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Ormskirk District General Hospital

Provider Mersey and West Lancashire Teaching Hospitals NHS Trust Type NHS Healthcare Organisation Region North West Last inspected 29 Nov 2019

Overall rating: Requires Improvement  View full CQC report

Domain ratings

Five CQC key questions
Safe
Requires Improvement
Effective
Good
Caring
Good
Responsive
Good
Well-led
Requires Improvement

Earlier inspection findings

pre-2024 framework · 3 must-do 5 should-do

Must-do actions (3)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 3
Must do
Safe
The service must ensure all staff are up to date with mandatory training including but not limited to pool evacuation.
Regulation: Regulation 12(1)(2)(c)
⚠ Records showed 89% of staff had received initial training on emergency evacuation of the birthing pool. However, 76% of staff had not had refresher training in the previous 12 months. Some staff we spoke to during the inspection could not describe how to safely evacuate a woman or birthing person …
Must-do action 2 of 3
Must do
Safe
The service must ensure staff accurately complete, and document modified early obstetric warning scores and newborn risk assessments, record CTG assessments and fresh eyes in order to identify and escalate women, birthing people and babies at risk of deterioration.
Regulation: Regulation 12(2)(a)(b)
⚠ Staff did not always utilise tools to identify if women and birthing people were at risk of deterioration and therefore there was a risk, they would not recognise concerns or act appropriately. The trust’s audit for December 2023 identified in 3 out of 10 casenotes had missing or late observations …
Must-do action 3 of 3
Must do
Safe
The service must ensure there are sufficient numbers of staff deployed to keep women, birthing people and babies safe.
Regulation: Regulation 18(1)
⚠ Staffing levels did not always match the planned numbers putting the safety of women and birthing people and babies at risk. Incident records identified a shortage of midwives had resulted in delays in women and birthing people being assessed within safe timescales and being delayed for other time-critical procedures. At …

Should-do actions (5)

Recommended improvements to enhance service quality.

Should-do action 1 of 5
Should do
Safe
The service should ensure that records are maintained for all discarded medicine used for epidurals.
Should-do action 2 of 5
Should do
Well-led
The service should ensure all staff receive supervision and annual appraisals.
Should-do action 3 of 5
Should do
Well-led
The service should consider making electronic records accessible to women and birthing people.
Should-do action 4 of 5
Should do
Safe
The service should ensure incidents are reviewed in a timely manner.
Should-do action 5 of 5
Should do
Well-led
The service should develop a maternity-specific strategy and vision.

Location details

CQC ID: RBN04
Local authority: Lancashire
Region: North West

Inspection report

Type: Location
Date: 5 April 2024
Rating: Requires improvement
Actions: 3 must-do 5 should-do
AI-extracted 3 Jun 2026

Related PFD reports

2024-0527 — Marina Young (Oct 2024)
2017-0123 — Michael Newell (Apr 2017)