- NHS hospital
Archived: Southport & Formby District General Hospital
Important:
This service is now managed by a different provider - see new profile
All Inspections
3 March 2021
During an inspection looking at part of the service
Southport and Ormskirk NHS Trust provides healthcare to approximately 224,402 people across Southport, Formby and West Lancashire.
Acute inpatient care is provided at Southport and Formby District General Hospital and Ormskirk District General Hospital.
The medical care service at Southport and Formby District General Hospital has 209 inpatient beds. The urgent care clinical business unit manages medical care services.
The medical care service operates from nine wards at Southport and Formby District General Hospital.
This consists of a cardiology ward (7a), a short stay unit (9a), a respiratory ward (14b), a stroke ward (15b with two hyper acute stroke beds), an emergency assessment unit (10a) and three care of older people wards (9b, 15a and 7b).
The trust had 18,293 medical admissions from November 2019 to October 2020. Emergency admissions accounted for 10,037 (54.9%), 168 (0.9%) were elective, and the remaining 8,088 (44.2%) were day cases.
For the reporting period (November 2019 to October 2020) admissions for the top three medical specialties across the trust were:
• General medicine: 12,144
• Clinical Haematology: 4,720
• Pain management: 637
We carried out this unannounced focused inspection following information of concern received from the public. We received information about patients absconding from wards and that patients and their families had not always been involved in decision making regarding the application of Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR). We inspected safety processes in the trust’s medical care services. We also looked at the wider oversight and management of risk, governance and safety of patients across the service.
On the inspection we were limited to the wards we could visit due to the COVID-19 infection risk. We visited five out of the eight medical wards which included the medical emergency assessment unit (EAU), ward 11b the general medical /gastroenterology ward, ward 7a the cardiology including coronary care ward, 14b the respiratory ward and 9a the short stay ward.
We did not inspect all of the key lines of enquiry as our concerns were related to specific risks. We inspected against parts of the safe, effective, caring and well-led key questions.
We previously inspected medicine at Southport and Ormskirk NHS Trust in August 2019 as part of our comprehensive methodology where we rated the medical care (including older peoples care) service as requires improvement in safe, effective, caring and responsive and inadequate in well led.
During this inspection on the wards visited there was an improvement across all assessed domains. All the staff we spoke with were friendly and helpful. They spoke positively about the culture and the support and visibility of leadership on the medical wards.
We spoke with 23 members of medical and nursing staff. We reviewed 23 patient records, where we looked at specific documentation including care plans, risk assessments, mental capacity assessments, DNACPR records, patient ‘rounding’ documentation and patient care charts. Patient ‘rounding’ is a process of regular nursing checks to ensure patient’s fundamental care needs are being met.
We spoke with nine patients during the inspection. We observed patient care using the Short Observational Framework for Inspection method (SOFI 2). The SOFI 2 tool provides a framework to enhance the observations we already make at inspections about the wellbeing of people using the service and staff interaction with them. We also interviewed key members of staff, medical staff and the senior management team who were responsible for the leadership and oversight of the service. We observed a handover/patient safety briefing, bed meetings, and a task force meeting with the local commissioners. We took into account nationally available performance data.
Following the inspection, we requested and reviewed information relating to the concerns raised and the evidence we had gathered following the observations we had made.
You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.
See the medical section for what we found.
09 July to 22 August 2019
During a routine inspection
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.
8 March 2018
During an inspection looking at part of the service
We inspected the emergency department as an unannounced responsive inspection on 7 March 2018 in response to concerns regarding patient safety and how responsive the department were to people’s needs. We had previously inspected the urgent and emergency care service in November 2017, when we rated the service overall as requires improvement and inadequate in terms of patient safety. At this inspection we looked at specific areas of concern including: patient safety, medicines, staffing levels, the environment, infection prevention and control, record keeping, mandatory training of staff, how services were planned, whether services met patients’ individual needs and how the flow of patient through the department was managed. We wanted to make sure patients were receiving safe care that was responsive to their needs.
We did not re-rate urgent and emergency care at the time of this inspection. We found the following areas for improvement:
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We had concerns about the safety of patients in the department. This was for a number of reasons. The department did not have enough capacity to accommodate all the patients requiring treatment.
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Patients waited a long time to receive medicines such as pain relief. Handover, initial assessment and responsibility for patients was not happening in a timely manner. Ambulance staff were waiting with patients for excessively long times in the department.
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Records were not completed in a comprehensive way and risk assessments were not documented as being carried out.
