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Northumbria Specialist Emergency Care Hospital Outstanding

Inspection Summary


Overall summary & rating

Outstanding

Updated 5 May 2016

Northumbria Specialist Emergency Care Hospital (NSECH) is one of the acute hospitals providing care as part of Northumbria Healthcare NHS Foundation Trust. NSECH opened on 16 June 2015, providing specialist emergency care for seriously ill and injured patients from across Northumberland and North Tyneside. It is England’s first purpose-built specialist emergency care hospital, with emergency consultants on site 24 hours a day, seven days a week, as well as consultants in a range of specialties working seven days a week. NSECH provides emergency care, critical care, medical and surgical services, a neonatal unit, children and young people’s services, maternity services and a full range of outpatient and diagnostic imaging services. The opening of this hospital had resulted in new models of care and different patient pathways in all of its services, with some services, departments and staff teams coming together from different hospitals within the trust.

Northumbria Healthcare NHS Foundation Trust provides services for around 500,000 people across Northumberland and North Tyneside with 999 beds. The trust has operated as a foundation trust since 1 August 2006. Northumbria Specialist Emergency Care Hospital has 337 beds.

We inspected Northumbria Specialist Emergency Care Hospital as part of the comprehensive inspection of Northumbria Healthcare NHS Foundation Trust, which included this hospital, North Tyneside General Hospital, Wansbeck General Hospital, Hexham General Hospital, and community services. We inspected Northumbria Specialist Emergency Care Hospital between 9 and 13 November 2015 and 2 December 2015.

Overall, we rated Northumbria Specialist Emergency Care Hospital as outstanding. We rated it outstanding for being effective, caring, responsive and well-led, and requires improvement for safe care.

We rated surgical services, critical care, children and young people's services, end of life and outpatient and diagnostic imaging services as outstanding. Urgent and emergency services and medical care we rated as good. Maternity and gynaecology was rated as requires improvement.

Our key findings were as follows:

  • The opening of NSECH had resulted in a new model of care and different patient pathways in emergency, maternity and medical and surgical care at this hospital. This had resulted in different ways of working for some staff.

  • Staff felt fully informed about all the changes which had taken place and were proud of the hospital and the care it provided to the local community and beyond.

  • Strong governance structures were in place across the hospital and there was a systematic approach to considering risk and quality management. Senior and site level leadership was visible and accessible to staff. Leadership was encouraged at all levels and staff supported to try new initiatives.

  • Managers at all levels understood the challenges of the new model of care and were actively addressing any issues that this had presented, specifically around nursing and medical staffing and patient acuity.

  • Staff and patient engagement was seen as a priority with several systems in place to obtain feedback.

  • The “Northumbria Way”, which incorporates the trust’s values, behaviours and culture was evident when we spoke with managers and staff throughout the hospital.

  • Staff delivered compassionate care, which was polite and respectful and went out of their way to overcome obstacles to ensure this. All patient feedback was extremely positive.

  • Access and flow within the hospital was improving. The new model of care was becoming embedded after only a short time. This was due to the positivity and commitment of staff at all levels embracing the new way of working.

  • The hospital had infection prevention and control policies in place, which were accessible, understood and used by staff.

  • Patients received care in a clean, hygienic and suitably maintained environment.

  • There was adequate personal protective equipment (PPE) such as aprons and masks available to staff. We routinely saw staff using this equipment during our inspection. Patients told us that staff washed their hands and used gloves and aprons.

  • The hospital routinely monitored staff hand hygiene procedures and compliance at the time of inspection was high.

  • Between April and October 2015 there had been no cases of methicillin resistant staphylococcus aureus (MRSA) at this hospital and six cases of c-difficile (five of which dated from October 2015 or earlier).

  • The hospital had implemented a ‘Safer Nursing Care Tool’ (SNCT) to assess the staffing requirements across wards. Nurse staffing was maintained at safe levels in most areas.

  • The ratio of consultants was better than the England average at this hospital.

  • The hospital utilised advance nurse practitioners to support doctors.

  • Mortality and morbidity meetings were held at least monthly and were attended by representatives from teams within the clinical business units.

