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Hexham General Hospital Outstanding

Inspection Summary


Overall summary & rating

Outstanding

Updated 5 May 2016

Hexham General Hospital is one of the acute hospitals providing care as part of Northumbria Healthcare NHS Foundation Trust. This hospital provides emergency care from an emergency care centre, medical and surgical services, midwifery led maternity services and a range of outpatient and diagnostic imaging services. Hexham General Hospital does not provide critical care, children and young people services and end of life care. Some services had been reconfigured in June 2015 when the Northumbria Specialist Emergency Care Hospital (NSECH) opened. The opening of NSECH had resulted in a new model of care and different patient pathways in emergency, maternity and medical and surgical care.

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. Hexham General Hospital has 115 beds.

We inspected Hexham General Hospital as part of the comprehensive inspection of Northumbria Healthcare NHS Foundation Trust, which included this hospital, North Tyneside General Hospital, Wansbeck General Hospital, Northumbria Specialist Emergency Care Hospital, and community services. We inspected Hexham General Hospital on 12 November 2015.

Overall, we rated Hexham General Hospital as outstanding. We rated it outstanding for being caring, responsive and well- led; with safe and effective rated as good.

We rated medical care, outpatient and diagnostic imaging services and surgical services as outstanding; with urgent and emergency services and maternity and gynaecology rated as good.

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.
  • There were processes to ensure patients were cared for in the right place at the right time. Patient flow was a priority, and the hospital proactively managed this.
  • For all performance measures relating to the flow of patients the hospital was performing the same or better than the England average.
  • The transfer of patients between NSECH and the ‘base’ hospitals was still being configured and embedded at the time of inspection and staff were working flexibly to accommodate patient needs.
  • 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.
  • Nurse staffing was maintained at safe levels in most areas. The hospital had implemented a ‘Safer Nursing Care Tool’ (SNCT) to assess the staffing requirements across wards.
  • The ratio of consultants was better than the England average.
  • 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.
  • 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:

  • The hospital had direct access to local authority, community services and care homes to ensure unnecessary admissions were minimised.
  • Staff demonstrated an outstanding level of care and compassion towards patients.
  • Experienced and cohesive senior management teams across the hospital demonstrated a clear understanding of the challenges of providing high quality and safe care. They had identified and implemented actions and strategies to manage this and this had been done with the involvement of frontline staff.

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.

In addition the trust should:

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

  • Ensure waiting time targets in ultrasound in diagnostic imaging services continue to improve as more staff are appointed.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Good

Updated 5 May 2016

Effective

Good

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

Good

Updated 5 May 2016

Overall we rated maternity services as good, with well-led as requires improvement because:

The birthing unit had effective systems in place for reporting, investigating and acting on serious adverse events. Information was collected, reviewed and investigated around standards of safety. This information was shared with the staff and the public. Information about safety issues was displayed on the wards and units and in staff areas. Medicines were stored and managed appropriately. The birthing unit was visibly clean and there was plenty of space for women and babies. Staff followed safety guidance for infection prevention and control. Staff planned and provided care and treatment in a way that ensured women’s safety and welfare. There were sufficient staff working on the unit and there were a minimum of three midwives on duty when the birthing pool was in use. Medical staff were available to attend, in an emergency, to gynaecology patients and women in the birthing unit. The criteria for admission to the birthing unit were rigorous and clear. This reduced the risk for women and transfer of women in labour was limited to an average of 18% of all births at Hexham.

The service used national evidence-based guidelines to determine the care and treatment they provided and participated in national and local clinical audits. Patient outcomes were monitored and action taken to make improvements. 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.

The individual needs of women were taken into account and they were offered compassionate care and emotional support from staff in the birthing unit. The written feedback from women and their families was positive. Staff were positive about the hospital and the services they were able to offer women and their families. They were proud to be part of the team and committed to providing high standards of care.

However, 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. 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 maternity dashboard. Staff were aware of the trust’s vision but did not seem to be involved in any plans to develop maternity services at Hexham. There was a recently established Maternity Services Liaison Committee that involved local users of the service.

