Archived: Ormskirk District General hospital

Updated 29 November 2019

Ormskirk and District General hospital offer maternity and gynaecology services, elective surgery, services for children and young people, a children’s accident and emergency department, outpatients and diagnostic services. The hospital provide these services for patients living across West Lancashire, Southport and Formby.

From February 2018 – January 2019 the hospital had 193,875 outpatients’ attendances, 4,780 inpatient admissions for children and 2,150 births. Accident and Emergency attendances for children were 30,005. Across the services there were 104 beds including 38 maternity beds, 21 children’s beds and 10 neonatal cots.

During our inspection we visited children and young peoples services and the outpatients department.

We spoke with 59 staff across a range of disciplines. We also spoke with 18 patients and two carers. We visited all areas providing care to children and young people including the neonatal unit. We also visited the general outpatients, treatment centre, dermatology, maxillofacial unit, eyes / ear, nose and throat (ENT) area and the orthopaedic outpatient service at the hospital as part of the inspection. We attended a range of meetings and reviewed 24 records.

Updated 29 November 2019

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

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

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

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

At this inspection we found:

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

However:

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

Updated 15 November 2016

At the last inspection in November 2014, we rated medical services at Ormskirk district general hospital as requires improvement overall. The service required improvement in the safe, effective and responsive domains and was rated good in the caring and well-led domains.

At this inspection we rated medical services at Ormskirk district hospital as requires improvement because;

A Resident Medical Officer (RMO) was employed to provide medical cover 9am to 5pm through the day and on call through the night for a whole two week period without a rest break. There was also a junior doctor who worked Monday to Friday 8am to 6pm. The RMO also covered other wards at Ormskirk hospital. This risked that if the RMO was called out that they would not receive adequate breaks leaving them overworked and exhausted.

Overnight there were two qualified staff and no regular unqualified staff. Staff reported that this caused some difficulties as it often meant having to stop giving medication and attend to personal care tasks. It also meant that if trained nurses were attending to deteriorating patients then there were no staff to support patients with their personal care needs.

The service was not equitable across the week. There was no routine medical cover on H ward at weekends to see and treat any patients that required medical attention.A junior doctor on the ward worked Monday to Friday 8am to 6pm and any medical cover outside of this time was provided by the RMO on call. The therapy team worked Monday to Friday 8.30am to 4.30pm and there was no routine cover for patients to receive therapy over the weekend this included swallow assessment and patients that were nil by mouth on a Friday would need to remain nil by mouth over a weekend  This risked vulnerable patients who were already malnourished without access to diet and fluids over a weekend.

Records on the ward were not stored securely in a lockable trolley on the ward next to the nursing station and nursing assessments were stored in a plastic box under the desk. This did not provide the security required to ensure the confidentiality of patient records.

Compliance with core competency training was variable. There were no formal cleaning rotas in place but it was evident  that the ward was being cleaned. We also found that matron checklists had not been completed formally since July 2015. The checklist ensures that ward quality is maintained and evidence that wards are compliant with all policy and procedures.

However,

Medical care services were delivered by hardworking, caring and compassionate staff who treated patients with dignity and respect. Local leadership was good, and staff felt supported by their immediate managers. All patients we spoke with were positive about their interactions with staff. They told us that the staff were kind, polite and respectful, and they were happy with the care they received.

The percentage of patients who returned back to their usual residence following rehabilitation was 77% and the average length of stay was17.3 days on the ward before being discharged. Discharge was supported by good communication and co-operation between the hospital staff and local community teams from both the NHS and local authority, which enabled safe, timely and effective discharge of patients.

Updated 29 November 2019

Our rating of this service improved. We rated it as good because:

• Staff had understood how to protect children and young people from abuse, however mandatory training compliance was below the trust target. The service controlled infection risk well. Nursing staff effectively assessed risks to children and young people and acted on them accordingly. However, some medical staff members did not always action concerns raised by nurses. The service’s staff kept good care records. They managed medicines well. The service managed safety incidents and learned lessons from them. Staff collected safety information and used it to improve the service.
• Staff provided good care and treatment, gave children and young people enough to eat and drink. Pain relief was given when it was needed. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of children and young people, advised them and their families on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Most services were available seven days a week.
• Staff treated children and young people 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 children and young people, families and carers.
• The service planned care to meet the needs of local people. The service took account of children and young people’s individual needs and made it easy for people to give feedback. People could access most of the service when they needed it.
• Leaders supported staff to develop their skills. Some staff members that felt they were listened to by senior staff. The service was focused on the needs of children and young people receiving care. Staff were clear about their roles and accountabilities. The trust engaged with the children, young people and the community to plan and manage services. Staff were keen to learn and develop the service.

