Southport and Formby District General Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We assessed a total of 6 quality statements from this key question. This assessment did not cover all parts of our Single Assessment Framework; therefore, the key question of safe remains unrated. During the assessment we found a breach of regulation for safe care and treatment, where we told the service it needs to make improvements. We found that the service did not have enough planned nursing staff within their establishments to support times of escalation and mandatory training compliance in specific subjects, was below trust targets. The service frequently had delays in ambulance handovers and triage. The emergency department was at full capacity, meaning patients had long waits and were cared for in temporary escalation spaces not designed for clinical care such as corridors. However, leaders had put processes in place to help mitigate the risks of care in temporary escalation spaces and efforts had been made to ensure that these areas were safer. We found that safety incidents and concerns were managed appropriately, and lessons were shared. The department was clean and well maintained.

This service scored 41 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We reviewed reports for incidents which demonstrated a detailed investigation of each incident. There was clear documentation confirming that families were notified of incidents. Patients and their families received copies of the final investigation reports.

Leaders could articulate the themes and trends of incidents in the department, the action they had taken to address these, and the methods used for feeding back to staff. Staff told us that although challenging to attend all sessions, the organisation promoted a good culture of safety and learning. Staff told us they felt comfortable to raise concerns with managers and senior managers where necessary. They stated they mostly received feedback when they reported incidents. Staff felt well supported by senior staff and that the trust would take action to ensure that incidents and near misses reported would not happen again.

The service had the relevant policies and procedures in place to learn from incidents and near misses and this learning was shared with staff. Risks were not overlooked or ignored. Safety incidents were investigated as an opportunity to put things right, learn and improve. Incident investigations were completed in a timely manner, were well laid out and easy to follow. There was evidence of multidisciplinary input within the investigation, and risk grading was appropriate. Managers kept staff aware of safety incidents and complaints, with learning shared through daily safety huddles. Weekly patient safety meetings were held and chaired by a consultant, with senior nurse presence, and representatives from pharmacy. All incidents of that week were discussed and reviewed. Once the investigation was concluded and ratified, lessons learned were then disseminated through safety huddles. The corporate governance team provided learning bulletins for trust wide learning. Ten-minute teaching was in place for clinical teams each morning after the safety huddle. Lessons were learnt, resulting in changes that improved care for others. Staff understood the duty of candour and audits provided assurance that processes were being followed within timescales. They were open and transparent and gave patients and families a full explanation if and when things went wrong.

Leaders told us that safety and continuity of care was a priority throughout people’s care journey and that this happened through a collaborative, joined-up approach to safety that involved patients, along with staff and other partners in their care. Leaders and staff had a strong awareness of the risks to people across their care journeys. The trust recently initiated the role of a discharge facilitator to co-ordinate arrangements for patients with complex plans of care in place. The patient flow team, who are responsible to identify an appropriate bed when a patient requires admission to hospital, had a clinical lead and a discharge matron. There was early contact with local authority colleagues and review of patients in the ED for any social admission or any known patients. The trust aimed to provide patients who did not require medical care, options for a package of care/support in the community. Leaders told us they were cautious about which patients were cared for in temporary escalation spaces and had a standard operating procedure for staff to follow. This included a risk assessment to ensure that patients allocated to this area did not need additional requirements such as oxygen. The service had triage processes in place to direct patients to the most appropriate care. The service also utilised virtual wards for frailty. Staff told us that the triage and flow pathways worked well and were safe, but highlighted the fundamental issues were due to lack of beds and long waits for speciality reviews.

Feedback from partners for systems, pathways and transitions emphasised that the ED team tried to take a prompt handover to accommodate the increased demand. However, despite this, the wait for ambulance staff to handovers patients to trust staff had lengthened. The nature of the local geography meant that ambulance response from outside the immediate area could take extra time.

