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Wansbeck General Hospital Outstanding

Inspection Summary


Overall summary & rating

Outstanding

Updated 5 May 2016

Wansbeck 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, a limited maternity service which included a pregnancy assessment unit, ante natal clinics and elective gynaecology, end of life care and a range of outpatient and diagnostic imaging services. Wansbeck General Hospital does not provide critical care and children and young people's services. 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 patients pathways in emergency, medical and surgical care and maternity services.

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. Wansbeck General Hospital has 207 beds.

We inspected Wansbeck General Hospital as part of the comprehensive inspection of Northumbria Healthcare NHS Foundation Trust, which included this hospital, Hexham General Hospital, North Tyneside General Hospital, Northumbria Specialist Emergency Care Hospital, and community services. We inspected Wansbeck General Hospital between 10 and 13 November 2015.

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

We rated end of life care, medical and surgical services, and outpatient and diagnostic imaging services as outstanding. Urgent and emergency care and maternity and gynaecology services, we 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.

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

  • 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 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 at the time of inspection, compliance was high.

  • Between April and October 2015 there had been no cases of methicillin resistant staphylococcus aureus (MRSA) at this hospital.

  • In the same time period, the hospital had reported very low numbers of cases of c-difficile and MSSA.

  • 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 proportion of consultants and junior doctors at this hospital was very similar to 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:

In surgical services:

  • The development of the ‘block room’ had resulted in a streamlined approach to the recovery of patients following surgery.

  • Guidelines for oncoplastic breast reduction and guidelines for best practice in reducing surgical site infections had been developed.

  • 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.

In end of life care:

  • The model of end of life care services at this hospital saw that dedicated palliative care beds were operated alongside a specialist palliative in-reach service to general ward areas. This meant that specialist staff worked alongside general staff to deliver effective, coordinated care within a holistic approach.

  • Services worked across both acute and community settings with a strong multi-disciplinary ethos.

  • An Oasis room was available for relatives of patients at the end of life where they could rest or take time to themselves. The room was stocked by volunteers with drinks, snacks and toiletries using funds that were dedicated for this purpose.

  • 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.

  • 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.

  • 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 understanding of spirituality and confidence around assessment.

  • The Palliative Care service had won the Quality Award for 2014 for their commitment to improvement and the excellent patient experience feedback received.

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 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 care centre:

  • Consider circulating guidance to staff about when to stop using the ‘see and treat’ model when the department is busy and revert to the triage model, to ensure patient safety and improve responsiveness.

  • Consider training for reception staff to help identify patients who may need to be brought to the attention of clinical staff more quickly.

  • Consider increasing the number of independent nurse prescribers to enable more flexibility in prescribing of medication in the ECC when there are no doctors available.

In Medical Care services:

  • Ensure that resuscitation equipment is checked consistently, in line with trust procedures, on all medical wards.

  • Ensure that fridge temperatures are checked consistently, in line with trust procedures.

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.

In outpatient’s and diagnostic imaging:

  • 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 the well-led domain rated as requires improvement because:

The service had effective systems in place for reporting, investigating and acting on serious adverse events. We saw that the supply of equipment, particularly in the antenatal clinics, was more than adequate. Medicines were stored and managed carefully and securely. The environment and equipment were clean and ready for use. Staff followed safety guidance for infection prevention and control. Staff planned care and treatment using strict admission criteria to support the assessment of patient risk so that complex births were handled by the consultant led unit at Northumbria Specialist Emergency Hospital (NSECH). Nurse and midwife staffing was appropriate. Medical staffing arrangements were such that they were available to attend as required which could lead to medical assessment and treatment being delayed.

The pregnancy assessment unit and gynaecology services provided effective care in accordance with recommended practice. Staff received the necessary training and assessment of competence so that they could respond appropriately to women’s care and treatment. Midwives had supervision of their practice and opportunities for development.

The individual needs of women were taken into account in planning the level of support throughout pregnancy. Staff respected the privacy and dignity of women and their partners. There were no issues related to the demands on the service or fluctuation of workload. Women using the service could raise a concern and be confident this would be investigated and responded to. Formal complaints were dealt with according to the trust’s policy.

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.

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 the 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. Staff felt valued and were encouraged to contribute to service development. The directorate had a clear vision and business strategy. Governance processes were embedded 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.

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

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 was sufficient equipment but there were gaps in the daily checking of resuscitation equipment and fridge temperatures on some wards. The level of staff completing mandatory training was good and above trust targets. Medicines management was appropriate. There were some nurse staffing vacancies but the trust was recruiting to fill posts. On some wards planned and actual levels were not always consistent. However it was evident that staffing numbers of unqualified staff were increased to supplement the shortages. We were also told that staff were brought from other wards to assist during these periods.

The service participated in national audits and had a robust system of local clinical audits. Information about peoples care and treatment and their outcomes were routinely collected and monitored. Outcomes are positive and meet 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

We rated the emergency care centre at this hospital as good because:

We observed that staff followed policies and procedures including infection control and medicines management. Cleanliness and hygiene were good and the environment was well maintained.

Safeguarding processes to protect vulnerable adults and children were in place and referrals were made in a timely manner when necessary. The department used a ‘See and treat’ model. If the department was busy there were no clear guidelines about when staff should switch from the see and treat model to the triage model.

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 however action plans were place to ensure that this was achieved by April 2016. 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.

