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North Tyneside General Hospital Outstanding

This service was previously managed by a different provider - see old profile

Inspection Summary


Overall summary & rating

Outstanding

Updated 5 May 2016

North Tyneside 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 with no obstetric intervention maternity services, mental health care for older people, end of life care and a range of outpatient and diagnostic imaging services. North Tyneside General Hospital does not provide critical care and children and young people 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 patient 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. North Tyneside General Hospital has 307 beds.

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

Overall, we rated North Tyneside General Hospital as outstanding. We rated it outstanding for being caring, responsive and well-led, and good in providing safe and effective care.

We rated medical care, surgery, outpatient and diagnostic imaging services and end of life services as outstanding. Urgent and emergency services, maternity and gynaecology and the service for older people with mental health problems 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.
  • 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 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 September 2015 there had been no cases of methicillin resistant staphylococcus aureus (MRSA) at this trust and five cases of c-difficile. No cases were reported in surgery 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 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.
  • 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 medical care:

  • The joint working by the falls team, which has raised the profile of falls and engaged staff, patients and their relatives in trying to reduce falls.
  • The role of nutritional assistants and the focus on the nutritional needs of patients which had improved the patient experience.
  • The ‘real time’ data collected on patient experience to assess how each ward is performing.
  • The inclusion of a psychological assessment for patients who require isolation for infection prevention reasons.
  • The development of comfort care packs for relatives.

In surgery services:

  • North Tyneside General Hospital is rated in the top five hospitals in the country for the treatment of emergency hip fractures.
  • North Tyneside General Hospital was recently recognised by the General Medical Council as the best in the country for the quality of training for orthopaedic surgeons of the future.
  • The service had developed a day case mastectomy service. This was proposed to save 201 bed days each year. Average length of stay had also reduced to between 2.7 and 4.2 days (depending on patient risk at the time of surgery). This compared to a national average of around 4.8 days.

In end of life care:

  • The model of end of life care services 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.
  • 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.
  • 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 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 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.
  • 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.

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 maternity and gynaecology:

  • 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.
  • Consider the provision of separate accommodation for women undergoing pregnancy loss and termination of pregnancy.

In outpatient’s and diagnostic imaging:

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

In wards for older people with mental health problems:

  • The provider should ensure that all steps are taken to maintain the safety, privacy and dignity of patients on mixed sex wards until the wards move into new same sex accommodation.
  • The provider should ensure that a programme of formal supervision is rolled out following completion of a pilot project.
  • The provider should ensure that ligature risk assessments are comprehensive and consistent across sites.
  • The provider should look to develop service specific key performance indicators to aid performance monitoring.

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

We rated obstetrics and gynaecology services as good overall with the well-led domain rated as requires improvement because:

There were systems for reporting, investigating and acting on adverse events. The service routinely collected and reviewed standards and safety and shared it with staff. Medicines were stored correctly and checks on emergency equipment were in line with trust policy and were complete. Staff followed safety guidance for infection prevention and control. We found clear safeguarding processes in place; staff knew their responsibilities in reporting and monitoring safeguarding concerns. There were plans in place to ensure staff attended mandatory training. There was no medical staff present on the pregnancy assessment unit, however, support was provided from the antenatal clinic and staff had open access to the medical team based at NSECH.

We found the service used evidence-based guidelines to determine the care and treatment they provided. We reviewed the annual audit plan.Staff were involved in regular local audit. We found staff had the correct skills, knowledge and experience to do their role, however, we found that training had not been provided to support staff on ward 7when gynaecology was relocated. Training ensured medical and midwifery staff could carry out their roles effectively. Competencies and professional development were maintained through supervision.

We found patients were respected and valued. Feedback from patients was positive about the care they experienced and were fully informed about what to expect. We observed patient care in the pregnancy assessment unit and antenatal clinic staff were supportive and compassionate.

The service had gone through a significant reconfiguration to a new model of care. Services were maintained at North Tyneside to support the local population. We found there were robust policies in place to ensure that patients were seen at the right place at the right time. We were informed of occasions where women experiencing miscarriage and termination of pregnancy were next to each other. The fertility control pathway provided an efficient and effective service to women in response to their respective needs, and was provided with choice in how they would like to dispose of pregnancy remains. Women using the service could raise a concern and be confident that concerns and complaints would be investigated and responded to.

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. 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.

Medical care (including older people’s care)

Outstanding

Updated 5 May 2016

We rated medical care as outstanding because:

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. Staff were committed to providing high quality patient focused care and took the time to meet the individual needs of patients and we were given examples of where staff had gone ‘the extra mile’ to make patients hospital stay a positive experience.