The percentage of ambulance handovers taking over 60 minutes at Southport ED (Emergency Department) was higher than the Cheshire and Mersey average served by the Ambulance Service at the time of our onsite assessment. However, until January 2024 Southport had consistently had shorter handover and turnaround times compared to the Cheshire and Mersey average. Southport ED applied reverse queuing when selecting patients to be cared for in temporary escalation spaces. Patients who had been seen by clinicians, had a management plan in place and were nursed on a hospital bed rather than a trolley. ED nursing staff provided staffing capacity to deliver care for up to 12 patients in temporary escalation spaces in efforts to be able to release ambulance crews. Between 1 December 2023 and 29 February 2024 there were 2,138 patients cared for in temporary escalation spaces. We saw improvement work had commenced to reduce ambulance handover delays. Work had begun to build upon existing ED streaming and direct GP access pathways in place for to the Acute Care Unit / Medical SDEC (Same Day Emergency Care), to broaden eligibility criteria and increase access and entry points for the ambulance service and other community clinicians. The trust had a Standard Operational Procedure Caring for Patients on ED Corridor Southport Site which provided a detailed guidance on the use of corridor area, including maintaining patient safety, safe staffing, and criteria to ensure that privacy and dignity were always maintained. The average time for triage was higher than the national standard between March 2023 to the end of February 2024 for adults, paediatrics, physical and mental health attendances. Up until January 2023 the trust reflected good handover times, however due to the challenges in discharging patients and congestion within the department, handover times were impacted. The trusts improvement plan reflected the systems plans for reducing handover times in line with national standar

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

Feedback from Healthwatch showed patients living with autism found it difficult to have their needs heard, to cope with the ED environment when crowded, and to understand their treatment plan adequately. It was recognised that this reflected a small sample of service users.

Leaders and staff could articulate what risk assessments they used to keep patients safe. Staff said that risk assessments were done when it was determined that patients required care and treatment in the emergency department. Care plans would be created and reviewed to reflect patient choice. However, staff told us that it was difficult to keep up to date with paperwork at times in extremis, as there was multiple documents to be completed, both for the ED and the ward, with limited staff and time constraints.

Partners told us that a recent audit of the emergency checklist encompassed the basic nursing care and risk assessments of patients within ED. The audits were undertaken using an electronic audit process (app used to assess and improve quality across clinical areas) and the result immediately shared with the staff so corrective actions were made in real time. The audit results for March and April 2024 for the Southport site had remained at between 83.9% and 89.0% compliance but the trust recognised that compliance started to fall after 4 hours onwards and put actions in place. The Southport site audit results for quarter 4 remained between 74.9% and 88.3% compliance with an action to improve the completion of the Bristol Royal Infirmary pre-operative assessment safety checklist section. Mental Health partners advised that the staff in the department had a good knowledge of risk and assessed and managed this well with patients and their families. They did however indicate that some of the mental health space and identified assessment room created risk. This had been raised and was being worked through with Senior Managers. The team indicated that communication was good between ED colleagues and external partners. It was noted that the ED team worked in collaboration to deliver risk plans. However, there have been occasions where observations of patients have been impacted due to resourcing however, senior managers are working with Mental Health partners to find a resolution.

Integrated software systems that output the national early warning score for patients in hospital were in place for the whole department so that staff could view live patient observations such as blood pressure and temperature recordings throughout the patient’s attendance. The ED co-ordinator had overview of all patient observations that were due to be undertaken including their risk assessments, and safeguarding status. The system flagged overdue patient observations so they could be acted upon by staff. Once in department there was a patient risk assessment booklet which included, for example, the falls risk assessment, alcohol screen, body map and manual handling assessments. Patients re-located to temporary escalation spaces for continued care and treatment whilst waiting for a ward bed received an additional dynamic risk assessments when care and treatment or the patient’s condition changed. An establishment review undertaken by the trust ensured that safer nursing tools and acuity tools were used for safer staffing. The process was peer reviewed regularly by professionals who understood the acuity in the department. There was a Mental health lead and mental health training in place for staff. The trust’s policy was that staff did not restrain patients and provided de-escalation training rather than restraint training. The Dementia and Delirium team were on hand to support patients with enhanced needs. There was a restrictive practice interventions policy in place. During the onsite assessment we were told of recent moves to seeing and treating patients on the back of ambulances due to overcrowding. We were informed of an occasion when a trauma call was dealt with on the back of an ambulance vehicle. Doctors told us that they had escalated concerns that this was not best practice.

