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Inspection Summary


Overall summary & rating

Good

Updated 24 February 2016

Queen Elizabeth Hospital is the acute hospital forming part of Gateshead Health NHS Foundation Trust. It provides a range of services including medical, surgical, maternity and gynaecology and services for children and young people, end of life and critical care. It has approximately 580 beds. The hospital also provides emergency and urgent care, outpatients and diagnostic imaging.

We inspected Queen Elizabeth Hospital as part of the comprehensive inspection of the Foundation Trust from 29 September to 2 October 2015 and undertook an unannounced inspection on 23 October 2015.

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

Our key findings were as follows:

  • The majority of areas inspected were clean; however, we did identify some infection control issues in the critical care unit and the waste disposal unit.

  • Rates of infection were within an expected range for the size of the trust.

  • Patients were able to access suitable nutrition and hydration, including special diets, and they reported that, overall, they were content with the quality and quantity of food.

  • There were processes for using and monitoring evidence-based guidelines and standards to meet patients’ care needs. Although policies and care pathways held electronically on the trust systems were in-date some paper copies held in ECC and SCBU were out of date or had no review date.

  • The trust promoted a positive incident reporting culture. Processes were in place for being open and honest when things went wrong and patients given an apology and explanation when incidents occurred.

  • The trust was not meeting all its waiting time targets; the national target for two week cancer waiting times had not been met for a number of tumour sites for four consecutive quarters. This was identified by the trust as a governance concern.

  • Systems and processes on some wards for the storage of medicine and the checking of resuscitation equipment did not comply with trust policy and guidance.

  • Nurse staffing was maintained at safe levels in most areas. However, there were occasions where staff had asked for additional support to provide ‘special’ nursing care (individual attention) to meet the physical and mental health needs of patients and shifts had not been covered. The trust had a business case to increase staffing levels in certain areas and had escalation processes when staffing fell below recommended levels.

  • The trust had gaps in medical staffing because of national shortages in certain specialties however; the trust was actively recruiting to these including international recruitment. This risk was further reduced by the use of advance nurse practitioners to support doctors.

  • Safeguarding procedures were in place and staff could demonstrate an understanding of their role and what action to take if they were concerned about a person.

  • Feedback from patients and their relatives was very positive about the care they received and there were examples of some outstanding caring practice.

  • Patient outcome measures showed the trust performed mostly within or better than national averages when compared against other hospitals. Death rates were within expected levels.

  • Following an external review of governance processes, the trust was reviewing its service strategies to ensure that they remained achievable and relevant. The Board had the experience, capacity and capability to ensure that the strategy was delivered.

We saw several areas of outstanding practice including:

  • The Rehabilitation after Critical Illness Team (RaCI) led by nurses, health care assistants and physiotherapists had developed new pathways to help patients recover from critical illness. The team provide rehabilitation while a patient was in the critical care unit, throughout their stay and following discharge.

  • Therapy staff were part of the frailty model and worked in the emergency care centre to support elderly patients with mobility aids and discharge plans avoiding unnecessary admissions to hospital.

  • A combined referral pathway and documentation was being used by GP practices to refer into the trust’s diabetes-integrated service. It included advice and guidance for GPs, a specialist nursing helpline and multi-disciplinary clinical assessment. Clear protocols were in place to identify when a patient could be managed within primary and/or secondary care and when care transfer was appropriate and/or possible.

  • Pathology services had achieved the national external quality assurance scheme (NEQAS) accreditation for cellular pathology and was recognised as a national centre for excellence.

  • Ward 23 was a 24 bedded acute ward providing specialist care to older people with physical and mental health illness (predominantly dementia care) in a dementia friendly therapeutic environment, respecting patient’s dignity whilst also promoting their independence in preparation for discharge from hospital. A team of specialists who had both physical and mental health skills and knowledge cared for patients, their philosophy was to deliver holistic, timely care to patients and their carers.

