responsiveness and the Well Led domains. The Caring domain continued to be good. Safety and Effectiveness were still seen as requiring improvement although improvement had been seen.

  • Some of the areas of concern which we found in this inspection had been highlighted in our last visit in 2015.

  • The service had an over reliance on agency staff to cover vacancies. At times agency staffing reached 50% of the workforce, especially in some district nursing teams. The service itself had recognised that this over reliance on agency staff was a risk. Time and energy was targeted towards filling in gaps through the use of agency staffing on a weekly basis. The reliance on agency staffing led to teams having limited time to reflect on future planning of care and reviewing the effectiveness of what they did.

  • The community health services for adults were unable to show us how they shaped service delivery. The managers in community health services for adults noted that information systems were slow and hard to make sense of both in interview and on the local management log. We felt the service needed to improve at showing how they made patients’ lives better and healthier with hard evidence.

  • Despite improvements in staffing numbers a legacy still existed of some teams having not undertaken staff meetings or supervision.

  • Mandatory training rates and personal development plans (PDPs) were below what was expected by the Trusts own standards in a number of community teams.A direct correlation existed between high use of agency staffing and the lack of personal development plans and mandatory training. The numbers of staff in community health services who had been appraised were below the numbers expected in the trusts own performance targets. In some district nursing teams the lack of appraisal was concerning.

However ;

  • The services staffing numbers were on an upward trend but still required improvement and this had an impact on how well it performed in the area of safety. In February 2015 the teams collectively had 53% of the staff they required to deliver its services. As of January 2016, this figure had risen to over 86% of required staff.

  • Considerable improvement had been made in leadership. The staff told us that they were listened to by managers and in most cases found that change had occurred after our last inspection.

  • The responsiveness of staff to patient need was seen as good with appropriate facilities, delivering planned care, in a way that suited individual’s needs.

  • Whilst teams focused on patient care, staff also told us they were unsure about where they would be employed in the future. Planning for changes in services was on hold until the completion of the final tender bid.

  • Community health services for adults had developed a reporting tool, which gave senior managers real time updates on staff numbers and enabled them to make high level decisions about filling staff vacancies quickly.

  • The service had made a concerted effort to fill its vacant staffing positions but this was, mainly by the use of employing agency staff in its teams.

  • Managers advertised posts based on established staffing levels and used agency to achieve safe levels  of care.  

    t all levels managed risk positively and responsively and reacted when needed. Senior managers showed flexibility and pragmatism in allowing the use of agency staff or allowing advertisement of posts due to service need.

  • We found that the majority of staff were happy about the progress made by the service in terms of staffing and they were appreciative of being listened to and had noticed positive change.

  • Good processes were in place to reduce the risk of abuse and avoidable harm to patients. Training was on offer so that teams could identify concerns regarding Adult abuse or Child abuse. Systems were in place to report and record concerns about patients who were in the services care.

  • The data we gathered provided us with evidence that incidents of harm to patients was relatively low when compared to the rest of the Trust.

  • We were told by staff that teams had an open culture, where they felt free to disclose concerns and report issues as they occurred. The managers showed us that they took those concerns on board by making changes when staff voiced an issue about potential patient safety.

  • Patients told us they felt safe and “in good hands”, whilst in the care of the community health services for adults.

  • The service and its teams were seen as providing good care and were person centred and committed. The staff showed empathy and concern for people they treated. We observed staff giving good care to patients in their homes and in clinic treatment rooms.

  • We found that staff were responsive to patient need and were good and competent at their job. The teams provided care to patients in different ways depending on circumstance.

  • The patients we talked to valued what the staff did for them and felt Involved in their treatment. The staff talked to them and their families about treatment and placed patients and carers at ease.

  • We saw a workforce who obviously supported each other and who were resilient and vocal about health care.

  • We found examples of good leadership across the individual services. The recruitment of some new staff has enabled managers to start to have some space to think about leading rather than covering gaps in their own services because of lack of staff.

  • We found on the whole that managers were visible in services. The staff noted how managers up to district level were available and supportive, often coming to services to see how staff were coping. Staff members talked of managers helping out at the shop floor when needed and they clearly had a fondness and respect for them.

  • Despite uncertainty in their future employment staff were positive about their role and told us they concentrated on patient care first before anything else.

Community health services for children, young people and families

Requires improvement

Updated 15 November 2016

Overall rating for this core service Requires Improvement

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

  • The computer system did not consistently flag up patients with safeguarding concerns. Systems in place to address this were not robust across the service’s different clinics.

  • The number of staff that were up to date with their statutory and mandatory training were below the trust’s target.

  • The lack of an electronic patient record presented risk of patients attending multiple clinics unknown to staff.

  • Patients were turned away from clinics which could not meet the demand and 168 clinics were cancelled in the 12 months to January 2016.

  • The management team did not document, monitor or manage the numbers of patients turned away from clinics or the cancellation of clinics when the service was not always meeting the demand for the service. However they told us that they were in consultation with the commissioners regarding the increased demand.

However,

  • There was a good incident reporting culture. Feedback was provided and staff met regularly to address how services could be improved.

  • The service followed British Association for Sexual Health and HIV (BASHH) Guidance and service audits demonstrated compliance with BASHH guidelines.

  • The Faculty of Sexual and Reproductive Health CEU clinical guidelines are accredited by NICE and the service was compliant with these guidelines.

  • Staff demonstrated a good understanding of people’s needs, ensured they maintained privacy and dignity and took extra time to support people.

  • The service worked closely with commissioners to ensure they were targeting local service users; needs.

  • The service regularly reviewed the provision it made with other stakeholders to ensure the needs of the community were addressed.

  • The service had created multi-agency relationships which ensured service leaders and those within the team were aware of current health economy factors.

Urgent care services

Requires improvement

Updated 15 November 2016

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

This is because:

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

However:

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