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Royal Victoria Infirmary Outstanding

Inspection Summary


Overall summary & rating

Outstanding

Updated 29 May 2019

Our rating of services stayed the same. We rated them as outstanding because:

  • People were truly respected and valued as individuals and were empowered as partners in their care, practically and emotionally, by an exceptional and distinctive service. Staff went the extra mile to support their patients. Emotional and spiritual support for patients and their families was second to none. Patients told us the care they received exceeded all expectations.
  • Services were tailored to meet the needs of individual people and were delivered in a way to ensure flexibility, choice and continuity of care. Care and treatment were holistically planned in collaboration with patients, making them active partners in their care at all levels.
  • We saw evidence of strong, innovative multidisciplinary and multiorganisational working. There was a robust strategic plan in place which demonstrated how the hospital worked with other organisations to ensure care was planned and delivered to meet the needs of patients in a sustainable, future proof way.
  • Specialist knowledge and expertise was readily accessible. Staff were proactively supported to acquire new skills and share best practice. Research and quality improvement were embedded in practice. All staff were actively engaged in monitoring and improving quality and outcomes for patients.
  • The leadership, governance and culture were used to drive and improve the delivery of high-quality person-centred care. Leaders set stretching, innovative objectives and conducted in depth analysis and planning as to how they would be achieved.
  • Staff were empowered to suggest and deliver changes and were encouraged to be innovative. Staff told us they felt strongly supported and invested in by leadership.
Inspection areas

Safe

Good

Updated 29 May 2019

Effective

Outstanding

Updated 29 May 2019

Caring

Outstanding

Updated 29 May 2019

Responsive

Outstanding

Updated 29 May 2019

Well-led

Outstanding

Updated 29 May 2019

Checks on specific services

Medical care (including older people’s care)

Good

Updated 6 June 2016

Services for children & young people

Outstanding

Updated 6 June 2016

Overall, we rated services for children, young people and families at the Great North Children’s Hospital as outstanding with safe as requires improvement because:

Although managers planned, implemented and reviewed staffing levels regularly, some wards and units reported staff shortages. Senior nurses and medical staff were taking appropriate steps to mitigate the risk and keep children and young people safe.

Managers and staff created a strong, visible, person-centred culture and were highly motivated and inspired to offer the best possible care to children and young people, including meeting their emotional needs. Staff were very passionate about their role and, in some cases, went beyond the call of duty to provide care and support to families.

Families were very positive about the service they received. They described staff as being very caring, compassionate, understanding and supportive.

The care and treatment of children and young people achieved good outcomes and promoted a good quality of life.

Staff protected children and young people from avoidable harm and abuse. Managers and staff discussed incidents daily.

The wards, clinics and departments were clean. Staff managed medicines safely and the quality of healthcare records was good.

Critical care

Outstanding

Updated 6 June 2016

We rated critical care as outstanding for safe, effective, caring, and well led and good for responsive.

Standards for infection prevention and control were good and rates of infections were better than national averages. Ward 18 was a large purpose built critical care unit with excellent facilities, in contrast to the inadequate environment of ward 38, although staff reduced risks and ensured patients received safe care.

Care was led 24 hours a day, seven days a week by a consultant in intensive care medicine. With the exception of pharmacist cover and consultant to patient ratios out of hours, staffing was in line with the Core Standards for Intensive Care (2013).

Critical care services were very well led. A genuine culture of listening, learning and improvement was evident amongst all staff.

Patients and their families had access to a range of support services. It was clear that patients were at the centre of decisions. There were many examples of compassionate care.

The critical care unit performed within or above national averages in governance and performance areas.