  • There was representation from the specialist palliative care team at regular mortality review meetings. Their remit was to review and comment on the end of life care journey of patients and provide constructive feedback and advice in relation to ongoing learning and improving patient care.

  • Patients were assessed regarding their nutritional needs using the Malnutrition Universal Screening Tool (MUST).

  • Nutritional assistants were employed to provide patients with eating and drinking assistance if required.

  • Most wards followed the ‘well organised ward’ model to ensure that equipment storage was standardised and consistent across the trust.

We saw several areas of outstanding practice including:

In critical care services:

  • Over 300 days without an avoidable pressure ulcer and the overall safety thermometer results.

  • Patient outcomes and the access and flow data were adjusted internally to monitor the standardised mortality ratio following the trust’s change to the model of delivery of care.

  • A member of staff had been nominated for multiple awards for their compassionate care: The NHS FAB stuff awards; patient champion of the year: North East, and the team came second in the patient experience national awards.

  • The culture of everyone was valued and had a voice seemed embedded in the daily multidisciplinary safety huddle.

  • The pit stop handover for all admissions to the unit had been developed with human factors training using formula one pit-stop models, to facilitate a structured handover and improve patient safety.

  • Staff considered patients individual preferences and evidently went out of their way to exceed expectations to meet their wishes particularly in end of life care.

  • Staff had adapted the “This is me” booklet and used it for long term patients where they included information from relatives and visitors about patients personal preferences.

  • The rehabilitation after critical illness service.

  • Leadership of the service was excellent particularly in relation to the planning, preparation and the move to NSECH. Time was taken to engage staff in cross-site working prior to the move and work undertaken to standardise guidelines, procedures and equipment.

In children and young people's services:

  • Planning for the new model of care and facilities in the hospital was excellent. Managers had fully engaged staff in planning which resulted in a smooth transition into the new build and services being quickly up and running. Following a training needs analysis, staff had received additional training to ensure they had the correct skills to deliver the new model of care. There was ongoing work to further support staff in adjusting to the new services especially in the Children’s Unit.

  • The volume of information collected from service users was outstanding. The trust had innovative ways of engaging with patients and used a number of different methods for collecting information. This was shared with managers and clinical staff in order to improve services for children and young people.

  • A mother told us that while she was in recovery following the birth of her baby, a member of staff from the special care baby unit brought her a picture of her baby. She was extremely happy with this, as she was upset that she had to be separated from her new born baby. We thought this was extremely caring and responsive to her needs.

  • A parent passport was in place in the special care baby unit. This was held and completed by parents to increase their involvement in caring for their baby. The passport summarised the parents confidence and competence in carrying out this care. Following discharge, it provided a record for other healthcare professionals to understand the continuing needs of the parents in caring for their baby.

  • The trust was supporting a Consultant Clinical Psychologist in a longitudinal study to address the question of how health services could contribute most effectively to facilitating successful transition of young people with complex health needs from childhood to adulthood. The study involved young people from the conception of the research idea and throughout the course of the programme. Information from the study was fed into the National Institute for Care Excellence (NICE) as part of a consultation on draft guidelines on transition. The trust had a robust trust policy, which included transition and transfer of young people with long-term conditions and disabilities, which was being rolled out across business units. We thought the work on transition was outstanding.

In end of life care:

  • The model of end of life care services working alongside acute services at NSECH and out into the community was an innovative and pioneering approach to care.

  • Specialist palliative care was aligned with emergency care to ensure patients received specialist palliative care at the earliest opportunity.

  • The trust had responded to a higher than anticipated number of referrals to the specialist palliative care team by increasing the specialist palliative care resource within the hospital.

  • The trust had adopted an innovative approach to providing an integrated person-centred pathway of care in partnership to provide services that were flexible, focused on individual patient choice and ensured continuity of care.

  • The trust had taken positive action to increase the number of patients who were dying in their usual place of residence.

  • The trust was supporting increasing numbers of non-cancer patients.

  • The leadership, governance and culture were used to drive and improve the delivery of high quality person-centred care through collaboration and partnership working. The trust had clear leadership for end of life care services that was supported at the top of the organisation.

