Archived: Southport & Formby District General Hospital

Updated 13 May 2021

At this inspection we inspected five of the hospital’s seven core services. We rated safe, effective, responsive and well-led as requires improvement. We rated caring as good.

We rated three of the hospital’s core services as requires improvement. The other two services we inspected were rated as good. From our previous inspection in 2018 the hospital’s remaining two core services were rated as good and requires improvement. This meant that overall four services were rated as requires improvement and three were rated as good.

During this inspection we improved the rating for safe in urgent and emergency care from inadequate to requires improvement, effective in end of life care and surgery improved to good. Caring improved in urgent and emergency care to good. Well-led in urgent and emergency care improved to good. Well-led in surgery and our overall hospital rating for the well-led domain improved from inadequate to requires improvement.

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 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 all subject areas, though compliance had improved.
• Across the hospital 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 We found out of date medicines. 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 were concerned regarding that the design, maintenance and use of facilities, premises and equipment did not always keep people safe. We found substances hazardous to health stored in unlocked rooms on three wards. This meant there was a risk they could accessed by vulnerable 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 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 risks.
• We were concerned that the hospital did not have enough nursing and support staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. A review had been completed identifying additional staffing levels were required, but wards were not 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. There were high numbers of vacancies for registered and unregistered nursing staff across the service which were not filled by bank or agency staff.
• 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.
• At our last inspection we saw patient records were not stored securely. At this inspection we found paper patient records were not stored securely.
• The hospital did not meet all required standards in the 2017 national lung cancer audit and 2017 national audit of impatient falls. It performed worse than the national average in the chronic obstructive pulmonary disease audit for October 2018 to April 2019. The hospital was higher than the national average for mortality.
• The hospital 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. Not all medical staff were supported to develop their skills and knowledge.
• We were concerned regarding the hospital staff members’ understanding regarding mental capacity and consent. Capacity assessments were not evident within records where patients were deemed to lack capacity. 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.
• Across most of the hospital’s services 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.
• 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.

• The hospitals’ services did not always take account of patients’ individual needs and preferences. This was because not all patients with dementia or a learning disability had a hospital passport or ‘This is me’ document completed.
• The hospital’s services did not always make reasonable adjustments to help patients access services. Not all wards were designed to meet the needs of people with dementia.
• It was not always clear to people how to raise concerns or complain about care received.
• The hospital service’s took longer than the time set out in trust policy to investigate and respond to complaints.
• Across the hospital not all staff felt respected, supported and valued.
• Local governance processes were not effective as we found areas of poor practice 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:

• During this inspection we improved the overall rating of urgent emergency services, the rating for effective in end of life care and our overall hospital rating for the well-led domain to requires improvement.
• 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.
• The hospital’s service provided care and treatment based on national guidance and evidence-based practice. Managers checked to make sure staff followed guidance.
• 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.
• The hospital planned and provided care in a way that met the needs of local people and the communities served. It also worked with others in the wider system and local organisations to plan care.
• Leaders had the skills and abilities to run the hospital. They understood and managed the priorities and issues the hospital’s services faced. They were visible and approachable in the service for patients and staff. They supported staff to develop their skills and take on more senior roles.