However:

• We found that monitoring of equipment to maintain medicines at the correct temperature was not always completed, or actioned. We found that not all equipment in the service was suitable. This was escalated to the trust during the inspection. We found that the service did not have enough medical staff, particularly at consultant level. This was raised with the trust and we were informed that there were alternative arrangements in place to ensure medical staffing was safe.
• We found that the range of food choices for children was limited. The kitchen on the paediatric ward was not locked. There was no standardised pain tool used, to ensure consistency.
• We found that access for CAMHS patients was limited at weekends. There was disparity of CAMHS services available to children and young people, dependent on where they lived, which led to some patients staying on the ward for longer periods of time.
• There had been an issue with the arrangements for paediatric outpatient appointments, leading to some appointments becoming lost.
• Some children had a long wait to be seen by the community paediatrician.
• Staff were not clear about the service’s vision and strategy and how to apply them in their work. Some of the staff we spoke to did not always feel that some of the senior leaders acknowledged them or supported them at times when the unit was particularly busy.

Updated 13 May 2015

We found that the end of life/palliative care services at Ormskirk Hospital were generally good, and were supported by a robust training programme and adherence to national guidelines.

Staff from both the general wards displayed enthusiasm to provide safe, effective and compassionate care to patients reaching the end of their life. The multidisciplinary team worked well together to achieve this. This enthusiasm and desire to maintain competencies was particularly commendable considering the small number of patients at the end of life that the staff came into contact with.

The 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.

Updated 15 November 2016

At the last inspection we found maternity and gynaecology services to be inadequate overall. They were rated inadequate in safe and well led, requires improvement in effective and responsive and good in caring. Improvements had been made and at this inspection we rated them as requires improvement in safe, effective, responsive and well led and good in caring.

In August 2015 the Royal College of Obstetrics and Gynaecology (RCOG) completed a review of the obstetric care provided. This was commissioned by the trust to “review the obstetric services at Ormskirk District General Hospital based on the findings of the CQC report dated November 2014 with an emphasis on patient safety and clinical governance”. As a result of this review 26 recommendations were made which included immediate changes to procedures to improve patient safety, review of staffing arrangements and improvements in governance.

At this inspection we found managers and staff had accepted the outcome of that report, identified the changes required and implemented an improvement plan to change practices and develop the service. Whilst some of this work was ongoing a vast majority had been completed and both midwifery and medical staff spoke about the positive changes which had taken place. There was acknowledgement that some changes were in their infancy and results could not yet be measured and others were still to be implemented. However there were examples of service improvements which had resulted in positive changes to patient care and improvements in staff culture.

Whilst improvements had been made to the investigation and system for learning from incidents there were some delays in the production of reports and sharing of information.

Some practices did not meet national or local policy guidance this included infection control practices, medicine management and checking of emergency equipment.

There were risks of safeguarding information not being shared due to issues with the new patient electronic record system.

There were environmental concerns with the second obstetric theatre and the administration area for community midwives in Southport and Formby District General Hospital.

Some of the risks to patients of not receiving blood products in a timely way remained the same as the last inspection.

The issues with access to the patient electronic record system for community midwives meant they could not easily access information for community visits they had to complete.

Not all patient outcomes were benchmarked against available national data.

84% of nursing and midwifery staff were up to date with their mandatory training which did not meet the trusts’ target of 90%. Appraisal rates for gynaecology nursing staff and midwives were below the trusts’ target.

There was a lack of understanding of the deprivation of liberty safeguards on the gynaecology ward.

The hospital scored worse than other trusts in three questions in the labour and birth section of the 2015 CQC survey of Women’s experiences of maternity services. An action plan was in place to address this.

Environmental constraints limited partners ability to be as involved as they would like during the hospital stay.

There was a lack of specialist midwives and a lack of facilities for bereaved parents.

However;

Changes to the risk assessments for patients at risk of a post-partum haemorrhage had been introduced with a process for meeting the RCOG recommendation of transferring those patients to other units.

Improvements had been made to mortality and morbidity reviews.

An electronic patient information system had been introduced although there were some issues with lack of compatibility with the other systems in use.

There was a full audit programme and changes were made as a result where necessary.

There were sufficient maternity, nursing and medical staff on duty.

Most guidelines were up to date and in line with relevant National guidance.

The referral to treatment times for gynaecology patients met the national recommendations.

Changes to the clinic environment meant gynaecology patients had a contained outpatient area.

Changes to the termination of pregnancy service meant those patients no longer came into contact with pregnant women.

A comprehensive information system for monitoring patient outcomes had been developed and monthly exception reports meant trends were identified, monitored and where necessary investigated.

There had been improvements in the training of midwives to assist in the operating theatres which increased their competence in this role.

We observed staff in the maternity and gynaecology services to be kind, caring and respectful. The privacy and dignity of patients was protected.