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Infection prevention and control practices were not following national guidance: staff were not always washing their hands, using gloves appropriately or arms bare below the elbow. The department was not always as clean as it should be with dirty rooms and smears of bodily fluids on walls.
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There were insufficient staff deployed to the department and from the evidence we looked at, this had been a long-term issue.
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Staff were not up to date with their mandatory training.
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We had concerns about the responsiveness of the department. It was not able to meet the demand from the number of patients attending. The department had severe problems with capacity.
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The hospital was also full to capacity and as a result, emergency department patients were waiting for long periods of time in corridors before being admitted to wards. There was poor flow through the department on to wards and from wards to home. From what we saw and what staff told us, the whole flow of the system did not appear to be working well.
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The department was performing poorly against national government performance indicators such as waiting time targets. This meant patients did not have access to treatment and care in a timely manner.
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There was no system of data validation in place to ensure waiting time information was accurately reflecting the time patients spent in the department.
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Escalation processes in place were not effective and patients were waiting excessive time in the department as a result.
However:
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Staff were working extremely hard to deliver care that was caring and compassionate under very difficult circumstances.
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We observed staff helping patients and supporting them as best they could.
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Nursing and medical staff worked well together and were doing the best they could for patients.
There were areas of poor practice where the trust needs to make improvements.
Importantly, the trust must:
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Ensure sufficient medical and nursing staff are deployed in the department to meet the need of patients.
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Prescribe and administer pain relief in a timely way to ensure patients are not left in pain for long periods of time.
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Improve the triage process and take responsibility for patients brought to the department by ambulance and as soon as handover has been carried out, administer their medicines and manage their needs.
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Improve the quality of record keeping and storage of paper records to ensure no information is lost or misfiled. This includes completion of risk assessments, safeguarding, mental capacity assessments and National Early Warning Scores (NEWS).
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Adhere to infection prevention and control standards including cleaning of rooms, and following hand hygiene and other infection control processes.
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Improve data validation oversight.
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Improve the escalation process to ensure senior decision makers are involved in the process as soon as possible.
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Make sure processes for the management of medicines is robust; that expired drugs are removed and replaced and oral medicines are dated and disposed of once expired.
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Ensure all staff follow the same triage process and assess patients in order of urgency and not chronology.
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Ensure patients receiving treatment have privacy and their dignity respected.
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Work towards improving performance against national standards such as the time from arrival to treatment and median total time in the department.
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Work collaboratively with other departments around the hospital to improve the length of time patients wait to see specialist medical staff and reduce the length of time before a decision whether to admit or not is made.
In addition, the trust should:
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Work towards a system, such as a patient group direction, that allows simple medicines such as pain relief to be given by nurses without the need for a doctor’s prescription.
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Continue the work being carried out to ensure staff attend their mandatory training in a timely manner.
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Consider having a robust process in place to ensure cannulas are checked for early signs of infection.
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Have a robust system in place to support patients who are self-medicating in the department whilst waiting for treatment.
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Monitor ambient temperature in clinic rooms to ensure medicines are stored within their recommended temperature ranges.
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Have a process for monitoring the compliance of staff against the hospital policy of prescribing all oxygen.
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Have a robust process for making sure all appropriate sepsis patients are started on the sepsis pathway.
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Have a robust process to make sure controlled drugs are routinely checked in line with trust policy.
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Ensure ‘corridor’ nurses are fully aware of the ‘tag’ process should they need to leave their designated corridor area.
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Consider raising the profile of patients living with dementia or a learning disability, or others with additional needs to improve the support they receive in the department.
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Explore alternative ways of discharging patients waiting for social care packages to improve flow through the emergency department.
Ellen Armistead
Deputy Chief Inspector of Hospitals (North)
20 November 2017
During a routine inspection
12 - 15 April 2016
During an inspection looking at part of the service
We rated the hospital as requires improvement overall which is no change from the last inspection in November 2015. The same four of the five domains were judged to be requiring improvement with the caring domain rated as good. Urgent care services had a worse rating in safety being rated as inadequate from requires improvement last inspection and surgery had changed to an inadequate from requires improvement in safety and being well led.
However the regional spinal injuries service had improved from inadequate ratings in safety and being well-led to good across all domains. Medicine remained in the same ratings for all domains. Critical care services had improved in safe effective and well led to a good rating but continued to require improvement in responsiveness. Outpatient services remained at a rating of requires improvement in safety but had improved to good in all other domains. End of life services continued with good ratings in all domains.
