Southport and Formby District General Hospital

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We assessed 1 quality statement from this key question. This assessment did not cover all parts of our Single Assessment Framework; therefore, the key question of effective remains unrated. We found that the service had good multidisciplinary working process in place within ED. However, during the assessment we found a breach of regulation for safe care and treatment. We found that almost half of the patient clinical pathways were either past their review date or did not have a review date planned.

This service scored 8 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Assessing needs during this assessment. There is no previous rating for the Effective key question so we cannot yet publish a score for this area.

We found that patient feedback was very mixed. Patients told us that they were not always offered food, drink, and pain relief in a timely manner. Some patients fed back that they did not experience effective communication in relation to their care and treatment and after many hours of waiting, did not understand the next step of their care plan. However, other patients explained that they had received “fantastic diagnostic, treatment, planning, and delivery of their care."

Leaders told us that the trust participated in the Royal College of Emergency Medicine (RCEM) annual national audit programme which comprised of 3 annual audits. Audits highlighted concerns would be subject to an action plan. The trust received National Institute for Health and Care Excellence (NICE) updates through the Audit department and a gap analysis against trust policies was undertaken when a new piece of guidance was released. The policy would be reviewed by Associate Medical Director, followed by the consultants and junior doctors. Clinical teams were separated into 4 houses for communication, appraisals, and quality improvement (QI) projects. The GIRFT programme was undertaken in 2018. The Getting It Right First Time (GIRFT) programme is a national NHS England programme designed to improve the treatment and care of patients through in-depth review of services, benchmarking, and presenting a data-driven evidence base to support change. Actions were identified around patient flow, computer systems etc. Leaders told us that prior to this winter, the ED were performing well on patient flow metrics. As part of the actions the trust visited high performing organisations to see how they can learn from them looking at ambulance handovers and 4-hour turnarounds. However, leaders told us the trust did not observe anything that they had not already tried. Nonetheless, they did identify some good elements around culture.

The provider’s systems did not ensure that all policies and clinical pathways were up to date with national legislation and standards. Although likely to remain relevant to practice, 28 policies/pathways were provided for review and we found 16 required review due to a lack of control dates, version control or were past the planned review period. The department took part in multiple national and local clinical audits and there were processes in place to monitor audit results to make improvements. We reviewed audit compliance action plans for the department, and these showed that actions were being taken to improve compliance. In 2023, the Regional Advancing Quality (AQ) team set a target of 70.1% for the Advancing Quality Alliance (AQUA) agreed domains for Sepsis audit. By the end of November 2023, the organisation's performance stood at 69.0%. A recent audit evaluated 16 randomly selected patients who visited the Emergency Department (ED) in January/February 2024. The audit revealed a performance of 70.8%, exceeding the AQ target. Areas requiring improvement have been identified, and plans are underway to address these deficiencies. These plans encompassed strategies for continuous monitoring and improvement to uphold ongoing compliance with standards. Additionally, staff completed training and education on updated protocols and guidelines for sepsis management within the ED, equipping them with the necessary knowledge and resources to deliver care. In response to the publication of new national sepsis standards in 2023 and NICE guidance released January 2024, the trust had scheduled meetings in March 2024 to comprehensively review processes, particularly those pertaining to the ED and sepsis management. The review aimed to ensure that trust processes were in line with the updated standards and guidance provided.

We did not look at How staff, teams and services work together during this assessment. There is no previous rating for the Effective key question so we cannot yet publish a score for this area.

We did not look at Supporting people to live healthier lives during this assessment. There is no previous rating for the Effective key question so we cannot yet publish a score for this area.

We did not look at Monitoring and improving outcomes during this assessment. There is no previous rating for the Effective key question so we cannot yet publish a score for this area.

We did not look at Consent to care and treatment during this assessment. There is no previous rating for the Effective key question so we cannot yet publish a score for this area.