Updated 29 November 2019

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

• We previously rated this service in November 2017. We rated it as requires improvement overall with safe, effective and responsive rated as requires improvement, caring rated as good and well-led rated as inadequate. At this inspection we rated safe, effective, caring and responsive as requires improvement, and well-led as inadequate.
• At our last inspection we told the service it must act to ensure all staff had the training they required to be able to safely care for patients. At this inspection we found not all staff had completed mandatory and basic life support training. The target for mandatory training for medical staff was not met in any module. The compliance rate for basic life support training level one was 48.9%.
• The service did not have enough staff to care for patients and keep them safe. The service had conducted a review of staff and had plans to increase the number of nursing staff but these were not in place at the time of our inspection.
• The service did not always control infection risk well. At our last inspection we found staff did not always use personal protective equipment and wards were not clean and well maintained. At this inspection we found staff did not consistently follow infection prevention and control measures.
• Staff did not always assess risks to patients: they did not consistently act on assessed risks. Care records were not stored securely in all areas, an issue that was the same as our last inspection. The service did not manage medicines well.
• The service did not meet all required standards in several national audits. Mortality rates were higher than the England average. The service did not make sure all staff were competent for their roles. Following our last inspection, we told the service it should act to ensure staff received an annual appraisal. At this inspection we found that not all nursing staff had an annual appraisal.
• Not all key services were available seven days a week. We found this at our last inspection and told the service it should consider improvements to provide an equitable service seven days a week.
• Staff did not support patients to make decisions about their care in line with best practice and legislation. Not all staff knew how to support patients who lacked capacity and we found deprivation of liberty safeguards were not always applied in line with legislation. Staff did not always follow national guidance to gain patients consent as ‘do not attempt cardiopulmonary resuscitation’ orders were not completed correctly and patients’ capacity to consent to this not always assessed.
• Patients privacy and dignity was not always respected. Some patients told us that not all staff treated them with kindness and compassion.
• The service did not always take account of individual needs. It took longer than timescales set out in the trust policy to investigate and respond to complaints.
• Leaders did not run services using reliable information systems. Though leaders and teams used systems to manage risk, issues and performance these were not always effective. Not all staff felt respected, supported and valued.

However,

• Staff understood how to protect patients’ from abuse and worked well with other agencies to do so. Staff collected safety information and displayed it for staff, patients and visitors.
• Staff gave patients enough to eat and drink and gave them pain relief when they needed it. Managers monitored the effectiveness of the service. Staff worked well together for the benefit of patients.

Updated 29 November 2019

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

• The service ensured that there were enough nursing staff in the right areas to keep people safe. All staff had received mandatory and safeguarding training, they knew what to do to protect patients from abuse and how to report an incident if things went wrong.
• The service had suitable premises and equipment and looked after them well. Wards were visibly clean and tidy, and staff had access to equipment they needed. Medicines were stored securely, and controlled drugs were well managed.
• The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers monitored the effectiveness of care and treatment and used the findings to improve them.
• The service assessed and monitored patients’ nutritional and pain needs effectively. Staff of different kinds worked together as a team to benefit patients and were competent for their roles.
• There was a person-centred culture and staff cared for patients with compassion. Patients emotional and social needs were seen as being as important as their physical needs and staff provided emotional support to patients to minimise their distress.
• The service planned and provided services in a way that met the needs of the people who used it and it took account of patients’ individual needs.
• Managers at all levels in the service had the right skills and abilities to run a service providing high-quality sustainable care. There was a vision for what it wanted to achieve.
• The service had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. Staff were encouraged to develop, influence change and be involved in research.

However

• The most recent network peer review completed in 2018 identified that the environment of the intensive care unit and the high dependency unit did not meet with the Guidelines for the Provision of Intensive Care Services 2015 and the NHS Estates Health Building Note (HBN) 04-02 for Critical Care Units 1.
• We were told that consultant led ward rounds were not consistently undertaken twice daily during the weekend.
• The results of the quarter three Intensive Care National Audit Research Centre April to December 2018 demonstrated that the service performed worse than comparative units for risk adjusted hospital mortality indicators but was within the expected range.
• Key services were not always available seven days a week to support timely patient care, this included speech and language therapy, dieticians and pharmacy.
• People could access the service when they needed it, however the service did not have a robust process in place to monitor admission times against the national standard.
• Whilst there had been some improvement since the last inspection. The service reported high numbers of mixed sex breaches, delayed discharges and bed moves at night this remained an area of concern.
• The divisional strategy document lacked focus for critical care and had limited links to specific actions and timescales to turn it into action and staff told us they had not been engaged in its development.

Updated 29 November 2019

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

• Staff completed risk assessments were and considered patients who were deteriorating and in the last days or hours of their life.
• Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date, stored securely and easily available to all staff providing care.
• The service used systems and processes to safely prescribe, administer and record medicine.
• Care and treatment provided was based on national guidance and evidence-based practice.
• The effectiveness of care and treatment was monitored. They used the findings to make improvements and achieved good outcomes for patients.
• Doctors, nurses and other healthcare professionals worked together as a team to benefit patients and supported patients to make informed decisions about their care and treatment.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.
• The service planned and provided care in a way that met the needs of local people. It also worked with others in the wider system and local organisations to plan and deliver care.
• Patients could access the supportive and specialist palliative care service when they needed it. Patients preferences were discussed and the numbers of patients who achieved their preferred place of care had improved.
• Leaders had the skills and abilities to run the service and were visible, approachable and supportive for patients and staff.