  • Investment in end of life and palliative care services was apparent and staff we spoke with consistently told us they felt that end of life care was a priority for the trust.

  • Innovations were seen in relation to a focus on spiritual support and an assessment model that aimed to increase staff's understanding of spirituality and confidence around assessment.

  • Partnership working with Marie Curie and joint management and nursing posts enabled the trust to provide prompt support and continuity of care for patients being discharged to their preferred place of care in the community.

  • The development of a tool for the assessment of patients spiritual needs that focused on providing staff with prompts that would make it easier for them to have this discussion with patients. The tool also helped staff to engage in a clearer way to ensure patients understood.

In outpatient and diagnostic imaging services:

  • The hospital provided a seven day a week consultant led outpatient trauma service for people from across Northumberland and North Tyneside to access, as well as a teleconference clinic for patients who lived in Berwick, almost 60 miles away.

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

Importantly, the trust must:

  • Complete a comprehensive gap analysis against the recommendation made for the University Hospitals of Morecambe Bay NHS Foundation Trust.

  • Ensure that the maternity and gynaecology dashboard is fit for purpose, robust and open to scrutiny.

  • Ensure that the entry and exit to ward 16 in Maternity are as safe as possible to reduce the risk of infant abduction.

  • Ensure that the storage of emergency drugs, within maternity services, are stored safely in line with the trust’s pharmacy risk assessment.

  • Ensure risk assessments in relation to falls, pressure ulcers, VTE and nutrition are consistently completed for all patients within medical care services.

In addition the trust should:

  • Ensure that levels of staff training continue to improve in the hospital so that the hospital meets the trust target by 31st March 2016.

In the emergency department:

  • Ensure nursing care documentation is completed consistently throughout the department.

  • Create a more dementia friendly environment (cubicle) to support patients with dementia.

In medical care services:

  • Continue to review staffing levels on medical care wards.

In critical care services:

  • Review the nurse staffing establishment to consider the inclusion of an additional supernumerary registered nurse over and above the clinical co-ordinator as recommended in Core Standards for Intensive Care Units (2013).

  • Review the provision of the critical care outreach service following the change in model of delivering care and in relation to national critical care outreach standards.

  • Consider the role of a clinical nurse educator on the unit as recommended in Core Standards for Intensive Care Units (2013).

In Maternity and gynaecology services:

  • Ensure that the clinical strategy for maternity and gynaecology services which is embedded within the Emergency Surgery and Elective Care Annual Plan, sets out the priorities for the service with full details about how the service is to achieve its priorities, so that staff understand their role in achieving those priorities.

  • Ensure all Patient Group Directions are signed by staff as appropriate.

  • Consider sorting emergency drugs in tamper evident boxes if they are stored in an open ward area.

  • Ensure that record keeping is consistent across all services.

  • Consider reviewing midwifery staffing levels across the trust to ensure the midwife to birth ratio at NSECH is reduced from 1:36 to 1:28 as recommended.

  • Consider the reconfiguration of pregnancy assessment unit to the Northumbria Specialist Emergency Care Hospital, to improve assess and flow of patients.

  • Consider the provision of midwifery support for Teenage mothers in Northumbria in order to provide an equitable service throughout the Trust.

In children and young people's services:

  • Fully embed the Duty of Candour with all staff.

  • Ensure patients clinical records are always available for children attending for day surgery at the hospital.

  • Address the issue of clerical support at weekends in the Children’s Unit, to ensure there is not a delay in sending out electronic discharge summaries to GPs.

  • Ensure that non-qualified staff in the Children’s Unit have clearly defined job roles and have robust competencies in place.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 5 May 2016

Effective

Outstanding

Updated 5 May 2016

Caring

Outstanding

Updated 5 May 2016

Responsive

Outstanding

Updated 5 May 2016

Well-led

Outstanding

Updated 5 May 2016

Checks on specific services

Maternity and gynaecology

Requires improvement

Updated 5 May 2016

We rated maternity and gynaecology services as requires improvement because:

