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Queen Elizabeth Hospital Outstanding

Inspection Summary


Overall summary & rating

Outstanding

Updated 14 August 2019

  • Staff were open and transparent, and fully committed to reporting incidents and near misses. Learning was based on a thorough analysis and investigation when things went wrong.
  • Patient’s care and treatment was planned and delivered in line with current evidence-based guidance, standards, best practice and legislation. This was monitored to ensure consistency of practice.
  • Feedback from patients who used the service, and those who were close to them were positive about the way staff treated patients. Staff cared for patients with compassion.
  • In surgery, there were innovative approaches to providing integrated person-centred pathways of care that involved other service providers, particularly for patients with multiple and complex needs.
  • Staff were proud of the organisation as a place to work and spoke highly of the culture.
  • There were processes in place to identify, understand, monitor and address current and future risks. The trust had clear governance processes in place to drive patient safety forward. The service proactively engaged and involved all staff.

However:

  • We found the medicine service did not always provide patients with a safe environment for the safe use and storage of substances hazardous to health. Across four wards, on different days of our inspection, we found examples of unimpeded access for patients to substances hazardous to health.
  • In the previous inspection we found that staff did not always check that resuscitation equipment was ready for use. At this inspection, while most medical care wards we visited had successfully checked their resuscitation equipment in accord with a new process introduced by the trust, two wards had not done so, and on one of these wards this applied to both resuscitation trolleys, which had only had a partial weekly check.
  • Staff in medical care (including older person’s care) did not reach the trust’s target for mandatory training in key skills or appraisals. But the trust did have systems in place to ensure staff completed mandatory training and appraisals. The trust told us compliance with its targets would improve as the year progressed.
Inspection areas

Safe

Good

Updated 14 August 2019

Effective

Good

Updated 14 August 2019

Caring

Outstanding

Updated 14 August 2019

Responsive

Good

Updated 14 August 2019

Well-led

Outstanding

Updated 14 August 2019

Checks on specific services

Medical care (including older people’s care)

Good

Updated 14 August 2019

We previously inspected medicine services at this site in 2015 and overall rated them as good with good in all domains, being safe, effective, caring, responsive, and well-led.

At this inspection we rated the service as requires improvement in the safe domain but good in all other domains leading to an overall rating of good.

  • We found the medicine service did not always provide patients with a safe environment for the safe use and storage of substances hazardous to health. Across four wards, on different days of our inspection, we found examples of unimpeded access for patients to substances hazardous to health.
  • In the previous inspection we found that staff did not always check that resuscitation equipment was ready for use. At this inspection, while most wards we visited had successfully checked their resuscitation equipment in accord with a new process introduced by the trust, two wards had not done so, and on one of these wards this applied to both resuscitation trolleys, which had only had a partial weekly check.
  • Staff did not reach the trust’s target for mandatory training in key skills or appraisals. But the trust did have systems in place to ensure staff completed mandatory training and appraisals. The trust told us compliance with its targets would improve as the year progressed.

However:

  • The service did control infection risk well. The ward environment was visibly clean with good infection control in all areas visited. Subject to the above, the environment was clutter free, wheelchair accessible and with enough equipment for staff to perform their role.
  • Staff had access to records which, while not locked when not in use, were stored within nurses’ stations. At the last inspection we found fridges temperatures were not always checked but at this inspection we found this was not the case. At this inspection we found medicines, including intravenous fluids, were stored and managed safely. Staff knew how to report incidents. Tools such as the safety thermometer were used to keep patients safe.
  • The service provided care and treatment based on national guidance. The services were effective because processes were in place to ensure that guidance used by staff complied with national guidance, such as that issued by National Institute for Health and Care Excellence.
  • Patients’ food, hydration and pain management needs were met. The service used audits within the specialities we visited to improve patient outcomes. Staff received training to assess if they were competent and received annual appraisals. Staff worked effectively as a multi-disciplinary team and had good knowledge about consent and mental capacity.
  • Staff cared for patients with compassion. The services were caring, with response rates in the friends and family test better than the England average. The inpatient score for recommending the service to friends and family from December 2017 to November 2018 was above 90%.
  • Staff supported the emotional needs of patients and could, for example, arrange psychological support. Staff tried to understand and involve patients and their carers where it was safe to do so, such as in family meetings or with feeding.
  • The trust planned and provided services in a way that met the needs of local people. The services were responsive, with a process in place at hospital to trust level to plan services. Wards had link nurses to champion the needs of patients with additional needs. Wards used various approaches to respond to challenges with access and flow.
  • Managers at all levels in the trust had the right skills and abilities to run a service providing high-quality sustainable care. The senior leadership team running the specialities worked well together and staff reported they were visible, approachable, and responsive and worked as a cohesive team to promote a positive culture that put patient safety first.
  • The trust had clear governance processes in place to drive patient safety forward; these were implemented and monitored at business unit level.
  • Staff and the public were engaged through meetings and surveys. The specialities we visited had access to dashboards to help monitor patient sensitive indicators and act when necessary. The specialities we visited all had examples of innovation, learning and continuous improvement.