However:

• The senior managers had no effective oversight of the effectiveness of the current process of monitoring staff competency with the syringe driver.
• Staff did not have access to accessible communication aids to assist when caring for a patient with additional needs.
• We did not see evidence that the pain care plan was consistently used.
• Good practice and areas requiring improvement identified in relation to end of life care were not shared with all staff across the hospital.

Updated 15 November 2016

The hospital was previously inspected by the Care Quality Commission in November 2014 and outpatients and diagnostic imaging received a rating of ‘requires improvement’ for safe and good for the other domains of caring, responsive and well-led.

At this inspection, we gave the outpatient and diagnostic services a rating of ‘good’ overall, however we rated the services as ‘requires improvement’ for safe. This was because:

The previous ‘requires improvement’ rating was due to safety incidents not being communicated with the trust board. This has since been addressed, however other issues of concern were found.

We had a control of infection issue in the eye clinic that was raised during the inspection. The trust responded quickly and an action plan to improve was put in place; however, some issues were not addressed.

At this inspection, we found the hospital performed well against national targets. Waiting times for appointments were better than average with 50% of patients receiving an appointment within five weeks of referral. Radiology figures were excellent for both receiving appointments and results. In the last 12 months, less than 1% of patients waited six weeks for a radiology appointment.

There were a large number of appointment cancellations that had a variety of causes including IT issues and patients receiving multiple appointments in error. However, managers were gathering evidence and had set improvement targets

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

Some areas of mandatory training showed poor results and managers acknowledged that work was needed. When something went wrong, the outpatients and diagnostic departments responded well to patients and investigated the causes to make sure errors did not reoccur.

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

Updated 13 March 2018

We visited the unit as part of our unannounced inspection on 27 and 28 November 2017. Our inspection was unannounced (staff did not know we were coming) to enable us to observe routine activity.

Before the inspection visit, we reviewed information that we held about these services and information requested from the trust. During the inspection visit, the inspection team:

• Reviewed the environment and staffing levels.
• Looked at 10 sets of patient notes.
• Spoke with 10 patients and two relatives.
• Spoke with 27 staff of different grades, including nurses, health care assistants, doctors and consultants, physiotherapists, psychotherapists, case managers and senior managers who were responsible for the regional spinal injuries unit.
• Observed a goal planning meeting involving a patient and their relative and an admission planning meeting involving 14 staff from different professions.
• Observed daily practice and reviewed management arrangements.

Our overall rating of this service went down. We rated it as requires improvement because:

• Nursing staff were not meeting trust targets for a number of mandatory training modules.
• The service was failing to minimise the risk of the spread of infections in the ward areas.
• There was a lack of security throughout the unit. People who had no business in the unit could freely gain access to all areas and this did not ensure that people were kept safe and personal property and equipment was kept protected at all times.
• Patient records were not always stored securely in locked trolleys and during inspection we saw patient details were left open on computer screens.
• Not all patient risk assessments were being completed fully and appropriately.
• Patient records were not stored centrally and were split into medical, nursing, therapy, case management and psychology notes and stored in separate places around the unit. This meant there was a risk that the full picture of a patient was not known when decisions were being made.
• In one instance, the decision to not resuscitate a patient in the event of a cardiac arrest had not been properly reviewed. The “Do not attempt resuscitation” documentation was not discontinued, despite the fact that the patient had regained capacity and this was against their wishes.
• There was only one isolation room. This meant that patients with existing infections could not be admitted to the unit in a timely way if this room was already in use.
• Patients’ privacy and dignity was put at risk when they were receiving treatment or therapy in the gym because the area was overlooked from above and the gym was also used by members of the public.
• Procedures and documentation for assessing patients who lacked capacity were inconsistently recorded.
• Trust leadership was new and local governance systems were not embedded. There was a lack of oversight of some key risks in the unit.
• Staff expressed the view that they often felt separate from the trust as a whole and there was a need to keep reinforcing the work of the unit within the organisation.