Our key findings since our last inspection were as follows:
Urgent care
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We found evidence of significant flow issues and significant delays for patients during our inspection. Higher (worse) than average numbers of patients were waiting between four and 12 hours to be admitted into the hospital following a decision being made. The department was not meeting the Department of Health target to admit, treat or discharge 95% of patients within four hours. We saw patients waiting in corridors in public areas which we were concerned impacted negatively on their privacy and dignity. We saw some elements of sepsis care which were worse than the regional average. Re-attendance rates for patients were consistently higher (worse than) than the national average. We also saw an example of poor management of a patient suffering with sepsis. National audits were undertaken which highlighted poor performance in a number of areas but action to improve care in these areas was not sufficient.
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Staff did not have a focused approach to reviewing mortality. Although most areas were visibly clean, the floor of a storeroom was not, with debris and dust on the floor and around equipment. Some major incident equipment was stored in a disorganised way with items piled high and unlabelled.
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Patient records were not audited the records we reviewed showed that tools to manage risks to patients such as observations, risk assessments and early warning scores were not always recorded. Although national and local guidelines and care pathways were in place, they also were not always evidenced in records.
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Compliance with mandatory training did not meet the trust target of 90%. We shared staff concerns that medical staffing levels were low and at times appeared unsafe. Although nurse staffing levels were adequate, sickness levels were higher than the NHS national average.
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Staff were open to risk because of a lack of security arrangements on site. Staff felt leaders from the executive team were not supportive and that the culture was reactive with action taken ‘too little, too late’, rather than having a proactive approach.
North West Spinal Injuries Unit
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Following a rating of inadequate during the inspection in November 2014, the service is now rated as good overall because the trust had invested significantly in nurse staffing and we saw that the staffing ratios had increased to adequate levels. The centre had a dedicated spinal medical team with on-site medical cover between the hours of 9am and 9pm Monday to Friday. Out of hours the centre was supported via spinal on-call including a consultant and the trust out of hours hospital at night team.
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They had renamed the former intensive care and high dependency units as it was revealed that intensive care was not delivered at the centre. The centre demonstrated a clear admission policy with strong individual assessment for admission in accordance with the national clinical reference group classification for clinical priority. There was also a focus on discharge planning and there was good multidisciplinary working to support this. A case manager facilitated the discharge process. The consultants reviewed their patients six monthly or annually to ensure patients were reaching their goals.
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In March 2016 the safety thermometer showed harm free care had been provided for pressure ulcers, catheter acquired urinary tract infections and VTE assessments. There had only been one fall with harm. Since the last inspection staff had been supported to manage patients with challenging behaviour. The partnership working document was discussed with all patients on admission and an explanation given regarding expected behaviour in line with the trust’s violence and aggression policy.
Medicine
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We found that not all wards appeared clean and well maintained. Equipment was left on wards and outside in corridors, and not all staff followed staff hygiene practices as they did not always wear suitable protective equipment between providing care and treatment to patients. There had been no formal process since July 2015 to April 2016, to ensure that the quality of care on the medical wards was maintained by senior managers and that all trust policies and procedures were being adhered to. Nurse staffing establishment levels across all wards was variable. All wards we visited had vacancies that were being filled by either staff working extra hours or agency workers. Consultant vacancy rates across medical services in March 2016 were high at 30%, and had been deemed as a high risk on the risk register. There was limited consultant cover on medical wards at weekends, and no ward rounds took place.
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Mandatory training statistics showed that only one medical ward had achieved the trust target of 90% in mandatory training in the period of October 2015 to February 2016. Staff training in some core areas was below the trust targets and staff reported that they had to cancel training due to low staffing levels. Not all staff had received an annual personal development review.
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Initial patient risk assessments were not consistently completed for example VTE assessments. Access and flow throughout medical services was poor and so patients were being cared for and treated on wards that were not appropriate to their needs. Due to a high demand for beds throughout the Hospital, some areas of the hospital were being used inappropriately to care and treat patients. For example the GPAU and the discharge lounge were being used as bedded areas. Escalation wards did not provide all the necessary amenities to ensure a high quality service was experienced by all patients, and call bells were not always in reach of patients.
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There was inadequate storage for staff belongings on the ward which posed a security issue for staff. There was no security team on site to ensure the safety of staff and visitors in the event of violence and aggression from patients or visitors. There had been 76 police call outs to the trust, with the main reason being due to physical abuse/violence from patients to staff.