End of life care

Outstanding

Updated 29 May 2019

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

  • The service had fully implemented the care of the dying patient document and addressed all the issues we previously identified at our last inspection. Additionally, patient care and outcomes had improved, and the team’s thorough education offer to staff on wards had meant that at this inspection, we found that care of the dying really was everyone’s business.
  • People were truly respected and valued as individuals. Staff went the extra mile to support their patients and people were positive about their care and treatment. Emotional and spiritual support for patients and their families was second to none.
  • The staff team were stable, experienced and committed. The team’s focus on continuous development meant that standards were constantly rising. Topic specific sub groups ensured that any areas in need of improvement remained ‘on the radar’ and progress was regularly checked. Staff were given sufficient time to develop new and innovative ways to improve.
  • There was a ‘can-do’ approach to end of life care when it came to people’s individual needs and preferences. The team were proactive in seeking solutions to barriers to fulfilling these and were not afraid to try new things to ensure patients’ care was right for them. People with protected characteristics under the Equality Act (2010) were offered care in a way that was tailored to suit them and empower them to make as many decisions about their care and their death as they wished.
  • Safety was a priority that the whole team were engaged with. Incidents were rare, and medicines appropriately managed. Information systems shared with local partners underpinned record keeping with paperless notes and clear audit trails.
  • Care and treatment were holistically planned in collaboration with patients and other local providers. Patients were identified earlier than at our last inspection, seen earlier by the specialist team, and discharged home earlier if this was their preference, leading to overall improvements in outcomes.
  • Leadership was strong and compassionate. The team’s vision and strategy were well articulated and progress against three-year plans was regularly checked. Ward staff had more awareness of the team’s key documents than at our previous inspection. Staff contributed to research and the development of national guidance and conducted regular audits of their service.

However:

  • The service was not meeting the trust’s 90% target for staff receiving an annual appraisal. Medical staff appraisal rates were 62.5% and qualified nursing staff 77% at the time of our inspection.
  • Leadership was shared by medical and nursing staff in different directorates. While this was working effectively, the lack of an operations manager had the potential to restrict future development of the service.

Maternity and gynaecology

Outstanding

Updated 6 June 2016

We rated maternity and gynaecology services as outstanding overall with the safe and responsive domains rated as good because:

We observed and were given examples by staff and patients of areas of good practice in the care and treatment of women.

The service provided safe and effective care in accordance with national guidance. Staff monitored outcomes for women continually 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.

Staff took women’s individual needs in planning the level of support they needed throughout their pregnancy. Staff treated women with kindness, dignity and respect. 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 women’s health directorate, which included 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 6 June 2016

Overall we rated outpatient and diagnostic imaging as good because:

The service had met national targets for urgent and routine appointment waiting times.

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.

There were sufficient staff of all specialties and grades to provide a good standard of care in all departments.

There was good leadership of staff to provide good patient outcomes in the outpatients and diagnostic imaging departments. There were well-organised systems for organising clinics.

The departments learned from complaints and incidents, and developed systems to stop them happening again.

However, diagnostic imaging reporting turnaround times for inpatients and A&E patients did not match national best practice guidance.

Surgery

Outstanding

Updated 6 June 2016

Overall we rated surgery as outstanding because:

Performance in surgery showed a very good record of accomplishment and improvement in safety. When incidents occurred, patients and relatives received a sincere and timely apology. Full investigations were routinely undertaken and both patients and families were told about any actions taken to improve processes to prevent the same happening again.

Staffing levels and skill mix were planned, implemented and reviewed to keep patients safe. Staff shortages were responded to quickly.

Surgical outcomes for patients were mostly better than expected when compared with other similar services. There was a holistic approach to assessing, planning and delivery of care with safe use of innovative and pioneering approaches encouraged.

Patients were supported and treated with dignity and respect. Feedback from patients, relatives and stakeholders was consistently positive. Services were tailored to meet the needs of individual patients and were delivered in a way to ensure flexibility, choice and continuity of care.

Leaders had an inspiring shared purpose and strived to deliver and motivate staff to succeed. Rigorous and constructive challenge was welcomed and seen as a way of holding services to account.