We found the infant abduction policy had not been tested since the move to the new unit, despite an incident reported by a member of the public who was able to leave and enter the unit unchallenged. On inspection we found placentas were stored appropriately, however, we found inappropriate non-clinical items stored in the placenta freezer. We raised concerns with staff, and the items were removed immediately by senior staff. The storage of emergency drugs on the birthing centre and ward 16 were not in line with the trust’s pharmacy July 2015 risk assessment, and the service was not using tamper evident boxes in which to store drugs required in ward areas. We reviewed 11 records of women who had completed the pregnancy pathway and found inconsistencies in the completion of which pathway women were following in particular who was the lead professional in antenatal and labour notes (partogram). This may lead to high risk women not receiving an appropriate plan of care or review by medical staff. We also found notes had incomplete fluid balance charts. Due to the unexpected levels of activity the unit had experienced staffing numbers which were worse than the national recommendations. However, service leads had recognised this and plans were in place to recruit additional staff. There were systems for reporting, investigating and acting on adverse events. The service collected and reviewed information about standards and safety and shared it with staff.

Although the senior management team were aware of the challenges to the service and had a vision for the future, the formal clinical strategy for maternity or gynaecology services which was contained within the surgical business unit annual plan was very generic in terms of outcomes and references to maternity and gynaecological services were minimal. This did not support identification of how the service was to achieve its priorities or support staff in understanding their role in achieving the services priorities. The risk register did not reflect the current concerns of the senior management team, and had no mention of the concerns raised about infant abduction. We found there were risk and governance processes in place; however, we were concerned with the levels of scrutiny provided by the directorate with regard to the clinical dashboard. Risks were reported and monitored and action taken to improve quality. The views of the public and stakeholders through participative engagement were actively sought, recognising the value and contributions they brought to the service. There was some evidence of innovative practice.

The service used evidence based guidelines to determine the care and treatment they provided. We reviewed the annual audit plan; however, staff we spoke with informed us that since the move to the new hospital they had not been involved in any audit activity apart from the regular local audit. We found staff had the correct skills, knowledge and experience to do their job. Training ensured medical and midwifery staff could carry out their roles effectively. Competencies and professional development were maintained through supervision. Women told us their pain was managed, also they were provided with choice. Women were offed support to feed their baby’s, and hot food and drinks were available for mothers 24 hours a day. Patient outcomes were monitored using the maternity dashboard but not all patient outcomes were within expectations; however, we saw that investigations were underway in areas of concern.

Patients were valued as individuals, and we were provided with examples of this. Following a number of complaints in 2014 at Wansbeck hospital, the service had put in place compassion training for all staff. In the 2015 CQC maternity experience survey placed the service in the top 10 hospital trusts. We observed patient care in the ward environment staff were seen to be supportive and respectful. Women received emotional support and were involved in their care.

The service had gone through a significant reconfiguration to a new model of care, which saw the amalgamation of delivery services previously based at Wansbeck and North Tyneside General Hospitals on the one NSECH site. Policies were in place to ensure that patients were seen at the right place and at the right time. We found the service had begun to engage with service users to inform developments within the service. There was no pregnancy assessment unit on site; women were triaged on the birthing centre. Staff we spoke with informed us on occasion this had reduced the capacity on the birthing centre for labouring women and the number of staff able to look after them. Service leads informed us this was high on their list of priorities and were working on short and long term plans for the future. There were a number of specialist midwifery roles to support women, for example, a high risk midwife and diabetes midwife specialist. Women using the service could raise a concern and be confident that concerns and complaints would be investigated and responded to.

Medical care (including older people’s care)

Good

Updated 5 May 2016

Overall, we rated medical care services at this hospital as good, with safe as requires improvement because:

Staffing levels and skill mix were planned and reviewed. Any staff shortages were responded to however there were times when rosters indicated that registered nurse staffing levels did not meet planned levels, particularly on one ward. This was managed and senior staff were regularly reviewing ward establishments following the collation of patient dependency data. We found varying degrees of completeness across all wards in relation to both nursing and medical records, specifically in relation to pressure area, falls and nutritional risk assessments. VTE assessment was variable on the medical wards. The lowest compliance was 55% on one ward in September; a second ward also reported only 60% compliance in assessment in August 2015. Data received from the trust indicated that, when VTE assessment compliance was low, this corresponded with lower percentages of patients receiving prophylactic treatment.In some areas, for example, when the assessment was identified at 55%, only 86% of patients received the appropriate preventative treatment. People were protected from avoidable harm and abuse. Staff fulfilled their responsibilities to raise concerns and report incidents and near misses. There was evidence of robust sharing and learning from incidents. All areas were visibly clean and well maintained. Staff were aware of and adhered to infection control procedures. When necessary patients were appropriately isolated to minimise the risk of cross- infection. The trust had policies and procedures in place for the safe management of medicines. Incidents relating to medicines were low. The trust had installed an electronic fingerprint recognition system for the safe and secure handling of medicines.

