• There was evidence of under reporting of incidents in surgery services. Staff did not always recognise incidents or report them appropriately. In maternity services, learning from incidents was not always disseminated in an effective way to staff.
• Processes and procedures in relation to the duty of candour requirement were not fully embedded and staff did not fully understand and discharge their duties in relation to this requirement. (The duty of candour is a regulatory duty that relates to openness and transparency and requires providers of health and social care services to notify patients (or other relevant persons) of ‘certain notifiable safety incidents’ and provide reasonable support to that person).
• The patient group directive (PGD) documents in urgent and emergency care services did not evidence regular review and approval since 2009. Whilst pharmacy had provided interim approval for the current use of paediatric PGDs, this was recorded as a risk on the directorate risk register.
• The quality of documentation and approach to frequency of observations was inconsistent. In urgent and emergency care services, both issues were being addressed through repeated audit and the issue of a new protocol to standardise observations. However, in maternity services, staff did not complete Maternity Early Warning Scores (MEWS) assessments in accordance with trust policy in order to detect deterioration in a woman’s condition. Women did not always receive a medical review when their assessment identified this was required and the World Health Organisations’ surgical safety checklist was not always fully completed.
• In urgent and emergency care services, documented evidence that staff offered food and fluids, where appropriate, to children during their stay in the department was inconsistent.
• Records in maternity services were not always up to date. We saw examples of delay in scanning records onto the online system meaning there were gaps in women’s care records. Only one member of staff could open a particular patient record at a time which meant that records around caesarean sections were not always entered onto the system in a timely manner.
• Care and treatment in surgery services was fully recorded. However, care records were kept in multiple locations and were difficult to follow. Staff also did not consistently print their name or document their designation when completing records, as per best practice guidance.
• Staff in maternity services did not follow the trust’s schedule consistently for checking all equipment was present and in working order. This included the anaesthetic machine in theatre and resuscitation equipment available on the wards. Whilst staff in surgery services completed emergency equipment checklists, we found equipment inside resuscitation trolleys that was out of date or with damaged packaging.
• In maternity services, we found that trust policies were not always reviewed in line with the schedule set out and there were some omissions within policies which made them difficult to follow. Staff were unaware if there was a review panel which had input into creating policies within the service.
• Due to staff shortages in surgery services, urology and gynaecology patients were sometimes moved between the urology and gynaecology wards at short notice. As a result patients recovering from gynaecology surgery could be moved to the urology ward shortly after surgery and vice versa. This compromised patient privacy and dignity as it often led to mixed sex breaches.
• In surgery services approximately one third of staff had not completed mandatory training and dashboards were not up to date and therefore did not reflect current completion rates. However, completion levels of mandatory training had improved since the last inspection.
• Staff in surgery appraisals stated they had appraisals annually however dashboards we reviewed did not reflect this.
• In surgery, unlocked doors to the dirty utility on all wards meant anyone could gain access. One ward had a fire door propped open on three consecutive days. Staff rectified this when highlighted by inspection staff.
• There was no clear vision or strategy in place across all services and this hindered innovations and improvements within the services. A potential risk to leadership capacity was developing in urgent and emergency care services following the recent transfer of bed managers from the Ormskirk site to Southport by trust management. Senior nurses across the paediatric department were required to support bed management duties on the site.
• Managers across maternity services did not always promote a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.

However:

• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it. This has significantly improved since the last inspection. Safeguarding supervision had been made part of mandatory training for all midwives and staff reported receiving good support from the safeguarding midwife.
• Mandatory training levels for nursing staff had improved since the last inspection. A practice development midwife had been appointed to ensure the training needs of midwifery staff were being met.
• In surgery and urgent and emergency care, medicines were stored, administered and recorded in line with best practice guidelines.
• The service had arrangements in place to recognise and respond appropriately to patient needs and risks.
• Incidents in urgent and emergency care were reported and managed well.
• Specialist midwives had been appointed since our last inspection to support midwives in the provision of care to women with complex needs.
• Across the hospital staff were passionate about delivering patient centred care. In urgent and emergency care patients’ parents expressed that the hospital was their preferred emergency department.
• Ward areas were visibly clean and tidy.
• Facilities and premises were appropriate for the services delivered. In urgent and emergency care a new ‘quiet’ room had been constructed in the emergency department to strengthen their ability to meets the needs of children with mental health needs.
• Across most areas of the hospital staffing levels and skill mix were planned, implemented and reviewed to keep people safe at all times. Where relevant, there were effective handovers and shift changes to ensure that staff can manage risks to people who use services.
• People’s care and treatment was planned and delivered in line with current evidence-based guidance, standards, best practice and technologies.
• The paediatric urgent and emergency care department performed well against the national urgent care standards including the Department of Health standard (95%) for the percentage of patients admitted, transferred or discharged within four hours (monthly average 99% in 2017).
• Staff in the paediatric urgent and emergency care department had clear roles and responsibilities to support the governance systems. Regular governance meetings took place at department and directorate level to monitor and review the quality of care and risk management. The service took complaints seriously and responded to lessons learned, for example staff developed a leaflet to improve parents’ understanding of the triggers for safeguarding referrals.
• In the paediatric urgent and emergency care service there was strong leadership and a positive, supportive culture amongst medical and nursing staff. Nursing and medical leads worked together with a focus on continuous learning and improvement supported by annual training days, the local audit programme, the appraisal process and mentorship to achieve competencies.

