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Provider: Southport and Ormskirk Hospital NHS Trust Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 29 November 2019

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

  • We rated safe, effective, responsive and well-led as requires improvement, and caring as good. At this inspection we inspected eight core services. We rated five of the trust’s services as good and three as requires improvement. In rating the trust, we took into account the current ratings of the four services not inspected this time. This means overall there are six services rated as requires improvement and six services with overall ratings of good.
  • We rated well-led for the trust overall as requires improvement.

  • We were concerned that issues raised at our previous inspection in relation to medical wards had not been effectively addressed and mitigated in a timely manner. Our concerns meant the rating for the well-led domain for medicine remained inadequate.
  • Across the trust we were concerned regarding the completion levels of mandatory training for resuscitation (61%).
  • At our last inspection we had concerns relating to the storage of hazardous materials. At this inspection we remained concerned.
  • We identified concerns during our last inspection as 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 found similar concerns at this inspection.
  • We were concerned regarding medicines, including medicines that were passed their expiry date and in relation to the way that controlled drugs were managed. We escalated this to the trust at the time of our inspection.
  • At our last inspection 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 had similar concerns at this inspection.
  • We were concerned regarding staff competencies including how they were evidenced. In relation to equipment, we were not assured that the trust had oversight as to whether staff were competent. We found gaps in records relating to competencies. Staff were also unclear regarding their roles and responsibilities in relation to capacity assessments.

However:

  • During this inspection we improved the overall rating of children and young people’s services and the rating for effective in end of life care to good. We improved the safe domain rating for urgent and emergency services to requires improvement. Our overall hospital rating for the well-led domain was improved to requires improvement.
  • Since our last inspection the trust had developed a strategy and a vision, which most staff were aware of.
  • Our full inspection report summarising what we found and the supporting Evidence appendix containing detailed evidence and data about the trust is available on our website – https://www.cqc.org.uk/provider/RVY/reports
Inspection areas

Safe

Requires improvement

Updated 29 November 2019

  • 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 mandatory training compliance had improved since our last inspection, in five of 12 subjects, including resuscitation training, completion levels for nursing staff were still below the trust’s target. Across the trust the mandatory training target had not been met by medical staff in all subject areas, though compliance had improved in some areas.
  • Across the trust services did not use systems and processes to safely prescribe, administer, record and store medicines. The hospital’s services did not ensure medicines were always safely prescribed, administered and stored. We found medicines that were past their expiry dates across most services. Staff did not consistently monitor ambient room temperature where medicines were stored and did not escalate this to estates when room temperatures were out of range. We saw patients were not always given the right medicine at the right time and staff did not consistently report medicine errors.
  • We found substances hazardous to health stored in unlocked rooms on three wards. This included areas where vulnerable patients were cared for. This meant there was a risk they could accessed by patients and was not in line with health and safety best practice.
  • Across the medical wards we were concerned that the services did not always have enough suitable equipment to help staff safely care for patients. The trust told us that an equipment review was being undertaken but this had not been completed at the time of our inspection and had been ongoing for several months.
  • Staff did not always complete and update risk assessments for each patient and they did not always remove or minimise known risks.
  • At the time of our inspection the trust was in a transition phase in relation to nurse staffing. A review had been completed identifying additional staffing levels were required. Wards had not been filled to these levels despite the fact the board had approved the additional staffing and funding for this. Published fill rates for nursing staff were good but these did not take account of the new staffing numbers established in the review. Following our inspection, we received updated information from the trust, which confirmed there were still staffing gaps, but this had improved since our last inspection.
  • At our last inspection we saw patient records were not stored securely. At this inspection we found paper patient records were not stored securely.

However:

  • Across the trust staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Nursing staff had training on how to recognise and report abuse and they knew how to apply it.
  • Staff kept equipment and the premises visibly clean.

Effective

Requires improvement

Updated 29 November 2019

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

  • Consultants did not lead daily ward rounds on all wards and consultants were not available on wards at weekends. This was the same as at our previous inspection.
  • The trust did not meet all required standards in the 2017 national lung cancer audit and 2017 national audit of inpatient falls. It performed worse than the national average in the chronic obstructive pulmonary disease audit for October 2018 to April 2019. The Trust was outside the expected range for mortality, however this position has continuously improved and at the time of reporting is now within the expected range The trust did not make sure all staff were competent for their roles. Managers did not appraise all staff’s work performance or provide support and development. Some medical staff told us that they were not supported to develop their skills and knowledge. We were also concerned regarding the lack of evidence of staff competencies for equipment usage.
  • At our last inspection we were concerned regarding the trust’s staff members’ understanding regarding mental capacity and consent. At this inspection we found capacity assessments were not evident within all records where patients were deemed to lack capacity. Approximately 40% of staff we spoke with were not able to explain the process and legal requirements for capacity assessment and deprivation of liberty safeguards. Record keeping was poor in relation to ‘Do Not Attempt Cardio-pulmonary Resuscitation’ (DNACPR) forms.
  • At our last inspection we raised concerns regarding the use of bedrails for patients who had capacity. We observed that this issue had not been resolved at this inspection. Staff did not consistently fully and accurately complete patients’ fluid and nutrition charts.
  • We were concerned that at Southport hospital staff did not always monitor and reassess pain or administer additional pain relief in a timely manner.
  • Key services were not always available seven days a week to support timely patient care. This included speech and language therapy, dieticians and pharmacy. This meant there was not continuity of care for patients and national standards were not always maintained.