Local pathways, policies and guidelines (that were regularly reviewed to ensure that these were in line with national guidance) and formal procedures to audit compliance with standards, were implemented. There was limited evidence of specific patient outcomes because of the limited period of time that the hospital had been open. Staff were aware of key quality performance indicators. Robust multi-disciplinary working with all disciplines was evident across all areas of the hospital. Seven day services were part of the new model of care and were becoming embedded within the hospital.

Feedback from patients and visitors was overwhelmingly positive. Patients felt involved in their care and their physical needs were not the only consideration. All patients said they felt emotionally supported by staff. Patients and relatives understood what their plan of care was and were able to be involved with this. Staff were committed to providing high quality patient focused care.

Engagement with local stakeholders was excellent. The service had many innovative projects in place to engage and respond to the health needs of the local population. The model of care at NSECH provided benefits for the trust’s other hospital sites. Separating serious emergencies from planned care meant that patients attending for planned operations, tests, and outpatient clinic appointments at other bases did not have their care affected by the need to prioritise seriously ill emergency patients. Patients could access the service in a timely way and continuity of care was maintained. Since opening 6,336 (93%) of patients had been admitted and discharged from the same ward or unit. 452 (7%) had only moved ward once during their admission and 16 patients had moved wards twice. This meant that the majority of patients had consistency in relation to their care and treatment.

The medical services were managed by an experienced and cohesive team who demonstrated an understanding of the challenges of providing high quality, safe care. Within this hospital, local managers had particular challenges regarding staffing issues and completion of risk assessments which were acknowledged but still required addressing and embedding. Governance processes were in place which allowed clear identification and monitoring of risk and we saw evidence of related progress and action plans. Staff and patient engagement was seen as a priority with several systems in place to obtain feedback. Innovation was encouraged. Diabetes research, in particular the long term self-management of diabetes, was at the forefront of medical research within the medical directorate.

Urgent and emergency services (A&E)

Good

Updated 5 May 2016

We rated the emergency department at this hospital as good because:

There was an open and transparent culture with regard to the management of risk. Staff reported incidents and we saw examples of the duty of candour. The department was visibly clean and we observed good hand hygiene. There was a programme of mandatory training and managers were working towards training and staff appraisal targets. The completion of documentation was variable. Staffing levels had been increased as a result of the increasing demand on the service and the department was achieving the government’s 95% target for admitting, transferring and discharging patients within four hours of arrival to the emergency department. There was an effective and comprehensive process in place to identify, understand, monitor and address current and future risks. However, processes and systems were still new and, as alternatives to improve patient flow, experience and outcomes were explored, were being revised. The department had an ongoing audit programme that encompassed both local and national audits. Where performance was noted below national standards, the department had implemented action plans to improve the care and treatment of patients.

Feedback from patients and their relatives regarding the care they received while using the service was consistently positive. Where people had cause to complain, the senior management team had processes in place for responding to their concerns. Staff were observed to engage with patients in a compassionate and caring manner. The nursing documentation was not comprehensive regarding the nursing assessments and care and there was no specific guidance or facility for caring for a patient with dementia or a learning disability.

All staff within the emergency department were clearly engaged with the new model of specialist emergency care at NSECH. The vision and strategy had been developed through a structured planning process with engagement from internal and external stakeholders, including people who use services, commissioners and others. The department’s clinical and managerial leadership drove a culture where change was embraced and where the focus was on the patient experience. The purpose built emergency department was equipped with new technology and equipment.