Surgery
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Safety did not have a sufficient priority across surgical services. Systems and processes were not always reliable to keep people safe. Incidents were not always properly identified and we saw evidence of previous incidents being repeated. Risk assessments were not always completed and mitigation of identified risk did not always take place. Medically deteriorating patients were not always identified promptly, nor did they always receive the prompt medical attention the required, once they were identified. The mortality and morbidity of surgical specialties are not reviewed by the trust board.
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Staffing levels on wards were frequently insufficient and these were not addressed quickly. Staff were distressed at the low staffing levels and the heavy workload. We observed the impact that the low staffing levels had on patient safety and patients’ needs being met.
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In addition to the above issues, matters identified during the previous inspection remained evident. There were problems with the replacement of theatre equipment and there was still no pager system in place which had connectivity across the entire hospital.
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There was no clear vision about the future of surgical services across the trust. However, decisions about the future of surgical services could only be made as part of a decision in the wider healthcare economy. Significant issues that threatened the delivery of safe and effective care were not identified and adequate action to manage them was not always taken. There was also a combative approach to dealing with disciplinary matters across the division for both nursing and medical staff.
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There were poor patient outcomes as indicated by high elective readmission rates and poor performance in national audit programmes. We found that nutrition and hydration needs were not always addressed. In addition staff were not implementing trust policy for fasting guidelines prior to surgery, meaning that people were being left longer than recommended without fluids.
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They experienced significant difficulties with patient flow. Services were not organised efficiently. This further exacerbated patient flow issues. Surgical services did not always meet the individual needs of patients who had complex requirements. Complaints were not used as a means of improving services.
Critical Care
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The critical care services were previously rated as ‘requires improvement’ for responsive following our last inspection because we had concerns around delayed discharges and the provision of single sex accommodation. During this inspection, we found that significant improvements had been made to reduce the number of delayed discharges. However, further improvements were still needed to ensure patients received appropriate care.
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The services provided care and treatment that followed national clinical guidelines and staff used care pathways effectively. The services performed in line with expected levels for most performance measures in the Intensive Care National Audit and Research Centre (ICNARC) audit. Patient’s relatives spoke positively about the care and treatment they received.
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Patient safety was monitored and incidents were investigated to assist learning and improve care. Patients received care in safe, clean and suitably maintained premises. There were systems in place to manage resource and capacity risks and to manage patients whose condition was deteriorating. The staffing levels and skills mix was sufficient to meet patients’ needs and staff assessed and responded to patient’s risks. The consultants covering the unit during out of hours were also responsible for other areas, such as providing anaesthetic cover for the surgical and maternity services however, there was a second on-call consultant to provide additional cover and support. There was one speech and language therapist across the hospital during weekdays. This meant staff on the unit occasionally experienced a delayed response after referring patients for this service.
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There was effective teamwork and clearly visible leadership within the services. Most staff were positive about the culture within the critical care services and the level of support they received from their managers. Key risks to the services, audit findings and quality and performance was monitored though routine departmental and divisional quality and governance meetings.
End of Life
- Conversations between district nurses and GPs around the commencement of the IPOC to support patients at the end of life were not always documented. The service should ensure that all GP involvement is documented in the IPOC when the decision is made for this to be commenced.
- Completion of mental capacity assessments was not consistent, even when indicated on the DNACPR. The trust was not using the unified DNACPR process and hospital DNACPR forms did not travel with the patient when they left hospital. There was no audit of DNACPR forms or decisions despite the system for reviewing these forms being identified as an area for improvement in the last CQC inspection in 2014.
- The complaints process and governance processes around monitoring incidents required improvement. The trust should ensure the new incident monitoring system includes dissemination of feedback and lessons learned to all relevant areas, including the mortuary.
- Syringe drivers were not being checked four hourly in line with hospital standards. The service should continue to educate and audit this process.
- Prior to our inspection there had been no-one actively taking the part of executive lead for EOLC and there was no non-executive director with responsibility for EOLC.
- Anticipatory EOL care medication was prescribed appropriately in hospital and in the community. Hospital staff were knowledgeable about responding to deteriorating patients and hospital care records reflected this with appropriate evidence or establishment of ceilings of care documented. There was evidence of the service delivering treatment and care in line with best practice, including the individual plan of care (IPOC) of those thought likely to be dying which was well embedded in community services. EOL services were adequately staffed and as well as the SPC team which was clinically led by a consultant in palliative medicine, there was a Transform team which promoted advance care planning, the amber care bundle and provided EOLC training.