The medical services were managed by an experienced and cohesive team who demonstrated a clear understanding of the challenges of providing high quality and safe care. The leadership team had a shared purpose to ensure that this was delivered. 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. Governance processes were embedded which allowed clear identification and monitoring of risk and we saw evidence of related progress and action plans as well as ongoing review of risks.

There were robust systems in place for reporting incidents and for feeding back learning from these. The trust was a high reporter of incidents. All staff demonstrated a good understanding of the duty of candour and safeguarding. There were clear guidelines in place to manage deteriorating patients and staff felt these worked well when they had to be implemented. The wards we visited were visibly clean and tidy and we observed good practice in relation to infection prevention. Nursing and medical staffing was at a safe level and following a safer staffing audit looking at patient acuity, we were assured ward establishments were being reviewed. We observed and found evidence of good practice in relation to medicines management and documentation was comprehensive and fully completed.

Policies were up to date and were evidence based. Patients were provided with pain relief as required and the nutritional needs of patients were viewed as a priority. The role of nutritional assistants had a positive impact on meeting nutritional needs of patients. We observed strong multidisciplinary team working to provide holistic care for patients which was confirmed by feedback from different staff groups.

The opening of the new hospital and a different model of care meant patients were cared for on appropriate wards with a clear plan in place. There was ongoing engagement with external stakeholders to continue to develop and promote this model of care. There were good systems in place to manage patient flow and if patients condition deteriorated. Discharges were MDT focused to ensure all the needs of patients were met and discharges were safe. There was an open culture in relation to complaints and they were seen as a way of learning and improving services.

Urgent and emergency services (A&E)

Good

Updated 5 May 2016

We rated the emergency care centre as good because:

We observed that staff followed policies and procedures. 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.

The care given to patients by the department was very 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’s 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 services as outstanding because:

There were consistently 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.

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.

Senior leaders welcomed innovation and there was a continuing history of innovation being embraced and promoted amongst staff. 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. Comprehensive leadership strategies were in place to promote and ensure delivery of the desired culture. This included pilot initiatives such as the ‘shared purpose’ wards and value based recruitment. The surgical services at this hospital used various innovative ways to gather feedback from patients. There was evidence of innovative practice to improve patient outcomes.

Surgery services at NTGH 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 at North Tyneside Hospital and emergency support 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. Staff understood the different needs of individual patients and were able to take a tailored approach to meet their needs. This included dementia pain training, access to bariatric equipment, and an understanding of the support needed for some patients with learning disabilities. This included individual experiences for patients with learning disabilities to ensure a positive patient experience. Low levels of complaints had been received. When a complaint was made they were actively reviewed and taken seriously.Action was taken as a result with improvements to the service.

The surgical services in this North Tyneside General Hospital received consistently positive feedback scores and comments through the NHS Friends and Family test. There were a number of approaches taken at the trust to gather feedback from people, 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. All patients we spoke with in wards 7 and 8 and reported staff were friendly, professional and caring. Staff offered patients positive encouragement and challenge when mobilising following surgery. Patients told us this support and encouragement struck the right balance between encouraging them while respecting their limitations. We observed examples of staff compassion with patients and caring communication amongst staff and patients. Comments were consistently positive without exception during our discussions with patients in both surgical wards.

Performance over time showed a good track record with regard to patient safety. Staff were confident in the reporting of incidents and felt supported in doing so. In order to improve services, we saw governance processes were in place to ensure incidents were discussed, and lessons learned and communicated to staff. Staffing levels were appropriate for the service being delivered and recruitment was underway to fill additional posts. Planning for staffing had taken into account the strategic changes in services and the new model of care in Northumbria NHS Foundation Trust. There was a comprehensive understanding of patient risk and staff monitored, recorded and assessed this appropriately. The hospital environment was clean. Medicines were stored and administered safely. Records were appropriate, well completed and stored appropriately. Compliance with wider mandatory training was good and was on target to be completed by the trust’s year end.

Staff used 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. Appraisals were in place with rates above the trust target levels. Patients pain and nutritional needs were appropriately monitored and met by staff. Staff also had up to date training and sound knowledge of consent and mental capacity issues.

End of life care

Outstanding

Updated 5 May 2016

We rated end of life care as outstanding because:

We found that the trust was providing 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 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. 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 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 that 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.

Feedback from patients and their relatives was positive about the way staff treated them with one person telling us that staff really care and go above and beyond what they would expect. There was a strong person-centred culture within the hospital and staff consistently appeared to be committed to providing compassionate care and promoting people’s dignity. 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.

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 North Tyneside 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.

Waiting times and cancellations were minimal and managed appropriately. Diagnostic image 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. A radiographer discharge programme facilitated the discharge of patients having soft tissue injuries directly from radiology by suitably trained radiographers. 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. 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.

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 North Tyneside General Hospital can be found at Northumbria Healthcare NHS Foundation Trust.