Nuffield Health Newcastle-upon-Tyne Hospital

Nuffield Health Newcastle upon Tyne Hospital was inspected as part of our planned inspection programme. This was a comprehensive inspection and we looked at the two core services provided by the hospital: surgery, outpatients and diagnostic imaging. The announced inspection was carried out on 24 and 25 May 2016 and an unannounced inspection on 7 June 2016.

The hospital contracted services for MRI and CT scanning and these services did not form part of this inspection report.

The Nuffield Health Newcastle upon Tyne Hospital was rated as good overall for being safe, effective, caring, responsive and well led.

Are services safe at this hospital/service

Overall we rated safe as good because:

• Incidents, accidents and near misses were recorded and investigated appropriately. Incidents were discussed during departmental meetings and at handover, so shared learning could take place. There was a Being Open and Duty of Candour policy. Staff were familiar with the process for Duty of Candour. We reviewed two Root Cause Analysis incident investigation reports, which showed Duty of Candour and explained the care and delivery problems, contributory factors and lessons learned.
• Risk assessments were completed at each stage of the patient journey from admission to discharge, with an early warning scoring system used for the management of deteriorating patients. The Five Steps to Safer Surgery checklist was completed and monitored appropriately. There was a clear procedure in the event of a major haemorrhage and obtaining blood components in such an emergency.
• The services reported no safeguarding concerns during 2015. The hospital matron was the designated lead for safeguarding and had completed level three safeguarding training. Staff were aware of their roles and responsibilities for safeguarding and could describe what types of concerns they would report and the system for doing so.
• There were processes to ensure safe nurse staffing levels. The hospital followed national staffing guidance such as the National Quality Board 2013 as a basis to provide safe and efficient rotas. All departments were appropriately staffed. Staff were flexible in working patterns to meet the needs of the service and patient requests. Staff turnover and sickness rates were low.
• Two resident medical officers (RMO) on duty were advanced life support trained and available for assistance 24 hours a day seven days a week. All patients were admitted under a named consultant who had clinical responsibility for their patient during their entire stay. There was a named anaesthetist responsible for the patient along with their named surgeon. However, it was identified that some anaesthetists left the recovery area before they should and although the patient was awake and well, they did not wait until the patient left recovery, which was not best practice.

Are services effective at this hospital/service

Overall we rated effective as good because:

• Patients received care and treatment in line with national guidelines such as the National Institute for Health and Care Excellence (NICE) and Royal Colleges. The hospital participated in national audit programmes including performance related outcome measures (PROMS) and the National Joint Registry. Results showed patient outcomes were within expected levels when compared to national averages.
• The rate of unplanned readmissions and unplanned patient transfers to other hospitals was within expected levels when compared to other independent hospitals.
• Patients were consented in line with Department of Health and hospital policy guidelines. There were systems to ensure a ‘cooling off’ period of two weeks for patients undergoing cosmetic surgery. Staff had received Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) training. There was access to an Independent Mental Capacity Advocate when best interest decisions were required.
• The Medical Advisory Committee (MAC) monitored compliance with practicing privileges and there was evidence of action taken by the MAC and executive director when competence issues arose.

Are services caring at this hospital/service

Overall we rated caring as good because:

• We observed patients being treated with compassion, dignity and respect throughout our inspection. Staff were courteous and helpful in all roles. All staff we met during inspection were approachable and friendly.
• All patients we spoke with told us they fully understood why they were attending the hospital and had been involved in discussions about their care and treatment.
• Results from the Friends and Family test showed 99% of patients attending for surgery were happy with the service they had received. 100% of patients attending outpatients would be extremely likely to recommend the service to friends and family.
• The in-patient led assessments of the care environment (PLACE) scores showed 98% for privacy and dignity.
• Patients were given appropriate and timely support and information to cope emotionally with their care, treatment or condition. All nurses were trained in counselling. Patients receiving cosmetic, bariatric or breast cancer treatment could receive support from a psychologist.