- The delivery of EOLC was planned in accordance with the Priorities for Care of the Dying Person set out by the Leadership Alliance for the Care of Dying People including the introduction of the IPOC. Actions were being taken to meet the national framework, Ambitions for Palliative and End of Life Care, including cross boundary working to coordinate care and the generation of data via national and local audits to review and improve services. Patients had comprehensive assessments of their needs which included pain assessments and in hospital, nutrition and hydration assessments. There was good evidence of multidisciplinary team working and seven day services were in place. There was a rapid transfer process in place which the team were working to improve.
OPD
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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.
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We raised 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.
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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.
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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
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Some areas of mandatory training showed poor results and managers acknowledged that work was needed.
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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.
However, there were areas of poor practice where the trust needs to make improvements.
In Urgent and Emergency Services
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The service must ensure mortality is discussed monthly and minutes taken to evidence discussion.
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The service must ensure mandatory training compliance reaches and consistently achieves the trust target.
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The service must ensure appropriate signage is displayed in areas where close circuit television cameras are used.
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The service must ensure the actions identified following our concerns about the death of a patient during our inspection, are implemented in accordance with planned timescales
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The service must ensure all patients receive timely (particularly initial) observations whilst in the department
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The service must ensure staff use and evidence use of the sepsis care pathway for patients suffering sepsis.
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The service must increase middle grade staffing to ensure rotas can be planned without the routine use of consultants or junior doctors to back fill vacant middle grade shifts. Where it is not possible to recruit staff, ensure suitable alternative and sustainable solutions are identified and implemented.
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The service must ensure action plans following CEM audits target areas of poor performance and improve practice.
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The service must ensure staff make use of the trust capacity assessment documents when required and properly evidence that where a patient lacks capacity best interests have been adequately considered.
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The service must improve performance, particularly in relation to the department of health four hour target, wait times following a decision to admit, ambulance handovers.
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The service must ensure robust processes are in place to mitigate risks to staff in relation to violence in the work place.
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The service must improve the organisation of major incident equipment in the store room.
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The service must develop and embed a clear escalation process with identified actions for managers and executives.
In surgery
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The service must take action to ensure that there are adequate staffing levels present on all wards to provide safe level of care and treatment for the acuity and dependency of the patients on the wards.
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The service must take action to ensure that Oxygen is prescribed to patients, in line with recommended guidelines, prior to administration.
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The service must take action to ensure that all patients, particularly those who are very confused and able to wander off a ward, are cared for in a secure environment.
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The service must take action to ensure that a system of feedback is in place for staff who have reported incidents.
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The service must take action to ensure that medically deteriorating patients are always identified as they deteriorate and are medically reviewed in line with trust policy.
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The service must take action to ensure that mortality and morbidity events in surgical services are reported to the trust board.
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Surgical services must take action to ensure that the plan for the replacement of old theatre equipment is implemented.
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Surgical services must take action to ensure that all risk assessments are appropriately completed for patients.
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Surgical services must take action to ensure that a system is in place to identify trends and reasons for the high readmissions rates in elective surgery.
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Surgical services must take action to develop an action plan to reduce the high readmission rate in elective surgery.
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Surgical services must take action to improve performance in relation to the indicators in the following national audits,
-The national emergency laparotomy audit
-The national bowel audit
-The national lung cancer audit
-The national hip fracture audit
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Surgical services must take action to ensure that patients are being fasted for surgery in accordance with national guidelines and trust policy.
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Surgical services must take action to ensure that the surgical admissions process is designed to facilitate a timely flow through the surgical process.
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Surgical services must take action to ensure that patients are cared for in treatment areas with full access to toilet facilities and meals.
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Surgical services must take action to ensure that care is provided to patients with complex needs in a manner that is responsive to the needs that they have.
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Surgical services must take action to ensure that patients with dementia and other cognitive impairments are cared for on wards that take account of these needs in terms of physical environment.
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Surgical services should use service user complaints about to drive service improvements.
In End of Life Care
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The service must improve the consistent use and completion of formal pain assessment; assessment of nutritional and hydration status in the community; mental capacity assessments when indicated on the DNACPR.
In Medicine
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The service must take action to ensure that all staff have the up to date training they require to be able to safely care and treat patients and performance development reviews are in line with trust policy.
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The service must take action to ensure that all wards and corridors are clean and well maintained, and equipment is stored appropriately.
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The service must ensure that all records relating to patients are kept securely and computers are locked when left unattended to prevent breaches in data protection.
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The service must take action to ensure that all Initial patient risk assessments are consistently completed for all patients.