The care given to patients by the department was good. Privacy and dignity were maintained and people were dealt with in a kind and compassionate way. Staff ensured that patients received the care and support they needed. Patients and families were involved in decisions about their care and they had emotional support during difficult situations.

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. Most patients were discharged within three hours of admission and four hour waiting time targets were met. The trust 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 policy and feedback was given to staff. Lessons were learned and where applicable, practice was changed to minimise the likelihood of recurrence.

Staff were fully engaged in the future development of the department and the vision and strategy of the trust were embedded in practice.

There were robust 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. Staff were encouraged and supported to be innovative and we saw examples of innovative ways of working within the department.

Surgery

Outstanding

Updated 5 May 2016

We rated surgery as outstanding because:

Senior managers had a clear vision and strategy for the division and identified actions for addressing issues within the division. 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.

The trust had a commitment to a people centred approach delivering high quality care with robust assurance and used for continuous improvement. Staff were encouraged to challenge existing practices, look for improvements and suggest ways to develop and introduce innovative practice. Strong leadership and visibility of senior members was evident throughout the inspection. Staff felt motivated and shared the trust’s vision and values. The trust was within the top 20% of trusts in England based on staff survey results. We saw constructive engagement with staff and managers at all levels. Leadership in the organisation inspired and motivated staff and staff told us repeatedly that they were proud to work for the organisation.

The number of operations cancelled by the trust was consistently below the England average. The trust was meeting the NHS operational target of 92% of patients waiting less than 18 weeks for treatment. Six theatres were open at Wansbeck General Hospital five days a week and also included regular weekend sessions. Innovative practice was demonstrated through the development of the ‘block room’ (improving the recovery of patients following surgery), guidelines for oncoplastic breast reduction and reducing surgical site infections and the development of dedicated bone health clinics. A dedicated team had been set up to contact patients by telephone following discharge.

The services at Wansbeck General Hospital received consistent positive feedback scores and comments from patients through the NHS Friends and Family test, the local ‘2 minutes of your time’ survey, a real-time feedback process and a social media feedback approach managed by the trust Communications and PALS team. We observed patients cared for with dignity, compassion and respect by all staff. Without exception, patients felt involved in their care and valued. All patients spoken to gave positive feedback about relationships with staff. Meeting people’s emotional needs was embedded and documented in the care plans, with well-established and skilled staff providing post discharge support after surgery.

Performance showed a good track record in regard to patient safety. The service had reported no serious incidents or never events at the hospital. We saw governance processes in place to ensure that incidents were discussed, and lessons were learned and communicated to staff in order to improve services.

Skilled, competent staff were available across site and staffing levels were appropriate for the service delivered and recruitment processes were in place to fill vacant posts. Mandatory training at the hospital was attended by all staff groups and overall compliance targets had been achieved.

Patients were treated based on national guidance and the division took part in all the national clinical audits that they were eligible for. Local protocols had been developed for the effective handover of patients to NSECH when needed.

End of life care

Outstanding

Updated 5 May 2016

We rated end of life care as outstanding because:

Leadership, governance and culture of the trust were designed to drive high quality end of life care services using an innovative model of working and effective partnership working. There had been significant investment in palliative and end of life care services and the trust was responsive to addressing the needs of the local population in the development of end of life care services across both acute and community. There was a clear vision, strategy and leadership at all levels of the organisation with a focus on good quality end of life care. 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.

There was a strong person-centred culture and we saw that staff were motivated and inspired to do more through a holistic approach to care and support. Examples included a trust wide emphasis on the assessment of spiritual, cultural and emotional needs and additional support to patients and families around discharge home where services crossed acute and community boundaries to ensure people received the support they needed. Information demonstrated that more patients were dying in their usual residence than there were five years before and we saw clear plans to continue this trend and ensure an emphasis on patients preferred place of care.

We saw evidence of the use of national guidance and appropriate anticipatory prescribing of medicines at the end of life. There was a strong culture of multidisciplinary working across services within the hospital and the community. The use of a dedicated palliative care unit and hospital liaison meant that there was a culture of understanding of palliative and end of life care that was integrated across disciplines and with other services. Patients and their families were involved in care and we saw a number of initiatives in use and embedded to record patient wishes including advance care plans, emergency healthcare plans and treatment escalation plans.

The trust performed in the top ten NHS trusts in England in the 2014 National Cancer Patient Experience Programme national survey, with 95% of respondents rating the care as being excellent or very good. 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.

Outpatients

Outstanding

Updated 5 May 2016

We rated Wansbeck 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 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.

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. 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. Prior to emergency services moving to NSECH in June 2015, the radiology department had developed trauma image reporting, which was swift with an emphasis on “results within minutes” for emergency patients. This was the process that had been adopted at the new NSECH hospital and enabled medical teams to complete assessments and manage risks quickly. A radiographer discharge programme facilitated the discharge of patients having soft tissue injuries directly from radiology by suitably trained radiographers. The departments for outpatients and diagnostic imaging learned from complaints and incidents, and developed systems to stop them happening again. The departments delivered services to respond to patient needs and ensured that departments worked efficiently.

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.

Patients were happy with the care they received and found it to be caring and compassionate. Staff worked within nationally agreed guidance to ensure that patients received the most appropriate care and treatment. Trust policies protected patients from the risk of harm by making sure they met any individual support needs. Staff demonstrated understanding of these policies and followed them.

Other CQC inspections of services

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