Are services responsive at this hospital/service

Overall we rated responsive as good because:

• There were effective arrangements for planning and booking of surgical activity through contractual agreements with clinical commissioning groups. Private patients did not receive priority over NHS patients and staff confirmed there was no difference in the way staff treated patients.
• Patients admitted to Nuffield Health Newcastle were assessed for admission suitability by their consultant using selected risk criteria in line with local and national guidelines. This meant that the majority of patients treated at the hospital were considered as ‘low risk’. There was a service level agreement with the local NHS hospital trust for the urgent transfer of patients who required a higher level of care.
• The hospital had four dementia champions. The hospital dementia rating in the PLACE audit was slightly lower than the England average (77% compared to 81%). This was due to some shortfalls in dementia friendly environmental indicators such as signage and flooring. The hospital were reviewing these findings to see what reasonable adjustments could be made to the environment to improve care for these patients. Staff were trained in dementia care and in the use of ‘This is me’ documentation for patients with learning disabilities.
• The hospital was consistently better than the national referral to treatment (RTT) waiting time target of 92% for incomplete admitted patients beginning treatment within 18 weeks of referral throughout 2015.
• In 2015, the turnaround time audit in diagnostic imaging confirmed 97% of all diagnostic imaging was reported within the five-day benchmark.
• Pathology services recorded performance and turnaround times against Nuffield benchmarking and national accreditation standards. In March 2016, routine turnaround times for selected pathology tests performed in the hospital showed 98% and 93% for standard biochemistry and haematology specimens accordingly. Overall, the hospital reported 94% compliance on turnaround times for all selected tests.
• The senior management team (SMT) discussed complaints on a weekly basis. Information was shared through the clinical heads of department, integrated governance and MAC meetings. Heads of department provided feedback to staff on outcomes and lessons learned from complaints. Unresolved complaints for private patients were past to the Independent Sector Complaints Adjudication Service (ICAS) or Parliamentary Health Service Ombudsmen for NHS patients. There were no complaints received since December 2015.

Are services well-led at this hospital/service

Overall we rated well-led as good because:

• There was a clear vision and strategy for the hospital, which staff understood.
• The hospital had an integrated governance framework to support the delivery of clinical excellence and patient satisfaction. We reviewed hospital board, heads of department, MAC and governance group minutes. All considered key governance factors such as safety, quality, performance and finances.
• There were various assurance systems and service measures to monitor compliance and performance. The hospital produced monthly quality and safety dashboard data. These included indicators covering safety thermometer variables, readmission rates, patient satisfaction data and departmental key performance indicators.
• The hospital manager through the MAC and human resources ensured any consultant seeking practising privileges had appropriate and valid professional indemnity insurance in accordance with the Indemnity Arrangements Order 2014. We looked at three files for the most recent consultant appointments all appropriate checks were in place.
• The hospital requested sight of relevant appraisal documentation from the consultant’s main employing organisation about performance against national standards. The hospital completed its own internal appraisal for sharing with the primary NHS trust appraiser. However, the information flow between the hospital and NHS trust particularly around scope of practice was currently based on a consultant’s self-declaration rather than a formal process and this area could be strengthened.
• The roles and responsibilities of the MAC were well defined and there was good engagement in governance oversight, particularly around reviewing practising privileges and advising on consultant performance.
• The hospital was prepared to meet the Fit and Proper Persons Requirement (FPPR) (Regulation 5 of the Health and Social Care Act (Regulated Activities) Regulations 2014). This regulation ensures that directors are fit and proper to carry out this important role. We looked at three employment files, which were completed in line with the FPPR regulations. All relevant pre-employment checks were evident such as identification, written references (and verbal in one case), checking of qualifications (Association of Chartered Certified Accountants for finance, Nursing and Midwifery Council, Disclosure and Barring Service and Occupational Health clearance).
• Staff were confident that leaders had the skills, knowledge, experience and integrity that they needed to manage the organisation. This included skills such as capacity, capability, and experience to lead effectively. There was an open and honest culture, which was reinforced through the hospitals’ values and behaviours.
• There were processes to monitor quality and sustainability. Although there were key financial targets to meet there was no evidence that this affected patient safety.

