The comprehensive inspection at Ormskirk 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 but the safe domain was rated requires improvement or inadequate in five of the seven services. In maternity services the well-led domain was also rated as inadequate. The concerns in this hospital were discussed with the trust at the end of the inspection.
Our key findings were as follows:
Safe
Ormskirk Hospital requires improvements in the safe domain as staffing levels were not always deemed sufficient to meet patients’ needs at times when senior staff were utilised as the designated on call person for the site. The trust were made aware and have made changes since the inspection.
Patients were supported with the right equipment; however there was no approved schedule for replacing older equipment used in the theatres. The staffing levels in the theatres were not sufficient, but the theatres department had plans in place to address this. There was a potential risk of unsafe care because the arrangements for medical cover on the wards were not sufficient. There was one resident medical officer who worked 24 hours per day continuously over a two week period.
The safety of people using the maternity service was compromised due to the reduced numbers of experienced midwives employed, a lack of learning from incidents and adverse clinical data and inadequate and out of date staff training. There were risks of patients whose condition deteriorated experiencing delays in receiving blood transfusions and inadequately trained staff assisting in the obstetric theatre. Whilst the service had recognised some of these risks they had not taken sufficient actions to mitigate them.
There were a higher than average number of deliveries using forceps and of peripartum hysterectomies (Peripartum hysterectomy is a major operation and is invariably performed in the presence of life threatening haemorrhage during or immediately after abdominal or vaginal deliveries). There were no plans in place to reduce these. There was a lack of monitoring of the quality of the service with resulting plans for improvement and change.
Effective
There were insufficient medical and nursing staff with the appropriate skills and experience to provide safe and effective care to patients outside of normal working hours.
However, 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 majority of patients had a positive outcome, however, the number of patients that underwent elective trauma and orthopaedic surgery and were readmitted to hospital following discharge was higher (worse) than the England average. The average number of days patients stayed at the hospital was better than the England average across all the elective specialties at the hospital.
Safeguarding measures were understood by staff and escalation processes were well managed. Staff understood the legal requirements of the Mental Capacity Act 2005 and deprivation of liberties safeguards.
In outpatients information had been used to make improvements including improving the waiting rooms for patients and staff; the privacy and dignity for bedded patients in diagnostics department; introduction of children’s activity boards and the production of a video to show young children or patients with a learning disability what it would be like when they attend the department. Additional services had been created, such as the ‘dressings’ clinics which had freed-up consultants time and reduced delays in fracture and orthopaedic clinics. Reviews were conducted into clinics which consistently ran late to identify blocks in patient flow.
Caring
Care was delivered by hardworking, caring and compassionate staff who treated patients with dignity and respect. Patients spoke positively about their care and treatment. Patients and their relatives were involved in care and supported with their emotional needs and there were bereavement and counselling services in place.
Responsive
The hospital had done a significant amount of work to tackle the capacity and patient flow challenges that had affected its performance. Ormskirk Hospital met its target to admit or discharge 95% of patients within 4 hours of arrival at A&E between April 2014 and September 2014.
Services provided on H ward were generally responsive to people's needs, but there was no adequate provision for patients who needed a blood transfusion without transferring them out of the hospital.
The number of cancelled elective operations was better than the England average, and there had been improvements in performance against 18 week referral to treatment standards. There were plans in place to improve theatre efficiency.
Children's services were provided in a child friendly environment by a workforce with a range of specific skills, competencies and training relating to children. All staff had relevant professional registration and were encouraged to be up to date with required training programmes.
Well-led
The organisation’s vision and strategy had been cascaded and staff were proud of the work they did. The overall ethos was 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.
H ward was well-led, although there was a disconnection between the staff providing hands-on care and the executive team. The system in place to communicate risks and changes in practice to nursing staff required improvement.