However:

  • The trust’s services provided care and treatment based on national guidance and evidence-based practice. Managers checked to make sure staff followed guidance.

Caring

Good

Updated 29 November 2019

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

  • Across most services staff treated patients with compassion and kindness and respected their privacy and dignity.
  • Staff provided emotional support to patients, families and carers to minimise their distress. They understood patients’ personal, cultural and religious needs.
  • Staff supported and involved patients, families and carers to understand their condition and make decisions about their care and treatment.

However:

  • Our rating for caring in medicine went down to requires improvement due to concerns in relation to privacy and dignity.

Responsive

Requires improvement

Updated 29 November 2019

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

  • People could not always access the service when they needed it and did not always receive the right care promptly. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were not in line with national standards.
  • 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 target, did not consistently address all the issues raised and on occasions lacked empathy.

However:

  • The trust planned and provided care in a way to meet the needs of local people and the communities served. It also worked with others in the wider system and local organisations to plan care.

Well-led

Requires improvement

Updated 29 November 2019

Our rating of well-led improved. We rated it as requires improvement because:

  • We were concerned regarding the pace of progress in some areas.
  • Across the trust not all staff felt respected, supported and valued.
  • Local governance processes did not consistently identify areas of poor practice. We found risks which had not been identified/ fully mitigated through governance processes.
  • Though leaders and teams used systems to manage performance, these were not always effective.

However:

  • Leaders had the skills and abilities to run the community and hospitals’ services. Across most services leaders understood and managed the priorities and issues the services faced. They were visible and approachable in the service for patients and staff. Across most services, leaders supported staff to develop their skills and take on more senior roles.

Assessment of the use of resources

Use of resources summary

Inadequate

Updated 29 November 2019

Combined rating

Combined rating summary

Requires improvement
Checks on specific services

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.

Community health sexual health services

Good

Updated 29 November 2019

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

  • The service provided mandatory training in key skills to all staff and made sure everyone completed it. The mandatory training was comprehensive and met the needs of patients and staff.
  • 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.
  • The service controlled infection risk well. Staff used equipment and control measures to protect patients, themselves and others from infection. They kept equipment and the premises visibly clean.
  • The service provided care and treatment based on national guidance and evidence-based practice which was specific to sexual health and contraception services. Managers checked to make sure staff followed guidance. Staff had links with community mental health services so that adults and children could get their mental health needs addressed when and if issues arose.
  • Staff gave patients practical support and advice to lead healthier lives. We found the community outreach team to be responsive and creative in its practice with young people and vulnerable communities.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.
  • Staff supported and involved patients, families and carers to understand their condition and make decisions about their care and treatment. The service provided bespoke training to parents to enhance family conversations about sexual health
  • The service was inclusive and took account of patients’ individual needs and preferences. Staff made reasonable adjustments to help patients access services. They coordinated care with other services and providers.
  • Patients had a wide range of access points into the service when they needed care and treatment. However, the service sometimes had long waiting times of up to two hours at specific times during some of its walk-in clinics.
  • Leaders had the integrity, skills and abilities to run the service and this was being done whilst teams and the whole service were going through transitional changes, including job roles. They understood and managed the priorities and issues the service faced and sought support to enhance leadership by gaining additional support due to structural change.
  • The service had an evolving vision for what it wanted to achieve and a strategy to turn it into action, developed with all relevant stakeholders.
  • The vast majority of staff felt respected, supported and valued, however the service was going through structural change which impacted on some staff members. Despite these changes staff were focused on the needs of patients receiving care.
  • The service collected reliable data and analysed it. Staff could find the data they needed, in easily accessible formats, to understand performance, make decisions and improvements.
  • All staff were committed to continually learning and improving services. They had a good understanding of quality improvement methods and the skills to use them. Leaders encouraged innovation and participation in research.

However:

  • We found the majority of staff were competent for their roles and were supplied nationally accredited enhanced training. However, supervision rates and appraisal rates needed to improve in some staffing groups.

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.

Reference: Urgent care services not found

Requires improvement

Updated 13 May 2015

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.