Changes to the maternity admissions system meant improvements for patients through triage and induction of labour.

Since the last inspection there had been significant and numerous changes to the management of the maternity services. This included improvements in the governance, risk management systems, development and implementation of a maternity improvement plan and increased staff and public engagement. The sustainability of these improvements would be vital to the continued success of the service.

Updated 29 November 2019

This is the first time we have inspected outpatients at the hospital as a separate core service. We rated it as good because:

• The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
• Staff provided good care and treatment, gave patients enough to eat and drink and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. 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 service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access most services when they needed and did not have to wait too long for treatment.
• Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However;

• Cleaning checklists did not include specific prompts for the cleaning of children’s toys.
• Staff did not always take appropriate actions when recommended temperatures for the storage of medicines were exceeded.
• The follow-up to new ratio for patient appointments was worse than the England average.
• The number of staff who completed appraisals did not meet trust targets.
• The services did not routinely achieve the waiting time standard for cancer patients receiving their first treatment within 62 days of an urgent referral.
• Complaint responses were not always within trust targets

Updated 15 November 2016

The previous inspection in November 2014 found all domains of surgical services at ODGH to be good apart from safe. Safe was found to require improvement because of the large number of vacancies in theatres, the lack of approved schedule for replacing older equipment used in theatres and that the only medical cover was provided by a resident medical officer (RMO).

This inspection identified that surgical services still required improvement in safe.We also found that it required improvement in well-led. For effective, caring and responsive we rated it as good.

There were still a large number of staff vacancies in theatres and there was still no approved schedule for replacing older equipment. There were 10 vacancies in theatres and although it was reported that five new members of staff had been recruited, they had not commenced in post and no start date had been identified. The situation was not very different from the last inspection.

There was still no approved schedule for replacing older theatre equipment. The issue appeared on the risk register of the planned care division, but there was no funding attached to it and it was clear that it would not be addressed until funding was identified.

In well-led, the situation had deteriorated from the last inspection because there was no clear vision for the future of surgical services at ODGH. There was extra capacity at the hospital, which contrasted sharply with the situation at Southport and Formby District General Hospital (SFDGH). We saw a business case for all urology procedures to be transferred to ODGH.We found that no decision had been made about the future, but could only be made as part of a decision in the wider healthcare economy.

Morale was poor amongst significant sections of clinical staff. Staff reported concern about the length of time that disciplinary investigations took and that clinical staff were suspended for lengthy periods of time. Staff reported that this approach created a culture of fear. There were high rates of sickness in some important areas of the service. Staff based at ODGH felt isolated from the rest of the trust and reported that they did not see executive directors.

However;

Since the last inspection a foundation year two doctor had been recruited to support the RMO at ODGH.

The standard of documentation was good, with evidence of all risk assessments being carried out and reviewed. Services were effective, implementing national and local guidelines. There were planned pre-operative assessments taking place.

Services were also responsive, in that they were planned to meet the needs of the local population and took into account the complex needs of individual patients.

Updated 15 November 2016

Following previous concerns about staffing in the paediatric emergency department (PED), we saw practice had changed to ensure staff were not routinely undertaking duties which pulled them away from the department (such as on call bed management duties).

There was a culture of reporting and learning from incidents. Areas we inspected were visibly clean and tidy and staff responsible for cleaning followed protocols which helped control infection. The infrastructure was fit for purpose and equipment, medicines and controlled drugs were stored appropriately.Records were stored securely with legible, relevant information recorded.

Processes, guidelines and pathways supported staff reporting safeguarding concerns, ensured staff maintained compliance with training and helped staff manage potential risks to patients. Some local audits were done to measure outcomes.

Staff worked together to provide care for patients. Where services were not available 24 hours per day, processes were in place to ensure care could still be provided. Pain was appropriately monitored, with pain relief provided if necessary.

Patients and carers felt happy with the care provided, and felt that treatment was fully explained in a way they could understand. We observed compassionate care being provided by staff who were mindful of privacy and dignity when moving between areas. Bereavement support was available for those who had lost someone.

Waiting areas catered for the needs of patients. Translation was available for patients whose first language was not English. A hearing loop and sign language facilities were also available. Specialist nurses provided specific care for certain ailments.

Wait times were not excessive and department of health targets were being met.

Low levels of complaints were received and findings were disseminated to staff to promote learning.

Staff had visions of how services could be improved for patients. Work had been done to strengthen governance since our last inspection with regular meetings and risk registers in place.

We saw examples of managers engaging with staff. Staff told us they felt happy to work for the trust and proud of the teams they worked with. Engagement with the public also took place to help educate and familiarise them with the service.

Innovative work for orthopaedic care and goal directed therapy was undertaken in the PED.