Surgery

Outstanding

Updated 5 May 2016

We rated surgery services as outstanding because:

The hospital provided a new model of elective and emergency care to its population and at the time of inspection NSECH had been open for 5 months. The provision of specialist emergency surgical care, with consultants on site 24/7, as well as consultants in a range of specialties working seven days a week was embedded across the trust and appeared to be working well. The change to the provision of emergency and high risk surgical services centred at NSECH ensured patients received the right care and treatment, support services, nursing and clinical staff at the appropriate time and location. The strategy of the service clearly identified the new model of emergency and high-risk surgery provided at NSECH and the relationship between NSECH and the base hospitals. The new model was under constant review to determine the most effective site to undertake different procedures depending upon risk and safety. Local communities had been engaged in the consultation and development of the strategy for the new model of care. This had a positive effect upon the feedback received from patients and relatives received during the inspection at NSECH and also at the base hospitals.

At the end of September 2015, the trust was meeting the NHS operational target of 92% of patients waiting less than 18 weeks for treatment. Six theatres were available at NSECH, seven days a week. There were innovative approaches to delivering patient care and evidence based practice based on national guidance and benchmarking was evident across the trust. A dedicated team contacted patients by telephone following discharge to gather information about any immediate concerns the patient may have and provide advice and guidance.

Strong governance structures were in place across surgery and there was a systematic approach to considering risk and quality management. Performance data and information was available and displayed at NSECH, albeit limited from the month of opening in June 2015. The trust team had been consistent in its approach to communication, and having good systems and processes in place to protect patients and maintain their safety. Staff we spoke with in surgery at NSECH understood the process for reporting and investigating incidents and there was a good reporting and feedback culture. There had been no serious incidents at NSECH and 150 reported incidents in surgery since June 2015, with very low incidence of minor patient harm being recorded at this site. Senior managers had a clear vision and strategy for the division and identified actions for addressing issues within the division. We were told the service had a commitment to a people centred approach delivering high quality care with robust assurance and safeguarding and saw this in practice during the inspection. Staff told us they were encouraged to challenge existing practices, look for improvements and suggest ways to develop and introduce innovative practice. Staff reflected on the strong leadership and visibility of senior members of the trust board. This motivated staff and they felt that senior leadership reflected the vision and values that they shared with the organisation. Surgical staff we spoke with at NSECH and across all base sites understood the new model of care and consistently spoke of being proud to work for the trust.

The surgical wards were a modern design with majority single room accommodation. They were spacious and visibly clean.We observed new pharmacy technology and new systems for monitoring patient/nurse calls. Staffing levels were good at the time of inspection. Staffing had been reviewed since opening and an increase in both medical and nursing cover had been agreed. Senior and site level leadership was visible and accessible to staff at NSECH. Staff spoke very positively about their immediate line managers and senior leaders and a positive culture was evident during the inspection.

We observed patients being cared for with dignity, compassion and respect in all surgical wards and departments. The 22 patients we spoke with were very positive about the service and staff and surgical services in NSECH had received positive feedback scores and comments for the first few months of delivering services at this hospital site. There was a comprehensive approach used by the trust to capture the patient experience but information was limited at the time of inspection of NSECH. Patients commented they had been treated: ‘…very well, promptly and by staff who were caring and treated them well’, ‘…although staff are busy, they always have time for a chat, couldn’t be better’ and ‘…the service was professional at all times’.

Intensive/critical care

Outstanding

Updated 5 May 2016

We rated critical care as outstanding because:

People’s individual needs were central to the planning and delivery of critical care services. The service involved patients and stakeholders in the new model of care and the build of the unit to ensure it provided an innovative approach to integrated person-centred care. The management team worked with leads in the trust to plan service delivery.

Governance and performance metrics were proactively reviewed. Governance arrangements enabled the effective identification of risks and monitored these risks and the progress of action plans. There was evidence that controls were in place to mitigate these risks.

An experienced and cohesive team managed the service. They demonstrated a clear understanding of the challenges of providing high quality, safe care. Continuous improvement was driven with the involvement of frontline staff that felt valued and who were engaged in service development. The leadership team motivated staff to succeed. It was clear that staff had confidence in the leadership at all levels and spoke highly of the culture within the unit. There were high levels of staff satisfaction.