Services for children & young people

Good

Updated 24 February 2016

Overall, services for children and young people were good because:

Children’s services monitored safety, risk and cleanliness. The levels of nursing and medical staff were adequate to meet the needs of children and young people.

Not all medical and nursing staff had undertaken Paediatric Immediate Life Support and Advanced Paediatric Life Support training although there was an action plan in place to address this.

Children’s services had made improvements to care and treatment where the need had been identified using programmes of assessment or in response to national guidelines.

Children, young people and parents told us they received compassionate care with good emotional support. Parents felt fully informed and involved in decisions about their child’s treatment and care. There was a strong person-centred culture and staff worked in partnership with patients and their families.

The service looked after children and young people’s needs and was well led. The service had a clear vision and was in the process of developing a strategy to support this.

A positive and proactive management team who worked together led the service. The service had introduced innovative improvements with the aim of improving the delivery of care for children and families.

Critical care

Good

Updated 24 February 2016

We rated the critical care department as good and outstanding for being caring because:

Details of incidents or harm or risk of harm and the lessons learned from investigating them were shared among staff and action was taken to prevent or minimise the occurrence of similar incidents.

The department was clean but there were gaps in daily recording to show if sinks and showers were flushed to avoid a build-up of waterborne bacteria; a known infection hazard. The department managed medicines.

Staff attended induction training to learn about the organisation and mandatory training to ensure they had the skills needed for their jobs.

The Core Standards for Intensive Care Units 2013 were followed to determine the number of nursing staff needed for each patient. The consultant-to-patient ratio was in accordance with national recommendations.

The critical care department provided rehabilitation after a critical illness (RaCI), which demonstrated an effective pathway for patients’ transition from the critical care department to ward-based care and support following discharge.

Data from the Intensive Care National Research Centre (ICNARC) between January 2015 and March 2015 showed that the unit was within statistically acceptable limits for hospital mortality and within the limits for unplanned re-admission within 48 hours when compared to national and peer average.

Staff respected patients’ privacy and dignity and treated them with understanding and compassion. Patients and relatives spoke highly about the care they had received. Services were planned and delivered in a way that met the needs of the local population. The importance of flexibility, choice and continuity of care was reflected in the services.

Critical care services were well led. A critical care strategy document outlined the services vision. Staff spoke positively about the culture and the service they provided for patients. Quality and good patient experience and care were seen as a priority and everyone’s responsibility. There was a strong cohesive team approach and a low number of complaints.

End of life care

Good

Updated 24 February 2016

Overall we rated end of life care as good because:

The hospital specialist palliative care team provided face-to-face support five days a week, with the hospice providing out-of-hours cover. There was visible clinical leadership resulting in a well-developed, strong, motivated team. The teams worked well together to ensure that end of life policies were based on individual need and that patients were fully involved in every part of the end of life pathway.

Palliative care link nurses championed good end of life care on the wards. Ward staff spoke about the importance of making sure they understood the preference of patients and relatives in the last stage of life.

Staff throughout the hospital knew how to make appropriate referrals. The specialist palliative care team assessed patients in a timely manner, meeting individual needs.

Medicines and equipment was provided in line with guidelines for end of life care. There were infection, prevention and control measures.

Staff cared for patients with dignity, respect and compassion. There were facilities to support different patient cultures and religions. The chaplaincy and bereavement service supported families’ emotional needs when people were at the end of life, and continued to provide support afterwards.

Maternity and gynaecology

Outstanding

Updated 24 February 2016

We rated maternity and gynaecology services as outstanding because:

The service provided safe and effective care in accordance with national guidance. Staff continually monitored outcomes for women and took action where improvements were necessary.

Resources, including equipment and staffing, were sufficient to meet women’s needs. Staff had the correct skills, knowledge and experience to do their job.

Overwhelmingly we received feedback that care was excellent and compassionate. Women reported being treated with respect and dignity and having their privacy respected at all times. Women told us that nothing was too much trouble for staff. Staff demonstrated a strong, visible person centred culture throughout the service. Staff were highly motivated and passionate about giving exceptionally high standards of care. The service took account of complaints and concerns and took action to improve the quality of care.

A highly committed, enthusiastic team, each sharing a passion and responsibility for delivering a high-quality service, led the maternity and gynaecology services. Governance arrangements at all levels, enabled managers to identify and monitor risks effectively, and review progress on action plans. Engagement with patients and staff was strong. There was evidence of innovation and a proactive approach to managing performance improvement.

Outpatients and diagnostic imaging

Good

Updated 24 February 2016

Overall outpatient and diagnostic imaging were rated as good with responsive requiring improvement because:

Overall, the trust delivered services to respond to patient needs and ensure that departments worked efficiently. However, some areas that required improvement included meeting national targets for urgent appointment waiting times, the percentage of clinics cancelled by the service and recording of actions taken following discussions.