During our inspection we visited two inpatient wards, the day ward and an operating theatre. We spent time with 17 patients and two relatives and invited them to share with us their experience and views of care and treatment at the hospital. Some of their comments included:

“My whole experience was of a dedicated professional team who made me feel very relaxed”, “Everything is explained really well and is very clear”, “Very impressed with the staff. Nothing is too much trouble”, “I can wash but the staff will help me if I need it” and “The staff make sure I am doing my exercises and not getting sore.”

Patients told us staff were responsive and attentive to their requests, with nurse call bells responded to in a timely way. Most of the patients we spoke with received support to order their meals via the TV screen. However one patient said, “I only had the scraps to eat as they (staff) didn’t come and tell me what to do.”

We observed the staff draw curtains around patients’ beds when attending to them and lowered their voices when they spoke to patients, to ensure their privacy.

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. Patients who were attending for an operation told us they felt reassured by the information provided to them about their procedure.

During our visit we were able to speak with seven patients and a few visiting relatives. Six patients gave us positive feedback for the outcomes we reviewed during this visit. We were told that they understood the care and treatment choices available to them. We heard they felt involved in making decisions about their care and treatment. Mostly patients told us their privacy, dignity and independence were respected. Comments we heard that reflected our overall view of the service included ‘Staff are very polite……... staff approach is pleasant, I feel reassured. Staff are smashing 100%..........staff very polite, can’t fault them. Very attentive and explain everything, particularly therapy staff.’

Other positive comments included patients telling us ‘Care was very good, can’t fault it. Everything is always explained.’ A few patients told us that staff give good explanations about their exercise and treatment programme and goals were set daily by the multi disciplinary team (MDT). This is a team involving all professionals including nursing/medical staff, physiotherapy and occupational therapy staff. One patient told us they ‘Feel well cared for and safe and was very impressed by the standard of care’. Relating to diet and nutritional support the six patients spoke positively and made comments such as ‘The food is good……drinks were always available….I had a daily menu to choose from…..good choices available’.

However these positive views were not expressed by one patient and their family. When we spoke they raised their concerns that they did not consider that care had been respectful and given with dignity at all times. They told us they had a lack of confidence in the ward staffs ability to support their parent at meal times and because of this they attended daily. This was reported immediately to the unit Matron.

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

We carried out a site visit at the service and reviewed the care on two of the wards over the period of a day. We spoke with a total of 14 patients across the two wards. We asked them their views specifically about their experiences of how the service involved them and kept them informed. We were also able to make general observations of people’s wellbeing as further evidence of inclusion. All but one person spoken with said that they felt like they were encouraged to express their views openly and that they were kept fully informed about their care and any decisions made. They were of the opinion that any views they had were being taken into account by staff in the decision making for the care and treatment they received. One patient said ‘the staff are excellent, from doctors through to nursing staff they keep me fully informed and explain everything’. Patients talked about some of the difficulties with being in hospital but said that staff were always patient and reassuring.

Although the findings above were generally the case and many expressed the view that they felt like they were treated with respect and dignity, we did find some inconsistencies in the different areas we reviewed and in the care of patients with higher levels of dependency. Some patients for example reported having to wait for long periods for attention [on one ward]. We also saw call bells out of reach for at least half the patients in two of the bays [on one ward]. One patient told us he has to ‘shout for staff to come’. We also made some observations that were a concern and evidence that there may be some patients who are not being monitored appropriately with respect to their privacy and dignity.

People we spoke with were positive about the food provided and said that there was choice made available on a daily basis. People said that dietary choices and requirements were discussed either prior to or during the admission process. Over all the comments we received were very positive and evidenced that most people were satisfied with the food in the hospital.