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The service must ensure that there are sufficient numbers of qualified, competent staff across all medical wards.
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The service must take action to improve the access and flow throughout the medical wards, to reduce bed occupancy and prevent patients being cared for on wards that are outside their specialty.
Professor Sir Mike Richards
Chief Inspector of Hospitals
12,13, 14 and 20 November 2014
During a routine inspection
The comprehensive inspection at Southport and Formby District General Hospital was conducted between 12 and 14 November 2014 and an unannounced inspection was carried out on 20 November 2014 between 10pm and 1am.
This inspection was conducted under the new model of inspection as part of the inspection of Southport and Ormskirk NHS Trust.
Overall the hospital was rated as requiring improvement as the safe, effective and responsive domains were rated requires improvement and responsive, caring and well led domains were rated as good.
Our key findings were as follows:
Safe
Systems were in place for reporting and managing incidents. There was a risk-aware culture and a willingness to learn from mistakes but feedback was inconsistent. We found that some risks had been on the risk register for over two years without full resolution of the issues. We were told of a major infection control issue in critical care which had not been put on the risk register although it was being addressed. Concerns raised by staff about the safety of the ophthalmology clinic at Southport had been taken to the risk management team and the trust risk manager had been to the clinic, but no action appeared to have been taken, and the staff who raised the issue had been given no feedback about proposed action or why action was not required.
There were insufficient members of nursing staff to provide a safe service for patients being cared for in the North West Regional Spinal Injuries Centre (NWRSIC). Corridors were cluttered with equipment, which had an impact on the control of infection within the centre and there was no planned replacement programme for essential pieces of equipment. Medicines were well managed within the centre and quality of record keeping was good.
Patients received care in safe and clean environments. Staff were aware of policies but adherence in medicine needs improvement. We noted 19 separate occasions in A&E in the previous month where two members of staff had not always checked controlled drugs such as morphine sulphate during dispensing or as part of the daily stock check in the resuscitation area and in critical care medicines storage was not in accordance with current guidance on security. This had been identified by the trust and was on the risk register, but had not been promptly addressed.
Staff assessed and responded to patients’ risks. Patient records were completed appropriately although some end of life individualised care plans were found to be incomplete, meaning that some patients and their families may not get preferred care at the end of their life. The system for reviewing ‘do not attempt cardiopulmonary resuscitation’ (DNACPR) forms was unclear to us and to the member of staff we spoke with, which may result in unnecessary confusion and distress if CPR is required.
Staff were aware of the safeguarding policy and got appropriate consent from patients. There were efficient and well managed handovers. There was an appropriate and up to date trust major incident plan.
Patients were supported with the right equipment; however there was no approved schedule for replacing older equipment used in the theatres and records across the hospital of service status were inconsistent.
Processes were in place to ensure resource and capacity risks were managed. However, the staffing levels in A&E, surgery and medicine were not always deemed sufficient to meet patient’s needs. The staffing levels were maintained through the use of bank and agency staff and this meant that the skills mix was not always sufficient to meet patients’ needs.
We found that the end of life/palliative care services at Southport Hospital were generally good, and were supported by a robust training programme and adherence to national guidelines
Effective
There was evidence of adherence to national guidance. The A&E department participated in national College of Emergency Medicine audits and there were clear action plans indicating what improvements need to be made as a result. In surgery the lack of an orthopaedic geriatrician meant that compliance with the national hip fracture audit had not been achieved and patients did not always receive the best possible care.
Evidence based guidelines were in place for the treatment of patients with spinal injuries. Care plans for patients with spinal injuries identified goals set by the patients and these were monitored by them in partnership with the staff. The discharge planning process was part of the goal setting undertaken with the patient and began as soon as the patient was admitted to the ward.
Staff on critical care told us that they had not achieved full implementation of the relevant guidance issued by professional and expert bodies such as the National Institute for Health and Care Excellence (NICE) and the national core standards for intensive care.
The adult critical care beds occupancy had been consistently above national average in the previous twelve months. This activity had reduced since June 2014. National Intensive Care audit data (ICNARC) showed that the service discharge out of hours to ward and delayed discharges over 4 hours was worse than the England average.
The majority of surgical patients had a positive outcome following their care and treatment; however, the number of patients that had elective urology and general surgery and were readmitted to hospital after discharge was higher (worse) than the England average. The average number of days patients stayed at the hospital was worse than the England average for elective and non-elective patients having general, trauma and orthopaedic surgery.
Caring
Staff treated patients with dignity, compassion and respect, even while working under pressure.