People were not always cared for in environments that were designed to meet their needs. People’s feedback showed that some were cared for in temporary escalation spaces such as corridors that were busy with people walking through and lacked appropriate space and facilities.

Staff and leaders acknowledged that the corridor was not the right environment for patients and stated it was also quite narrow. Leaders advised that formal risk assessments were completed as well as dynamic risk assessments when required. The emergency physician in charge held oversight of the safety of the department and identified the most appropriate patients to be on the corridor. Staff stated they actively worked to see ambulance patients early on for rapid triage to understand risk. However, when the department was over capacity, staff made the areas as safe and as dignified as possible for patients. Leaders gave examples of changes they had made to the environment to improve patient experience and safety when being cared for in the temporary escalation areas. Staff told us that all equipment was taken to and was available in these areas when needed.

Due to demand on the ED service, capacity was regularly exceeded. Due to this, the department required to care for patients in temporary identified escalation areas which when exceeded required for clinically safe patients to be cared for in the corridor area. Whilst these areas had no facility for piped oxygen, suction, with reduced privacy a dynamic risk assessment was undertaken by the senior nurse coordinating the department to ensure appropriate patients, against their clinical acuity, were nursed in the most appropriate place in the department. This included aiming to maintain privacy and dignity of patients and responding to requirements for those placed in these areas while ensuring IPC measures were in place. Patients waiting to move to a ward were cared for on the corridor on beds and not trolleys to prevent pressure ulcers caused by long stays. Although measures had been put in place to improve privacy, dignity, and safety for patients, these areas were still unsuitable and did not have the facilities or equipment for clinical care. Equipment was in date and serviced.

The trust had appropriate risk assessments in place for the environment, however people were not cared for in environments that were designed to meet their needs. Patient-Led Assessments of the Care Environment (PLACE) inspections were completed in November 2023.There were 6 actions relating to ED from the 2023 PLACE assessments. All actions were either related to estate maintenance or capital projects. Out the 6 actions 3 actions were completed, 3 remained open and were planned for completion as part of the ongoing Capital Project Improvement plans for ED. These works would cause significant disruption to the department and service and would need to be planned with areas decanted. National Standards of Cleanliness (NsoC) assessments were completed weekly within the ED Department. The latest inspection was completed 10 March 2024. The Inspection checked up to 50 factors for cleanliness such as low and high surfaces, sinks, taps, baths, showers, toilets, macerators, mirrors etc. 38 rooms/areas in ED were inspected, out of those 38 rooms, 32 scored 100% giving the overall ED a score of 99%.

The friends and family test responses for March 24 showed a theme of patients saying that they had long waits and that more staff were required. Some commented that they could tell that ‘Staff were under pressure.’ However, people we spoke with, spoke highly of the staff that directly cared for them.

Staff told us that additional staffing was required due to crowding, especially during occasions when staff tended to patients on ambulances or in non-clinical spaces. Leaders advised that from March 2024 band 2 nursing staff were 2.42 (WTE) over established, nurse band 3 had a 9.52 WTE vacancy, nurse band 4 were 1.36 WTE over established, nurse band 5 were 1.92 over established, nurse band 6 had 4.07 WTE vacancies and nurse band 7 had a 3.3 WTE vacancies. The leadership team were actively seeking approval for investment into the nursing workforce within the Emergency Department at the Southport site. The 2023 staff survey results for ED showed only 43% of respondents felt they were “able to meet all the conflicting demands on my time at work.” And 17% of respondents felt “there are enough staff at this organisation for me to do my job”. Leaders acknowledged on the risk register that there was a risk to medical staffing due to increased activity levels and high dependency on bank doctor provision. However, controls were in place to mitigate and reduce risks where possible. Ongoing risk was assessed by leaders as high. Staff of all grades told us that access and completion of mandatory training was problematic due to the demands and high activity in the department. Leaders told us there were also medical vacancies. As of March 2024, there were vacancies for 1 WTE Foundation Year 2 doctor, 1 WTE Core Training Level doctor, 3.11 WTE Clinical Fellows, 1.60 WTE Senior House Officers, 3.25 WTE Specialty Training doctor, 1.75 WTE Specialty Doctor, 0.20 WTE Consultant and 2.0 WTE Locum Consultants. In addition, there were vacancies for Physician Associates with Band 6 vacancies at 5.64 WTE and Band 7 vacancies at 1.61 WTE.