However,

• Staff understood how to protect patients from abuse and the service planned for emergencies.
• Equipment was looked after well and medicines were stored and prescribed appropriately.
• Care and treatment was based on national guidance and evidence of its effectiveness was monitored.
• Patients were supported to be self –managing for their care needs and families were educated in how to assist patients in this approach.
• Patients received adequate pain relief, nutrition and hydration.
• Patients reported that they were treated with dignity and respect. They were very positive about staff and the care that they received and told us that nurses went the extra mile to ensure that their needs were met.
• The spinal injuries unit team was strongly person centred in its approach to patient care. Patients’ individual needs were considered as a priority and assessed on a case by case basis, with appropriate support available.
• Staff received appraisals and at 30 June 2017 the appraisal rates for staff on the ward areas of the unit were only marginally below the trust target of 90%. All staff in administration and the allied health professionals in the case management team had received an appraisal.
• Staff received adequate training and competencies were assessed.
• Patients were admitted to the unit in a timely way and all referred patients were assessed for suitability to be admitted to the unit within five working days.
• There were very few complaints against the unit (four in the year from July 2016 to June 2017). Complaints were treated seriously, investigated and lessons learned were shared.
• There was a set of vision and values local to the unit and the service had a work plan in draft for service improvements from 2017 to 2019.
• Information was collected, analysed and managed to support activities and make improvements.
• The unit led and participated in spinal injuries research and development activities, involved in regional and national specialist networks.
• There was wide engagement activity with patients, staff and different community groups related to spinal injuries care.
• Staff spoke highly of the unit management team and told us that they were very supportive and responsive to new ideas to improve the service. Managers were knowledgeable, competent and communicated well with staff at all levels.

Updated 29 November 2019

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

• Compliance rates for mandatory training was below the trust target, patient records were not clear or securely stored and processes in place to prescribe, administer, record and store medicines were not safe, however; the service had enough staff to care for patients and keep them safe. understood how to protect patients from abuse. The service controlled infection risk well. Staff assessed risks to patients and acted on them. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
• The service did not always provide care and treatment based on national guidance and evidence-based practice. Compliance rates for appraisals were below the trust target and staff did not always understand how to support patients who lacked capacity to make their own decisions or were experiencing mental ill health. However, staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives. Key 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 acute surgical services were based mainly at this location with elective surgery at another location. At times patients were delayed leaving recovery following surgical procedures, due to a lack of available beds, leading to overruns or cancellations. Complaints investigations were not always completed in a timely manner and longer than the trusts target. However, the service took account of patients’ individual needs, people could access the service when they needed it and did not have to wait too long for treatment.
• Theatre staff were not feeling supported, the service recognised areas of performance and risk that needed attention and improvement. Staff could not always find the data they needed, in easily accessible formats, to understand performance, make decisions and improvements. response rates for friends and family test were low. However, Leaders ran services well and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service was committed to improving services continually.

Updated 29 November 2019

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

• Staff did not always assess the risks to patients appropriately and did not always keep good care records. The maintenance and use of equipment did not always keep people safe.
• Pain relief was not always monitored or reassessed in a timely manner. Staff did not always follow the principles of the mental capacity act and mental capacity assessments were not always undertaken appropriately or documented correctly.
• People trying to access the service sometimes waited too long for assessment and treatment.
• Not all staff felt listened to, supported or valued.

However:

• The service managed patients at risk of deterioration well. Staff understood how to protect patients from abuse. The service controlled infection risk well and improved safety by monitoring results.
• Pain relief was assessed appropriately, and measures had been put into place to enable swift administration of pain relief by nursing staff. Managers made sure staff were competent. Key services were available seven days a week.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, and helped them understand their conditions. They provided emotional support to patients, families and carers.
• The service was planned to meet the needs of local people and tailored services to meet individual patient needs.
• Staff were clear on their roles and responsibilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services.