  • The design of the Emergency Care Centre was innovative and recognised by NHS England as a best practice model providing a single point of access for emergency care.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • Ensure that a clean and appropriate environment is maintained throughout the critical care department and waste disposal unit for the prevention and control of infection; including the provision of appropriate personal protective clothing for staff working in the waste disposal unit.

In addition the trust should:

  • Take action to meet the national 2-week cancer waiting time targets in all tumour sites.

  • Ensure that staffing and skill mix is reviewed on ward 23 to take account of the dependency of patients and ensure that sufficient staff are in place, particularly where special one to one support is identified as being required.

  • Ensure that processes are consistently followed in all areas for checking the storage of medicines particularly recording of fridge temperatures and signing and dating medication entries.

  • Ensure that SCBU moves towards introducing a National Early Warning Score chart.

  • Ensure that there is a strategy for optimising patient outcomes from medicines in line with best practice guidance from the Royal Pharmaceutical Society that has Board approval and reviewed regularly.

  • Ensure processes are consistently followed particularly in SCBU and critical care for the checking of resuscitation equipment.

  • Ensure where required, staff are up to date with Paediatric Immediate Life Support (PILS) and Advanced Paediatric Life Support (APLS) training.

  • Review processes to reduce the number of clinic appointments cancelled.

  • Continue to implement and strengthen governance processes in response to recommendations following an external independent review including strengthening the board assurance framework, clinical engagement and management of performance and risk.

  • Review version control arrangements for the updating of paper copies of polices and care pathways held in clinical areas to ensure staff are using policies which are in date and reflect the latest best practice guidelines.

  • Ensure cause for concern-safeguarding forms identify if a child is, or is not, subject to a child protection plan to enable swift and appropriate action.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Good

Updated 24 February 2016

Effective

Good

Updated 24 February 2016

Caring

Outstanding

Updated 24 February 2016

Responsive

Good

Updated 24 February 2016

Well-led

Good

Updated 24 February 2016

Checks on specific services

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.

Medical care (including older people’s care)

Good

Updated 24 February 2016

We rated medical care (including older people’s care) as good because:

Although the service faced challenges to maintain suitably qualified, skilled and experienced staffing levels at all times it was actively recruiting to fill vacant posts and there were processes to ensure wards were adequately staffed.

The level of staff completing mandatory training had improved, but remained below trust targets of 90%. Staff managed medicines appropriately but did not always check that fridges used for storing medicine were cold enough or that resuscitation equipment was ready for use.

Staff assessed, monitored and managed risks to patients. Patient clinical outcomes were similar or better than national expectations in most areas.

Staff followed systems to report incidents of harm or risk of harm. Managers analysed incidents and provided feedback to staff to help prevent similar incidents. Wards were visibly clean and staff followed infection control principles. Staff worked together to understand and meet the range and complexity of patient’s needs.

The majority of patients and relatives said that staff were polite, caring and respectful. Patients were aware of what treatment they were having, understood the reasons for it and, in many cases, had been involved in the decisions.

Staff were generally positive about the leadership and the levels of engagement with their line management through to executive level. There was a positive open culture within teams. Staff were encouraged to put forward ideas for improvement and had been finalists in national awards.

Urgent and emergency services (A&E)

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.

Surgery

Good

Updated 24 February 2016

We rated surgical services as good because:

Staff reported incidents and felt supported by managers when considering lessons learned.

There were processes for the management of deteriorating patients. Infection prevention and control was managed. Patient nutrition, hydration and pain relief needs were met.

Staff treated patients with compassion, dignity, and respect.

All wards and theatres had appropriate staffing levels. An escalation policy and procedure dealt with busy times and bed meetings monitored bed availability on a daily basis.

There was effective multi-disciplinary working to ensure patients received appropriate care and treatment. Patients were treated based on national guidance and enhanced recovery (fast track) pathways were used.

Surgical services were well-led with a vision and strategy for the service. There were systems to monitor governance, risk and quality performance.

Intensive/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.

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.

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.

Outpatients

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.

Other CQC inspections of services

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