Although patients spoke positively about the care and treatment they had received and we observed many positive interactions data showed that the A&E department scored worse than the England average for similar departments which might indicate that patients would not recommend the department to their friends and family however the low response rate between April 2013 and July 2014 means the results were not fully reliable.
In the NWRSIC most patients were treated with compassion and respect, but low nurse staffing levels meant that sometimes staff were slow to respond to the needs of patients.
Responsive
Performance was improving trust wide, but on its own, Southport Hospital struggled to meet the national Department of Health target for emergency services to admit or discharge 95% of patients within 4 hours of arrival at A&E between April 2014 and September 2014.
There were rehabilitation and sports facilities within the NWRSIC but sometimes patients were unable to access them due to shortages of staff.
Improvements were needed in the management of stroke. Timely access to computer passwords for newly appointed medical staff, including locum doctors, was required. The flow of medical patients throughout the hospital was disorganised and medical staff had no formal process by which to locate their patients. At the time of the inspection 15 surgical beds were occupied by medical patients and 4 surgical patients were being care for in medical beds. There was insufficient bed capacity in the wards and theatres, which meant that extra beds were occasionally placed on the surgical wards although we had been assured that this practice was no longer custom and practice. There were plans in place to improve theatre efficiency.
Despite this being an integrated trust there were few examples of integration between community and acute services. Although there was often good communication and co-operation, the community and acute services were usually managed and operated separately. This did not provide a seamless or holistic service for patients, particularly those with chronic health conditions that required frequent hospital admissions. We noted that patients who lived within the area covered by one clinical commissioning group had access to services of a specialist respiratory team. This service was not commissioned by the neighbouring clinical commissioning group. This meant that the respiratory service provided to patients was not equitable.
The mortuary and bereavement service was focused on making its environment and interaction with patients and relatives as minimally distressing as possible, and displayed excellent, innovative care.
National targets for referral to appointment times were exceeded in all areas. Clinics that consistently ran late were reviewed to identify blocks in patient flow.
Well led
The overall ethos centred around the quality of care patients received. Key risks and performance data were monitored. There was clearly defined and visible leadership, and staff felt free to challenge any staff members who were seen to be unsupportive or inappropriate in carrying out their duties. There was a disconnection between the staff providing hands-on care and the executive team in some areas. The system in place to communicate risks and changes in practice to nursing staff required improvement.
The emergency department faced challenges such as patient flow and local changing needs, such as an increased elderly population, and had initiatives in place to tackle these.
There was no clear strategy for the development of the NWSIC and there were insufficient senior nursing managers allocated to the NWRSIC to be able to provide effective leadership for this service.
We saw several areas of outstanding practice including:
- 85% of patients who had a documented preferred place of death died where they chose to, facilitated by an effective end of life rapid transfer programme.
- An access film showing the experience of a child attending an outpatient department is being posted on the trust website. This will allow parents of young children or carers of patients with learning difficulties to view the film with them and explain the process and what to expect before they attend for their own appointment.
- The introduction of dressing clinics to complement fracture and orthopaedic clinics, reducing the need for formal appointments and freeing up consultants’ time.
- Improvements to help children and patients with learning disabilities settle into the outpatients department.
However, there were also areas of poor practice where the trust needs to make improvements.
Importantly, the trust must:
- Ensure adequate nurse staffing levels and an appropriate skill mix in all areas
- Ensure equipment used in the theatres is fit for purpose and older equipment is replaced under a planned replacement schedule.
- Ensure medicines management meets national standards in the critical care unit and in the Accident and Emergency department.
- Improve infection prevention and control processes within the medical directorate.
In addition the trust should:
Medicine
- Take immediate action to prevent the sharing of computer passwords between medical staff.
- Improve storage on medical wards for essential pieces of equipment and staffs' personal clothing and belongings.
- Improve feedback and learning from incidents.
- Increase 7 day working for all disciplines across the medical directorate.
- Improve the flow of medical patients within the hospital.
- Improve learning from complaints.
- Improve the way risks are communicated to nursing staff within the medical directorate.
Surgery
- Reduce clutter in the theatres.
- Improve compliance with the national hip fracture audit.
- Reduce the number of patients that are readmitted to hospital after having elective urology and general surgery.
- Improve performance relating to the patient length of stay at the hospital.
- Reduce delays to admitted patients awaiting surgery in the theatres.
- Improve bed utilisation on the surgical wards to ensure patients are located in the best available place.
Urgent and emergency services
- Continue to ensure that all staff complete their mandatory training in a timely manner.