All staff considered patients individual preferences and evidently went out of their way to exceed expectations to meet their wishes. Staff were motivated and inspired by leaders to deliver person centred, holistic care. One visitor told us the staff made them feel like their relative was the only patient on the unit and nothing was too much trouble. Staff had been nominated for awards for their compassionate care. Formal feedback from patients and relatives was continually positive about all aspects of their care.

Care was led 24 hours a day, seven days a week by a consultant in intensive care medicine and staffing was in line with Core Standards for Intensive Care (2013). Patient outcomes were the same as or better than the national average and care and treatment was planned and delivered in line with current evidence based guidance and standards. There was evidence of excellent joint and patient centred multidisciplinary team working. The culture of ‘everyone had a voice’ was embedded.

Governance

arrangements enabled the effective identification of risks and monitored these

risks and the progress of action plans. There was evidence that controls were

in place to mitigate these risks.

The service had a good track record in safety. There had been no never events or serious incidents reported. Between July and October the unit achieved 100% harm free care on three out of four months and it had been over 300 days since there had been an avoidable pressure ulcer.

Services for children & young people

Outstanding

Updated 5 May 2016

We rated services for children and young people at NSECH as outstanding because:

Access to the Children’s Unit and 24 hour care was excellent with patients reporting they were seen by relevant staff and treated quickly. The performance for children being seen and either discharged or admitted within 4 hours in the Children’s unit was 99%. A triage assessment tool was in place to identify clinical acuity and fast track children when necessary. There were robust arrangements for the transfer of babies and children needing a higher level of care. Other organisations and the local community had been involved in the planning and delivery of this service. There was a proactive approach to understanding the needs of children and young people to ensure that care was delivered to meet their needs. The new facilities were excellent, met national standards and the needs of children and young people.

There was a clear vision for this service with strong leadership. The management team were very positive about their services and very proud of their staff. They sought to make continual improvements and were passionate about and strived to deliver high quality patient care. Staff told us that managers were both visible, approachable and open to new ideas. Robust and effective governance arrangements were in place to protect patients from harm. Governance arrangements and the risk register were proactively reviewed. There was a high level of staff engagement and excellent team working. Staff felt proud of the services they delivered to patients and there was a culture of continual improvement. There were inventive ways of engaging the public and service users in order to improve the patient experience. The service supported and encouraged innovation.

There were arrangements in place to protect patients from abuse and avoidable harm. There was a positive culture of reporting and learning from incidents. The clinical environment and equipment was clean and staff observed good infection control practices. Medicines, including controlled drugs, were stored securely and dispensed safely. Safeguarding systems were robust in protecting children and young people from harm. Staffing levels were safe although further work was being undertaken to ensure staffing levels in the Children’s Unit could meet future demand. There were effective measures in place to assess and respond to a child whose condition was deteriorating.

Services for children and young people were effective. Clinical practice was based on local and national standards and was regularly audited to ensure standards continually improved. There was involvement in regional networks to learn and share good practice. Staff were competent to deliver care. Additional training needs were being identified and training planned as the new service continued to develop. Policies and procedures were in place, up to date, and staff knew how to access them.

Staff provided compassionate care and treated children and parents with kindness and respect. We heard consistent praise from children and parents who told us they felt well informed and involved in decisions about their care. Both the Children’s Unit and the Special Care Baby Unit (SCBU) scored highly in patient surveys. In the Special Care Baby Unit, we saw that staff gave special attention to siblings to help them feel included. They also gave parents a call 48 hours after discharge to offer advice and support. Emotional support was good with the availability of specialist bereavement midwives in SCBU and easy access to in-reach mental health services in the Children’s Unit.

