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Royal Victoria Infirmary Outstanding

Inspection Summary


Overall summary & rating

Outstanding

Updated 6 June 2016

We inspected the trust from 19 to 22 January 2016 and undertook an unannounced inspection on 5 February 2016. We carried out this inspection as part of the CQC’s comprehensive inspection programme.

We included the following locations as part of the inspection:

  • Royal Victoria Infirmary incorporating the Great North Childrens Hospital
  • Centre for Ageing and Vitality

We inspected the following core services:

  • Emergency & Urgent Care
  • Medical Care
  • Surgery
  • Critical Care
  • Maternity & Gynaecology
  • Services for Children and Young People
  • End of Life Care
  • Outpatients & Diagnostic Imaging

Overall, we rated the Royal Victoria Infirmary, as outstanding.

Our key findings were as follows:

  • The trust had infection prevention and control policies, which were accessible, and used by staff. Patients received care in a clean, hygienic and suitably maintained environment. However, there were some infection control issues in the Emergency Care Department.

  • 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.

  • 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.

  • Patient outcome measures showed the trust performed mostly within or better than national averages when compared with other hospitals. Stroke pathways and long-term cancer outcomes were particularly effective. Death rates were within expected levels.

  • There were clearly defined and embedded systems and processes to ensure staffing levels were safe. The trust had challenges due to national shortages however; it was actively addressing this through a range of initiatives including the development of new and enhanced roles, and overseas recruitment. There were particular challenges in staffing in the neonatal unit and provision of consultant to patient ratios and pharmacy cover in critical care.

  • The trust was meeting its waiting time targets for urgent and routine appointments. The trust was effectively meeting its four-hour waiting time targets in the Emergency Care Department.

  • The diagnostic imaging department inpatient and emergency image reporting turnaround times did not meet nationally recognised best practice standards or trust targets

  • 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.

  • Information written in clinical notes about the care patients received in the Emergency Department was minimal and not subject to frequent local clinical audit carried out by staff within the department. The sister in the department confirmed to us that local audit of nursing records did not take place.

  • Although improvements had been made to ensure patients received antibiotics within one hour to treat sepsis, the latest audit showed a compliance of 55%, which was still low.

  • There were some issues with the environment and facilities in critical care (ward 38) at the RVI. This was highlighted in the critical care risk register and in a trust gap analysis report to the Trust Board in 2015. However, the service was managing risks consistently well in this area to ensure safe care.

  • Feedback from patients, those close to them and stakeholders was consistently positive about the way staff treated people. There were many examples of exceptional care where staff at all levels went the extra mile to meet patient needs.

  • The trust used innovative and pioneering approaches to deliver care and treatment. This included new evidence-based techniques and technologies. Staff were actively encouraged to participate in benchmarking, peer review, accreditation and research.

  • The trust worked hard to ensure it met the needs of local people and considered their opinions when trying to make improvements or develop services. It was clear that the opinion of patients and relatives was a top priority and highly valued.

  • There was a proactive approach to understanding the needs of different patients This included patients who were in vulnerable circumstances and those who had complex needs.

  • There were strong governance structures and a systematic approach to considering risk and quality management. Senior and local site management was visible to staff. Staff were proud to work in the organisation and spoke highly of the quality of care provided.

  • There were consistently high levels of constructive engagement with patients and staff, including all equality groups.

We saw several areas of outstanding practice including:

  • The home ventilation service delivered care to around 500 patients in their own home. The service led the way for patients who needed total management of their respiratory failure at home with carers. The team offered diagnostics, extensive training and patient support. The team had written the national curriculum for specialist consultant training. The domiciliary visits covered the whole of the North of England, up to the Scottish border, West Coast and Teesside.
  • The liaison team from the bone marrow transplant unit had developed an open access pathway so post-transplant patients could access urgent care quickly and safely. Children and young people presented their unique passport upon arrival in A&E, which included all information about their condition and any ongoing treatment. The team had worked with other trusts across the country, as many patients lived outside of the local area, to ensure a smooth transition. Feedback from families about the passport was very positive.
  • The Allied Health Professionals (AHP) Specialist Palliative Care Service was a four-year project currently funded by Macmillan, which embedded AHPs into the existing Acute Specialist Palliative Care Service. The primary outcomes being to improve patient experience, manage symptoms, maximise and increase well-being and quality of life.
  • There was an integrated model where palliative specialists joined the cystic fibrosis team to provide palliative care in parallel with standard care. Specialist palliative care staff saw all patients with advanced disease including those on the transplant waiting lists.
  • The trust had an Older Peoples Medicine Specialist Nurse led in-reach service into the emergency department. In addition, there was an Elderly Assessment Team at weekends in the department, which included a social worker and specialist nurse.
  • The critical care pressure ulcer surveillance and prevention group had developed a critical care dashboard for pressure ulcer incidence. A new pressure ulcer assessment tool was developed and implemented this had led to a major reduction in pressure injury.
  • The Newcastle Breast Centre was at the forefront of treating breast cancer. The trust was the first unit in the UK to offer 'iodine seed localisation' in breast conservation surgery. Many breast cancer patients were given the chance to take part in national and international breast cancer treatment trials, as well as reconstruction studies.
  • In cardiology, the service had developed a new pathway for patients requiring urgent cardiac pacing. This was a 24/7 consultant led service and reduced patients length of stay.
  • Eye clinic liaison staff had worked with the Action for Blind People charity to improve links between medical and social care. Studies showed that there had been a reduction in patient falls and consultations.