Medical care (including older people’s care)

Outstanding

Updated 5 May 2016

We rated medical care services as outstanding because:

An experienced and cohesive team who demonstrated a clear understanding of the challenges of providing high quality, safe care, managed medical services. They had identified and implemented actions and strategies to manage this and this had been done with the involvement of frontline staff. This meant staff we spoke with felt valued and were engaged with the process. The directorate had a clear vision and business strategy. Staff felt valued and were encouraged to contribute to service development. Staff and patient engagement was seen as a priority with several systems in place to obtain feedback. Governance processes were embedded which allowed clear identification and monitoring of risk and we saw evidence of related progress and action plans. Diabetes research, in particular the long term self-management of diabetes, was at the forefront of medical research within the medical directorate. The service had a significant national profile and influence as a result, including research papers on person centred care in long term conditions.

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.

Staff were encouraged to report incidents of harm or risk of harm and learning from incidents was demonstrated. The wards were visibly clean and organised. There were some nurse staffing vacancies but the trust was recruiting to fill posts. On most wards, adequate cover was in place and actual staffing numbers reflected the planned figures. Staff worked additional hours and could be brought across from other wards or the trust if needed. The level of staff completing mandatory training was good. Medicines management was appropriate. Clinical records were well organised and fully completed.

The service participated in national audits and had a robust system of local clinical audits. Information about people's care and treatment and their outcomes were routinely collected and monitored. Outcomes were positive and met expectations.

There were processes to ensure patients were cared for in the right place at the right time. Patient flow was a priority, and the bed management team proactively managed this. The movement of patients during admission was monitored effectively.

Urgent and emergency services (A&E)

Good

Updated 5 May 2016

Overall we rated the emergency care centre as this hospital as good, with caring as outstanding, because:

The care given to patients by the department was outstanding. Privacy and dignity were maintained and people were dealt with in a kind and compassionate way. Patients were treated as individuals and care was tailored to their specific physical and mental health needs. All staff went the extra mile to ensure that patients received the care and support they needed. Patients were the focus of staff. Patients and families were seen as partners in decisions about their care and emotional support was given during difficult situations. Results from national and local surveys and questionnaires were consistently excellent.

Staff were engaged in the future development of the department. Managers had robust plans in place to ensure the sustainability of the department for the future, including contingency planning and plans to develop the skills and knowledge of staff. The trust has consulted and engaged comprehensively with staff about the recent development of the department and their roles. There were governance, risk management and quality measurement processes in place to enhance patient outcomes. ‘Patient voice’ was seen as important and there were a number of initiatives within the trust designed to ensure that the opinions of patients influenced the delivery of services.

Staff felt that there was good leadership not only in the department but also within the trust. There was an inclusive, learning and supportive culture in the department and staff felt valued and appreciated. The culture in the department supported staff to deliver outstanding patient focussed care.

We had no concerns about safety in the department. We observed that policies and procedures were followed. Safeguarding processes to protect vulnerable adults and children were in place and referrals were made in a timely manner when necessary. There were sufficient medical and nursing staff employed by the department and staffing levels were acceptable. There were some areas where the department was not meeting the trust expected compliance rate for mandatory training. Staff were up to date with annual appraisals.

There were evidence based policies and procedures in place which were easily accessible to staff. These were audited to ensure staff were following relevant clinical pathways. Information about patients such as test results were readily accessible. There was evidence of multi-disciplinary working throughout the department and the department offered a seven-day service. Staff understood their responsibilities in relation to taking consent from patients and the principles of the Mental Capacity Act 2005.

Patients who visited the department had their individual needs met. Interpreters were available and there were facilities available to assist patients with disabilities or specific needs. Pain relief and nutrition and hydration needs of patients were met. The department was meeting the four-hour target and were discharging most patients within three hours of admission. The service was performing better than the England average for a number of other performance measures relating to the flow of patients. Patient complaints were managed in line with the trust’s policy and feedback was given to staff. Lessons were learned and where applicable, practice was changed to minimise the likelihood of recurrence.