- Have a list of appropriate staff that have been trained with the required scene safety and awareness training.
- Ensure the environment in the triage area can allow patient conversations to be private.
- Ensure that all items of equipment have a record of being serviced or calibrated and that the service is in date.
- Ensure that two members of staff check controlled drugs during dispensation and as part of the daily stock check.
- Designate a lead for education in the department.
- Look to improve the location target to treat 95% of patients within 4 hours.
- Tackle the issue of junior medical staff who felt bullied by senior staff
Outpatients
- Ensure concerns raised about outpatient services are addressed appropriately and in a timely manner
Professor Sir Mike Richards
Chief Inspector of Hospitals
29 August 2013
During a routine inspection
'In general staff do their best but they are under pressure. They have got too much to do', 'Usually buzzers are answered quickly. It takes a bit longer in the middle of the night', 'Most of the staff are pleasant', 'I get my medication on time. Some (staff) watch you take it, others just leave it on the table', 'There are plenty of staff and they are good. They work hard' and 'I have no complaints. Staff are kind. They struggle because there are not enough of them."
Patients we spoke with said they were treated with dignity and respect and that staff came promptly when they needed them. We observed staff draw curtains around patients' beds when attending to them and they lowered their voices when they spoke to patients, to observe their privacy. However, on one ward the staff handover was held in a bay on the ward.
The health care records we looked at were not consistently completed in a timely manner on admission to the hospital or reviewed by medical staff on some of the wards we visited. Some patients did not have care plans or risk assessments. We found regular observations were made and recorded.
We found there were staff vacancies on all of the wards we visited. Staff were in the process of being recruited. We were told of the process for finding staff to cover for absences on the wards. However we found staff shortages on the day of our inspection on one ward because an absence had not been covered.
17 October 2012
During an inspection looking at part of the service
Patients said they were provided with enough information about their medicines and treatment. One patient said 'Medicines are given to me correctly.' Another patient told us 'I get pain relief medicines when I need them.'
Overall, patients were aware of their plan of care and felt they had received adequate information to understand their condition and treatment. The health care records we looked at showed that care and treatment was planned and delivered in a way that ensured patient safety and welfare. Some patients told us the discharge process had not been efficient. Senior managers were aware of this concern and explained that plans were in place to improve the discharge process.
The trust had reviewed and revised its quality and risk management systems. For example, the trust had invested in new storage facilities, including the provision of lockable doors to all medicine storage areas, new lockable fridges, new medicine trolleys and secure medicine disposal bins. These developments had assisted in ensuring medicines were safely stored to help prevent misuse and mishandling.
2 May 2012
During an inspection in response to concerns
We heard from a patient say that, 'The hospital is brilliant and the care excellent'. All the patients we talked with said the majority of staff were pleasant, caring and had a nice attitude. They said staff were respectful of their privacy and dignity. We heard that staff were responsive and attentive to requests, and nurse call bells were generally responded to in a timely way.
Patients were aware of how to make a complaint but were not sure about how to provide formal feedback on the quality of the service.
29 November 2011
During an inspection in response to concerns
Before this inspection visit we were told by a number of patient relatives that staffing levels at the Trust was "poor" and for some concerns were raised about staff competence. We asked patients we interviewed about the care they received specifically around the numbers of staff available to provide this. We were told by all patients there were not enough staff available to meet their needs. They said staff were well trained and highly skilled, but they did not have the time to meet thier needs in full. Patient comments included "Staff were on the go all the time, I see them flying about and sometimes it's hard to catch their attention". One patient said "Bells were left ringing for a long period of time and if you ask for anything it takes a long time before you get it".
We asked patients their views on how well staff knew them and their needs and we got mixed comments. One patient reported that staff knew her needs well but mostly patients responded by telling us staff did not have enough time to get to know them.
25, 26 April 2011
During a themed inspection looking at Dignity and Nutrition
We asked patients about how they are involved with decisions about their care. All said the staff had discussed the reasons for admission and that they were able to express their views openly and be involved with the care and treatment. We received the following comment:
'The nurses are very informative'
Patients we spoke with were positive about the quality of the food provided. They said there was plenty of choice and staff asked about their dietary preferences at the time of admission. Patients told us every effort is made to ensure meal times are a pleasant experience and the wards are quieter at these times. Their experience is captured in the following positive comments:
'Very good food'
'I enjoy the lunches'
Although patients spoke positively about standards of privacy and dignity and the food, we did find some inconsistencies in these areas.