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

Importantly, the trust MUST:

  • Ensure that care documentation in the Emergency Care Department and on some wards are fully completed to reflect accurately the treatment, care and support given to patients, and is subject to clinical audit.

In addition the trust SHOULD:

  • Ensure processes are in place to meet national best practice guidelines for diagnostic imaging reporting turnaround times for inpatients and patients attending the Emergency Care Department.
  • Continue to develop plans to ensure that staffing levels in the neonatal unit meet the British Association of Perinatal Medicine guidelines.
  • Ensure that all groups of staff complete mandatory training in line with trust policy particularly safeguarding and resuscitation training. Ensure that all staff are up to date with their annual appraisals.
  • Continue to develop processes to improve compliance for patients to receive antibiotics within one hour of sepsis identification.
  • Ensure that Emergency Care Department display boards in waiting rooms are updated regularly and accurately reflect the current patient waiting times.
  • Ensure that the departmental risk register in the Emergency Care Department and End of Life Care accurately reflects the current clinical and non-clinical risks faced by the directorates.
  • Ensure that all housekeeping staff who undertake mattress contamination audits are aware of the trust policy relating to mattress cleanliness and the criteria for when to condemn a mattress.
  • Ensure staff follow the systems and processes for the safe storage of medicine and the recording and checking of resuscitation equipment.
  • Ensure that the storage of patient records is safe to avoid potential breaches of confidentiality.
  • Ensure the maternity service implement the maternity dashboard, with appropriate thresholds to measure clinical performance and governance.
  • Ensure that arrangements are robust to enable patients to transfer safely with continuity of syringe drivers in place from hospital to the community to avoid the risk of breakthrough pain being encountered.
  • Ensure that the Care for the Dying Patient documentation is fully implemented and embedded across acute hospital sites.
  • Ensure that processes are developed to identify if, patients achieved their wish for their preferred place of death.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 6 June 2016

Effective

Outstanding

Updated 6 June 2016

Caring

Outstanding

Updated 6 June 2016

Responsive

Outstanding

Updated 6 June 2016

Well-led

Outstanding

Updated 6 June 2016

Checks on specific services

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.

Medical care (including older people’s care)

Good

Updated 6 June 2016

Urgent and emergency services (A&E)

Good

Updated 6 June 2016

Overall we rated the emergency department as good with safe rated as requires improvement because:

The department was not meeting the trust’s expected target for mandatory training. Nursing records did not always contain enough information about the care patients had received, some equipment was not identified as soiled and there were some gaps in records to show that checks of equipment and medication had taken place.

There was enough medical and nursing staff. Staff followed safeguarding processes to protect vulnerable adults and children from abuse.

The department followed evidence-based policies and procedures relating to care. There was evidence of different kinds of staff working well together throughout the department.

Staff provided good care to patients. They maintained patients’ privacy and dignity and dealt with people in a kind and compassionate way.

Patient’s individual needs were met. The department was 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 regarding the flow of patients.

Managers had plans in place to ensure the sustainability of the department. There were effective governance, risk management and quality measurement processes to enhance patient outcomes. There were many examples of innovative ways of working in the department.

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.

Intensive/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.

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.

End of life care

Good

Updated 6 June 2016

Overall we rated end of life care as good with well-led as requiring improvement because:

The Caring for the Dying Patient document to replace the Liverpool Care pathway, although fully embedded in the community had only been piloted on a small number of wards in the acute hospitals. Interim guidance was available for ward staff and plans were in place to roll out training for the new documentation across all wards but there were no formal timescales to specify this at the time of inspection.

Although risks were identified in the End of Life and Palliative Care update reports to the Board, there was no end of life care risk register used to identify and monitor risks.

Whilst ward staff were engaged in the provision of end of life care there appeared to be a lack of understanding of the strategies and priorities for end of life care by ward staff. The trust had taken steps to engage with staff to increase awareness of the strategy.

Although there was some audit for monitoring if patients achieved their wish for their preferred place of death, this was limited and was not routinely identified. The trust acknowledged that future audits would include this.

The results of the End of Life Care Dying in Hospitals Audit 2016 showed that the trust met all clinical audit indicators and seven of the eight organisational indicators.

The Specialist Palliative Care Team and End of Life Care Team were highly visible and accessible. Medical and nursing staff were very positive about the advice and support they received from these teams. Patients received compassionate care and their privacy and dignity was respected.

Outpatients

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.

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.