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.

Communication was effective between senior management and staff, and there was good overall leadership of staff to provide good patient outcomes. The outpatients department had well organised systems for managing clinics. The department was well led, proactive and all staff worked as a team towards continuous improvement for good patient care.

Surgery

Outstanding

Updated 14 August 2019

Our rating of this service improved. We rated it as outstanding because:

  • All staff were open and transparent, and fully committed to reporting incidents and near misses. The level and quality of incident reporting showed the levels of harm and near misses, which ensured a robust picture of quality.
  • Learning was based on a thorough analysis and investigation when things went wrong.
  • There was a comprehensive ‘safety management system’, which took account of current best practice models.
  • Safeguarding vulnerable adults, children and young patients was given sufficient priority. Staff took a proactive approach to safeguarding. They took steps to prevent abuse from occurring, responded appropriately to any signs or allegations of abuse and worked effectively with others to implement protection plans.
  • Staffing levels and skill mix were planned, always implemented and reviewed to keep patients safe. Any staff shortages were responded to quickly and adequately. There were effective handovers at shift changes to ensure staff could manage risks to patients who used the service.
  • Risks to patients who used services were assessed, monitored and managed on a day-to-day basis. Staff recognised and responded appropriately to changes in risks to patients who used services.
  • Patient’s care and treatment was planned and delivered in line with current evidence-based guidance, standards, best practice and legislation. This was monitored to ensure consistency of practice.
  • Patients had comprehensive assessments of their needs, which included consideration of clinical needs, mental health, physical health and wellbeing, and nutrition and hydration needs.
  • Information about patients’ care and treatment, and their outcomes, was routinely collected and monitored. Outcomes for patients who used services were positive and met expectations.
  • There was participation in relevant local and national audits, including clinical audits and other monitoring activities such as reviews of services, benchmarking, peer review and service accreditation.
  • Feedback from patients who used the service, and those who were close to them were positive about the way staff treated patients. Patients were treated with dignity, respect and kindness during interactions with staff and relationships with staff were positive. Patients felt supported.
  • Staff respond compassionately when patients needed help and supported them to meet their basic personal needs as and when required.
  • There were innovative approaches to providing integrated person-centred pathways of care that involved other service providers, particularly for patients with multiple and complex needs.
  • It was easy for patients to complain or raise a concern and they were treated compassionately when they did so. There was openness and transparency in how complaints were dealt with.
  • Facilities and premises were appropriate for the services being delivered.
  • Waiting times, delays and cancellations were minimal and managed appropriately. Patients were kept informed of any disruption to their care or treatment.
  • There were high levels of staff satisfaction across all equality groups. Staff were proud of the organisation as a place to work and spoke highly of the culture.
  • There was an effective and comprehensive process in place to identify, understand, monitor and address current and future risks. Performance issues were escalated to the relevant committees and the board through clear structures and processes. Clinical and internal audit processes functioned well and had a positive impact in relation to quality governance, with clear evidence of action to resolve concerns.
  • Candour, openness, honesty and transparency were the norm.
  • The service proactively engaged and involved all staff and ensured that the voices of all staff were heard and acted on. The leadership actively promoted staff empowerment to drive improvement and a culture where the benefit of raising concerns was valued.
  • Service developments and efficiency changes were developed and assessed with input from clinicians to understand their impact on the quality of care. Financial sustainability was monitored effectively.

Urgent and emergency services

Good

Updated 24 February 2016

Overall, we rated the Emergency Care Centre as good because:

Serious incidents were investigated and lessons learnt and shared with staff.

The service had challenges in recruiting medical staff due to national shortages and was actively recruiting to fill vacancies. One consultant had been appointed and five emergency nurse practitioners were in post to support doctors in the department. The service did not use an acuity tool to ensure the department had the required registered nurses on duty but there were processes to escalate staffing concerns when staffing dropped below recommended levels.

Staff used good infection prevention and control practices. Equipment was clean and maintained. Staff managed medicines effectively. Patient Group Directives were all within review although some paper copies held in clinical areas were older versions. The department had systems to respond to emergencies and deterioration in patients’ health or concerns for their safety.

Staff based their care on clinical guidelines and pathways. Electronic copies of these were in-date however some paper copies of pathway documents were not in-date or showed when practice should be reviewed. The emergency care centre took part in national and local audits, to assess the outcomes of patients.

Patients and relatives were treated with dignity, respect and compassion.

There were systems to facilitate the flow of patients through the department. The department was achieving the national target of 95% of patients being seen within four hours.

The service ensured that patient’s individual needs were met. It responded to complaints but this had not always been within the trust target of 25 days. There was evidence of learning from complaints.

There was strong leadership and management across the service. Staff reported an open and supportive culture, with good relationships across the teams.

Other CQC inspections of services

Community & mental health inspection reports for Queen Elizabeth Hospital can be found at Gateshead Health NHS Foundation Trust.