Our key findings were as follows:

• There were processes for the effective control and prevention of infection. There were no hospital-acquired infections during 2014/2015. All areas were visibly clean. There was however a lack of storage facilities in theatres and some wards. Staff on the ward showed us their concerns about the lack of storage. Storage cupboards were organised and tidy but full to capacity.
• Medical and nurse staffing levels were adequate on the ward, theatres, outpatients and diagnostic services. Staffing establishments and skill mix were reviewed regularly and levels increased to meet patient needs where required.
• There were no expected or unexpected deaths during 2014/2015.
• Records were well maintained and documents were completed to a good standard including completion of patient risk assessments.
• Staff understood their responsibilities to raise concerns and record patient safety incidents and near misses. There was evidence of a culture of learning and service improvement.
• Processes were in place to ensure patients nutrition and hydration was effectively managed prior to and following surgery. Access to dietician input was available.
• There was sufficient equipment to ensure staff could carry out their duties. There were systems for monitoring and maintaining equipment.
• Patients were treated with respect, dignity and compassion. Patients described positive experiences at the hospital.
• There were systems for the effective management of staff, which included an annual appraisal. All doctors were appropriately assessed to ensure they had the skills to undertake surgical procedures. There were no whistleblowing concerns.
• Clinic appointment times were managed around patient need. Waiting times and reporting of diagnostic and pathology requests met the required national standards.
• Senior and departmental leadership at the hospital was good. Leaders were aware of their responsibilities to promote patient and staff safety and wellbeing. Leaders were visible and there was a culture, which encouraged candour, openness and honesty.
• Integrated governance arrangements enabled the effective identification and monitoring of risks and action was taken to improve performance. Progress on achieving improvements were reported and measured through the relevant management committees with oversight and scrutiny from the provider’s quality governance committees with ultimate responsibility resting with the group chief executive and board.

We saw several areas of outstanding practice including:

• At pre-assessment, the provider had access to information held by community services, including GPs. GPs were asked for faxed summary sheets which provided the hospital with details of the patient’s medical history and medications. This meant that hospital staff could access up-to-date information about patients, for example, details of their current medicines.
• The development of breast services to include areola micropigmentation had brought about positive outcomes for patients. Local referrers recognised this and the service had been extended to reduce NHS waiting times.

• In oncology outpatients, the lead nurse adapted a regional network policy for the benefit of patients receiving chemotherapy who may require telephone advice and triage (assessment of clinical need) out-of-hours.

• Departmental initiatives to support children attending outpatients or diagnostic imaging were innovative with infection prevention education and try at home ‘role-play’ exercises to reduce anxiety and distress.
• The hospital worked closely with the local Jehovah witness hospital liaison group, who provided staff training, information leaflets such as what to do prior to surgery and alternatives to blood transfusion.

However, there were also areas of where the provider needs to make improvements.

The provider should:

• Ensure that processes for evidencing changes to a consultant’s scope of practice are strengthened between the independent hospital and NHS trust rather than solely relying on a clinician’s self-declaration.
• Ensure that staff follow best practice guidance post operatively (for example, anaesthetists to wait until a patient leaves the recovery area even though the patient maybe awake and well).
• Continue to address the storage issues in theatres and on some wards.
• Continue to improve the environment where reasonable to ensure it is appropriate for patients with dementia.
• Review the room risk assessments in radiology, which were generic and lacked specific detail.
• Local written procedures in radiology should clarify what annotation is required by operators and practitioners to satisfy correct safety checks have been made.
• The hospital should ensure there is a robust x-ray equipment capital replacement plan to ensure future reliability and quality.
• Ensure a clinical record of every attendance is kept in a patient record on site.
• Consider the provision of a disabled access toilet in diagnostic imaging.
• Consider putting a formal process in place to support those patients with learning difficulties or special needs.
• Revisit the patient journey in outpatients regarding confidentiality at reception desks, conflicting signage in outpatients and the Jesmond Clinic.
• Progress refurbishment plans for the replacement of material covered chairs to alternatives, which can be easily cleaned.

Professor Sir Mike Richards

Chief Inspector of Hospitals