Urgent and emergency services

Outstanding

Updated 29 May 2019

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

  • There were enough medical and nursing staff employed by the department and staffing levels were acceptable. Staff followed safeguarding processes to protect vulnerable adults and children from abuse and referred suspected cases of abuse to the proper authority in a timely way.
  • The department had evidence-based policies and procedures relating to care, which were easily accessible to staff and were audited regularly to ensure that staff were following relevant clinical pathways.
  • Information about patients (such as test results) was readily accessible and there was a process in place to identify when results were ready and bring this to the attention of staff.
  • There was strong evidence of different disciplines of staff from across the trust working well together throughout the department.
  • Staff understood their responsibilities in relation to patients giving consent to treatment and the principles of the Mental Capacity Act 2005 that applied where a patient’s capacity to consent was in doubt.
  • Staff provided holistic care to patients. They maintained patients’ privacy and dignity and dealt with people in a kind and compassionate way. Staff treated patients as individuals and the care they provided met people’s physical and mental health needs. Families and carers were also offered support when staff identified this was needed.
  • Patients and relatives were involved in decisions about their care and staff gave them emotional support in difficult situations. Results from national and local surveys and questionnaires about the care patients received were consistently excellent and the department received frequent thank you cards and nominations of thanks.
  • Patients who visited the department had their individual needs met. Interpreters were available for people with hearing support needs and those who spoke English as a second language.
  • There were facilities available to assist disabled patients and those with specific needs. Staff gave patients pain relief, food and drinks when they needed them.
  • The department was mostly meeting the target for patients to be admitted or treated and discharged within four hours, although this was a challenge.
  • The trust was performing better than the England average for a number of other performance measures relating to the flow of patients thus indicating patients were receiving the most appropriate care in a timely manner.
  • The vision and strategy of the trust were embedded in practice. Managers had robust and strongly evidenced plans in place to ensure the sustainability of the department for the future and to develop the department in line with local need.
  • There were robust governance, risk management and quality measurement processes to enhance patient outcomes. These were overseen and reviewed by senior managers across the trust on a regular basis.
  • The views and opinions of patients were important and the trust engaged with hard to reach patient groups to improve their patient journey experience.
  • Staff felt there was strong supportive, forward thinking, innovative leadership not only in the department but also within the trust.
  • There was an inclusive, learning and supportive culture in the department for example by the approach the department took to dealing with incidents and complaints.
  • Staff felt appreciated by their colleagues and managers.
  • The culture in the department supported staff to deliver good patient care. Staff were encouraged and supported to be innovative and we saw examples of innovative ways of working.

Diagnostic imaging

Good

Updated 29 May 2019

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse, and they knew how to apply it.
  • The service controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection.
  • The service had suitable premises and equipment and looked after them well.
  • The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment.
  • Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date and easily available to all staff providing care.
  • The service followed best practice when prescribing, giving, recording and storing medicines. The service managed patient safety incidents well.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers monitored the effectiveness of care and treatment and used the findings to improve them. Staff of different kinds worked together as a team to benefit patients.
  • Staff understood how and when to assess whether a patient had the capacity to make decisions about their care.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. Staff provided emotional support to patients to minimise their distress. Staff involved patients and those close to them in decisions about their care and treatment.
  • The service planned and provided services in a way that met the needs of local people. The service took account of patients’ individual needs. People could access the service when they needed it.
  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff.
  • Managers at all levels in the service had the right skills and abilities to run a service providing high-quality sustainable care. The service had a vision for what it wanted to achieve and workable plans to turn it into action.
  • Managers across the service promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
  • The service systematically improved service quality and safeguarded high standards of care by creating an environment for excellent clinical care to flourish.
  • The service had good systems to identify risks, plan to eliminate or reduce them, and cope with both the expected and unexpected.
  • The service collected, analysed, managed and used information well to support all its activities, using secure electronic systems with security safeguards.
  • The service engaged well with patients, staff, the public and local organisations to plan and manage appropriate services and collaborated with partner organisations effectively.
  • The service was committed to improving services by learning from when things went well or wrong, promoting training, research and innovation.

However:

  • The service did not meet the diagnostic imaging reporting time targets. To assist in addressing challenges with reporting times, the trust had recently started to outsource some MRI and CT elective reporting work.
  • The service did not always meet the two-week urgent waiting time targets.
  • While mandatory training was provided to all staff and managers told us staff were being asked to complete it, mandatory training compliance rates were not achieving the 95% target the trust set. Mandatory safeguarding training compliance did not achieve the trust target. Mandatory training and safeguarding training compliance was between April 2018 and April 2019 and therefore was expected to improve as the year progressed.
  • Resuscitation trolley checks had not been consistently completed between 1 October 2018 and 16 January 2019.
  • The service had challenges with paediatric radiologist staffing levels and were under resourced by three paediatric radiologists.
  • The interventional radiology department used the World Health Organisation (WHO) safety checklist. However, audit of the checklist had only recently commenced
  • While privacy and dignity was maintained in department areas visited, there were occasions during the inspection where patients were waiting to be seen on beds in the corridors on the main x-ray department which did not support a patient’s privacy and dignity whilst in the department.
  • During the inspection there was limited evidence staff had access to communication aids to enhance communication with people with additional needs where required.
Other CQC inspections of services

Community & mental health inspection reports for Royal Victoria Infirmary can be found at The Newcastle upon Tyne Hospitals NHS Foundation Trust.