Surgery

Outstanding

Updated 5 May 2016

We rated surgery as outstanding because:

There was a clear vision for the service and the new model of care being delivered, with a clear focus on improving the quality of care and people’s experiences. 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 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.

Innovation was welcomed by senior leaders and there was a culture of innovation embraced and promoted amongst staff. There were high levels of staff satisfaction and staff spoke strongly about the supportive and open culture at the trust. Staff were proud to work for the service. Strong and robust governance structures were in place across the directorate and there was a systematic approach to considering risk and quality management. Senior and site level leadership was visible and accessible to staff. Staff spoke very positively about their immediate line managers and senior leaders and a positive culture was evident during the inspection, supported by initiatives such as the ‘shared purpose’ wards and value based recruitment.

Surgery services at this hospital were planned and delivered to meet the needs of local people in a timely way. The service was part of the wider hospital network and incorporated the NSECH emergency care model. This allowed patients access to elective care and emergency support across hospital sites when needed. The service reported waiting times better than NHS averages and had been responsive in analysing, assessing and considering patient risk when identifying where best to care for high risk patients.

There was a strong patient centered culture that patients reflected on when making decisions on choosing to attend Hexham General Hospital for their surgery. All staff we spoke with were highly motivated and offered care that promoted people’s dignity without exception. The service had consistently high patient feedback scores in the national NHS friends and family test and in the local surveys. Patients explained that all staff ‘went the extra mile’ to help them and all patients reported to us that their care was excellent or very good. Patients we spoke with had chosen to travel significant distance to access this service.

Staff made use of evidence based guidance to inform their practice and were encouraged to seek out new evidence-based techniques and technologies to support the delivery of high quality care. This helped Hexham to achieve patient outcomes and audit results that were better than Trust and national averages. This included readmission rates for elective surgery, mobilisation rates following joint replacement, revision rates for hip replacement procedures, and audits of surgical consent.

Hexham General Hospital had a good track record in regard to patient safety. The surgical service had reported no serious incidents or never events and very low incidences of patient harm were recorded at the hospital. Incidents were discussed in staff meetings and staff felt confident to report incidents, and reported that lessons were shared and senior staff were supportive.

Staffing levels were appropriate for the service being delivered and processes were in place to ensure safe staffing levels. Mandatory training compliance targets had not been achieved in all areas at the time of inspection and it was planned that targets would be met. Staff had access to safeguarding, consent and mental capacity training and had good understanding. Handovers were well planned, attended by the multidisciplinary team and managed to ensure that patient information was accurately passed on. A handover process for patient transfers was also in place. There was a comprehensive understanding of patient risk and this was monitored, recorded and assessed appropriately by staff. There was good understanding of the recognition of the deteriorating patient and staff understood the policy for escalation and transfer of patients to the emergency site when required.

Outpatients

Outstanding

Updated 5 May 2016

Overall, we rated Hexham General Hospital outpatients and diagnostic imaging services as outstanding because:

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. 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 were 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.

Waiting times for all types of appointments consistently met national targets. Some specialties had experienced capacity and performance difficulties but these had been well managed and resolved. All appointments were booked within acceptable timescales. Outpatient 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. The department teams recorded concerns and complaints and used patient feedback proactively to prevent recurrence that might affect others. They reviewed and acted on problems quickly and demonstrated an open and transparent outlook with the aim to learn from them and improve patient experience.

Staff respected patients’ privacy, dignity, and confidentiality at all times. Patients told us, and we saw without exception, that staff treated them kindly, and in a consistently caring and compassionate way. Staff spent time with patients and those close to them to give explanations about their care and encouraged them to ask questions. Staff, from volunteers to senior managers regularly went out of their way to provide help and assist patients in all aspects of care. There were a range of services and opportunities to provide emotional support for patients and their families.

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.

Other CQC inspections of services

Community & mental health inspection reports for Hexham General Hospital can be found at Northumbria Healthcare NHS Foundation Trust.