However, Midwives described a culture which was not open and transparent and where the leadership was inconsistent resulting in staff feeling they could not easily raise issues or concerns. There were a high number of newly qualified midwives employed which resulted in inexperienced staff fulfilling roles for which they lacked experience and competence.
We saw several areas of outstanding practice including:
- Compassionate improvements and re-design of the outpatients departments to reduce anxiety for young children and patients with a learning disability. Child friendly activity boards are being erected. 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 work of the children’s community nursing outreach team had been further recognised by the successful publication in the British Journal of Nursing (“Paediatric community home nursing, acute paediatric care” British Journal of Nursing 2014, vol 23, No. 4).
- Specialist paediatric nurses were employed to support children with diabetes and respiratory conditions. They held specialist multidisciplinary clinics on a regular basis. We heard of exemplary good practice such as specialist nurses visiting schools to give support and training to teaching staff.
- The trust paediatric diabetes service was peer reviewed in July 2014. Multidisciplinary team work scored 90% and hospital measures scored 100%. Some good practice was recorded, including having a support group.
- The trust and hospital proactively implemented the ‘New priorities for care of those thought to be dying’, before the compulsory withdrawal of all references to the Liverpool care pathway. This had been supported by a robust training programme.
- Patients at the end of life and their relatives were supported by the palliative care team to plan for their future, and a national system was in place to identify them when accessing emergency care in order to speed up admission and discharge.
- 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.
- The mortuary team was outstanding in its responsiveness and its innovative approach to caring for the patients and relatives who used their services.
However, there were also areas of poor practice where the trust needs to make improvements.
Importantly, the trust must:
- Ensure adequate medical and nurse staffing levels and appropriate skill mix.
- Ensure medical and senior nurse cover out of hours is safe and fit for purpose.
- Ensure consent for obstetric operations is recorded accurately.
- Ensure all staff working in obstetric theatres are appropriately trained and experienced to ensure safe care.
- Review the incident of peripartum hysterectomies and the use of forceps for delivery are appropriate and safe.
- Ensure all newly qualified midwives receive support and supervision, as per their preceptorship guidance, taking into account the number of experienced midwives working with them on any shift.
- Ensure the leadership of the maternity services encourages and enables an open and transparent culture.
- Ensure equipment used in the theatres is fit for purpose and older equipment is replaced under a planned replacement schedule.
In addition the trust should:
In Urgent and emergency care
- Keep a list of appropriate staff that have had the required scene safety and awareness training.
- Ensure sufficient numbers of staff are recruited.
- Ensure the department is safely staffed when staff are called away from the A&E department to assist in other duties such as covering the bed management and being the designated on call person for the site.
In Medicine
- Improve feedback and learning from incidents.
- Increase seven day working for all disciplines across the medical directorate.
- Improve the way risks are communicated to nursing staff within the medical directorate.
- Improve access to blood transfusions for medical patients.
In Surgery
- Ensure there is suitable medical staffing cover on the orthopaedic surgical ward.
- Ensure there are sufficient numbers of trained staff in the theatres department.
- Improve the completion of the WHO Safer Surgery procedure.
- Improve performance relating to patients having elective trauma and orthopaedic surgery who are readmitted to hospital.
In Maternity
- The records in the maternity services should be stored securely at all times.
- Staff in the maternity services should be aware of their role within the major incident plans.
- The layout of the waiting areas for patients in the termination of pregnancy outpatients area should be separated from the ante-natal and fertility clinic.
- Ensure all staff receive information of lessons learnt following incidents.
In Outpatients
- Ensure that people are protected from the risks associated with unsafe use and management of medicines. This is something that is required as part of Regulation 13 of the Health and Social Care Act 2008 (Regulated activities) Regulations 2010, in relation to the management of medicines. However it was considered that it would not be proportionate for that one finding to result in a judgement of a breach of the Regulation overall at the location.
- The trust should consider the process for formalising team and multidisciplinary team meetings in order increase understanding and information flow.
Professor Sir Mike Richards
Chief Inspector of Hospitals