We observed that there were not appropriate staffing levels to make sure people received consistently safe, good quality care that met their needs at times of escalation. We reviewed staffing rotas and saw that all planned shifts were RAG rated green, signifying that shifts were adequately covered. However, we were not assured that appropriate skill mix was achieved for both nursing and medical staffing. We were aware that some doctors and nurses were supporting main ED from SDEC as part of the ED escalated staffing plan. We visited the SDEC and found this area had full medical cover. Whilst 1 consultant was observed at the time of the assessment, there was a medical team assigned and further ANP roles supported t the rostered medical team.

The trust advised that staff sickness rates had increased from June 2023 to March 2024, but had reduced overall for ED. Specific area of focus had been Health Care Assistant (HCA) with significant amount of long-term sickness. NHS Professionals (NHSP) bank staff covered HCA absences. To cover Registered Nurse sickness the trust back filled with NHSP staff and a tier process within the governance framework identified when agency staff could be used. For mandatory training, medical staff were below the target compliance for resuscitation training (41% for adults, 68% for paediatrics), and below target for The Oliver McGowan Mandatory Training on Learning Disability and Autism training (62%), with a target of 90%. However, nurse staffing were compliant at 92%. Nurse staffing (93%) and medical staff (92%) compliance with mandatory NHS Conflict Resolution (England). In addition to mandated training 39% of staff had also received additional training in De-escalation training. Nurse staffing appraisal rates were on target with 97.87% completed.

People told us that the department was clean and hygienic, and they had seen domestic staff, staff using personal protective equipment (PPE) appropriately and hand washing. Patients told us there were plenty of stations for hand cleaning and sanitising gel.

Infection prevention and control was audited regularly, and action plans were created in response to any concerns or issues. Each area of the department had a dedicated cleaner 24 hours a day to ensure all areas were cleaned thoroughly. There were several single door cubicles in the department. There were clear roles and responsibilities around infection prevention and control (IPC). Staff checked patient infection status when allocating spaces in the department. The Nurse in Charge (NIC) and the Emergency Physician in Charge (EPIC) worked together to isolate patients appropriately. ED patients were reviewed every day by the IPC team before the 9am patient flow meeting. The IPC practitioner linked with ED co-ordinator and any possible or known infection concerns were prioritised. The IPC team updated the dashboard daily. Respiratory pathways were also in place.

We observed a clean and tidy ED department. We saw staff cleaning regularly and both nursing and medical staff were all bare below the elbows, in line with national guidance. The department had cubicles available to provide areas for isolation and we saw these being used appropriately.

There was an effective approach to assessing and managing the risk of infection, which was in line with current national guidance. IPC audits for January showed a compliance percentage of 82.6%, February 2024 was 80.43%, and March was 86% compliance. IPC Practice audits took place monthly, and quarterly environmental audits were in place. Following the audit in January 2024, meetings commenced between senior nurses in ED and IPC senior nurses to agree actions following lessons identified. This included recruitment of an additional housekeeper to support with general housekeeping of the environment, and additional domestic was recruited in January 2024 to support improvements in environmental cleanliness. Deep cleaning of areas had been undertaken across the department including non-clinical areas. All side rooms are deep cleaned after transfer of a patient with suspected or confirmed alert infection. The domestic cleaning schedule was reviewed in January 2024 to ensure that it met the needs of the department. Weekly Estates walkarounds commenced in 2024 by the Deputy Director of Estates and the Head of Hard Facilities for Southport and Ormskirk Sites. There had been no blood stream infections (MSSA, MRSAB, E. coli ) or C difficle related to care provided by ED in the last 12 months. COVID and flu vaccinations were offered annually to all staff.

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