End of life care

Outstanding

Updated 5 May 2016

We rated end of life care as outstanding because:

We found that the hospital was providing high quality end of life care services using innovative approaches and effective partnership working. There had been significant investment in palliative and end of life care services and the trust was responsive to addressing issues as they arose with flexibility in relation to staffing and resources. There was a clear vision, strategy and leadership at all levels of the organisation with a focus on good quality end of life care. Patients were cared for using a truly holistic approach and staff teams were committed to working collaboratively to meet individual needs. The structure of the hospital liaison service that had been developed in partnership with Marie Curie provided additional flexibility to enable specialist palliative care staff to provide support to patients at the end of life irrespective of the complexities of their condition. This was sometimes in the form of supporting a rapid discharge to the patients preferred place of care in the community and as such involved a very hands on approach to ensuring as straightforward a transition as possible with hospital staff accompanying the patient in order to handover to community staff.

We saw evidence of the use of national guidance and appropriate anticipatory prescribing of medicines at the end of life. Multidisciplinary working was apparent between different disciplines and across services within the hospital and the community. The hospital liaison palliative care team worked well alongside the acute teams at NSECH to provide palliative and end of life care specialist support at the earliest appropriate opportunity. There was an emphasis on working to increase the confidence and competence of ward based staff to ensure all patients had access to good quality end of life care. Patients and their families were involved in care and we saw a number of initiatives in use to record patient wishes including advance care plans, emergency healthcare plans and treatment escalation plans.

There was consistent evidence that staff were motivated to go the extra mile. Spiritual care was seen to be important with initiatives having been developed in supporting staff in the assessment of spiritual needs through training and the use of an internally designed assessment tool. Chaplaincy support saw multi-denominational ministers and faith leaders available for patients, relatives and staff.

The leadership, governance and culture were used to drive and improve the delivery of high quality person-centred care through collaboration and partnership working. The trust had clear leadership for end of life care services that was supported at the top of the organisation. There was a clear proactive approach to seeking out and embedding new and more sustainable models of care. Staff we spoke with consistently told us they felt that end of life care was a priority for the trust.

Outpatients

Outstanding

Updated 5 May 2016

We rated outpatient and diagnostic imaging at NSECH as outstanding because:

The service was flexible and ensured continuity of care. People accessed services in a timely and convenient way. The hospital provided a seven day a week consultant led outpatient trauma service for people from across Northumberland and North Tyneside to access, and a teleconference clinic for patients in Berwick, almost 60 miles away. Trauma clinics and related services were organised so patients only had to make one visit for investigations and consultation or, if possible did not have to return to hospital for unnecessary appointments. It also provided patients with timely advice on the management of their injuries while at home. Radiology reporting was swift with an emphasis on “results within minutes” for trauma patients. This enabled medical teams to complete assessments and manage risks quickly. Reporting times for urgent and non-urgent procedures consistently met or were better than national and trust targets for all scans and x-rays for emergency patients, inpatients, and outpatients. There was widespread involvement with the local population, primary care, and commissioners to plan this new model of emergency care to ensure that the service met people’s needs. Since the departments opened in June 2015, there had been no formal complaints. However, the department teams recorded any concerns and informal complaints and used patient feedback proactively to prevent recurrence that might affect others.

Staff and managers had a clear vision for the future of the service. They knew the risks and challenges the service faced. Staff we spoke with at all levels felt supported by their line managers, who encouraged them to develop and improve their practice. Staff embraced change and there was a real focus on patient experience and leaders and managers drove this. There were well embedded systems and processes for gathering and responding to patient experiences and the results were well publicised throughout the departments. Early feedback provided by patients for the virtual trauma service was very positive. There were effective and comprehensive governance processes to identify, understand, monitor, and address current and future risks. These were proactively reviewed. There was an open, honest and supportive culture where staff discussed incidents and complaints, lessons learned and practice changed. All staff were encouraged to raise concerns. The departments supported staff who wanted to work more efficiently, be innovative, and try new services and treatments and ways of engaging with the public.

The hospital had good systems and processes in place to protect patients and maintain their safety. The departments were clean and hygiene standards were good. Medical records were stored and transported securely. Staff followed professional best practice guidelines to plan and deliver good quality care and took part in a wide range of national and clinical audits. Diagnostic imaging provided services for inpatients and emergency patients seven days a week and service availability was increasing and continuously improving. Staff undertook regular departmental and clinical audits to check practice against national standards.

Staff respected patients privacy, dignity, and confidentiality at all times. Staff spent time with patients and those close to them to give explanations about their care and encouraged them to ask questions.