As with issues around privacy and dignity, we did find some inconsistencies with the monitoring of dietary intake for more vulnerable people and these are discussed in the body of the report.

We rated the hospital as requires improvement overall which is no change from the last inspection in November 2015.The same four of the fivedomains were judged to be requiring improvement with the caring domain rated as good. Urgent care and outpatient services remained at a rating of good. Surgery and children's services moved down from a good rating to requires improvement andmaternity services had improved moving from an overall rating of inadequate to requires improvement. End of life services were inspected and reported in the Southport and Formby DGH report as the service was delivered by the same team trust wide.

Our key findings since our last inspection were as follows:

• Concerns raised regarding staffing in the paediatric emergency department (PED) had been addressed and staff were no longer pulled away from the department to undertake other duties. Work had been done to strengthen governance with regular meetings and risk registers were in place. We also found innovative work for orthopaedic care and goal directed therapy was undertaken in the PED.

• In the medical service the RMO position was unchanged however a foundation year two doctor had been recruited to support them. There were concerns regarding the nurse staffing especially at night and the lack of seven day working across the therapy services was having a detrimental effect on patients rehabilitation particularly in regards to swallow assessments where patients could wait three days over a weekend for assessment. There also appeared to be a lack of documented oversight of the matrons in regard to regular reviews of infection control measures, equipment and records.

• In the surgery services there remained 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 unchanged from the last inspection. There remained no approved schedule for replacing older theatre equipment and there was no funding identified to address this. 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.

• Following a rating of inadequate in maternity services the Royal College of Obstetrics and Gynaecology (RCOG) completed a review commissioned by the trust in August 2015. 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 on-going 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.

• In the Children’s and young people’s services safe, caring and well-led were rated as ‘good’ but it was deemed requires improvement in the effective and responsive domain because patient records were kept in unlocked trolleys across the service; paediatric policies, pathways and procedures were out of date or available and the dissemination of actions from complaints required strengthening as complaints were not addressed in a timely manner and there was no evidence of learning from them. The 2014 CQC inspection identified that the children and adolescence mental health service was limited, which often meant that children were not assessed during the weekend. CAHMS support from West Lancashire team out of hours for patients who presented with psychosis or severe intent to self-harm remained restricted due to financial provisions. The ward did not have an isolated room available for CAMHS patients but side rooms were used if available however, staff carried out risk assessment before patients were placed in rooms.

• The rating remained the same for the outpatients and diagnostics departments who received a rating of ‘good’ for being safe, caring, responsive and well-led (effective is not rated under the current guidance). We found the hospital performed well against national targets. Waiting times for appointments were better than average. Radiology figures were excellent for both receiving appointments and results. In the last 12 months, less than 1% of patients waited six weeks for a radiology appointment. There were a large number of appointment cancellations that had a variety of causes including IT issues; patients received multiple appointments in error. However, managers were gathering evidence and had set improvement targets.

However, there were areas of poor practice where the trust needs to make improvements.

In surgery

• The service must ensure that there are sufficient staff in theatre area.

• The service must ensure that that there is a schedule for the replacement of old theatre equipment.

• The service must ensure that the WHO checklist is completed in full on every occasion.

• The service must take action to develop an action plan to reduce the high readmission rate in elective surgery.

• The service must take action to ensure that mortality and morbidity events in surgical services are reported to the trust board.

In medicine

• The service must take action to ensure that all staff have the up to date training they require to be able to safety care and treat patients in line with trust policy.

• The service must ensure that all records relating to patients are kept securely.

• The service must ensure that there are always sufficient numbers of qualified, competent staff on the ward and ensure there is adequate medical cover to provide the RMO with sufficient time off.

• The service must take action to ensure that any patient who is deemed not to have capacity to consent to remain in hospital and does not wish to do so has a relevant and up to date deprivation of liberty safeguard in place. All actions taken in the patients best interests must be recorded.

In maternity and gynaecology

• The service must take action to ensure that controlled drugs on the labour ward are correctly stored and staff do not have to leave the operating theatre to obtain controlled drugs.

• The second obstetric theatre must be suitable for the purpose for which it is being used.

• The administration area for the community midwives must be fit for the purpose for which it is being used, including provision for ensuring the privacy of a service user when speaking on the telephone and between professionals.

  In children’s

• The service must ensure that all clinical pathways are up to date and reflect current standards and guidance.

• The service must ensure complaints are dealt with robustly and in a timely manner.

In children’s

• The service must ensure that all clinical pathways are up to date and reflect current standards and guidance.

• The service must ensure complaints are dealt with robustly and in a timely manner.

Professor Sir Mike Richards

Chief Inspector of Hospitals