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Royal Victoria Infirmary Outstanding


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.

Inspection carried out on 15 Jan to 28 Feb 2019

During a routine inspection

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 carried out on 19 – 22 January 2016 and 5 February 2016

During a routine inspection

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 carried out on 20, 21 January 2014

During a themed inspection looking at Dementia Services

We spent two days looking at records and speaking with patients, their relatives and staff about the care and treatment provided at these hospitals.

We visited the accident and emergency department, triage, assessment suite, and wards 30 and 31 at the Royal Victoria Infirmary � ward 30 is a short stay, acute medical ward for adults and ward 31 is a specialist ward for adults diagnosed with diabetes or endocrine related complications.

At the Freeman Road Hospital we inspected wards 14, 15, 16, 17, 19 and 29. Patients are referred to wards at the RVI and the Freeman Hospital from the Assessment Suite at the RVI. Wards 14 and 19 specialise in orthopaedic care and rehabilitation, ward 15 cares for acutely ill older patients and ward 29 cares for adult patients with respiratory conditions.

We saw that patients were assessed on arrival at the hospitals and on admission to the wards if they needed to be admitted to the hospitals for longer term care and treatment. Patients were placed on a care pathway appropriate to their identified needs. We saw that patients with dementia were kept safe because their risks were managed appropriately by committed and caring staff with good personal skills. Care was given in a responsive and unrushed manner.

We found the hospital had made a commitment to the Dementia Action Alliance�s �Right Care: creating dementia friendly hospitals� initiative. However, this was being introduced and there is a considerable amount of work still to complete to fully embed the initiative in to hospital practice. We saw there was a clear action plan in place to ensure this happens effectively. We saw there were identified dementia champions on each ward visited.

We found the hospital worked closely with outside agencies to ensure patients received the support they needed when they were deemed medically fit and ready for discharge back into the community.

Inspection carried out on 2 August 2012

During an inspection looking at part of the service

We did not speak to people who used this service as part of this review.

Inspection carried out on 22 May 2012

During a routine inspection

We spent time on three wards areas including an acute stroke unit, a medical ward and the assessment suite where patients had been admitted as emergency cases.

Overall we spoke with 17 patients and 14 staff of varying designations.

Patients told us how they felt able to approach the staff including the ward sisters who were available at visiting times to talk with them and their families. They also provided positive feedback about the ways doctors addressed them and spoke with them at the bedside. Their comments included, �The staff have introduced themselves and told me their names when they�ve been talking to me�; �Staff have checked that it�s ok before they�ve done anything. They are very polite�.

They also told us about how they felt involved in their care and treatment. Their comments included, �Nothing is too much trouble, without exception the staff are kind, patient and attentive when I need help�; �The nurses and doctors have included my family in what has been happening to me and have always listened to our questions and views�; and, �They regularly discuss my discharge plans with me and know what I will be able to do for myself�.

All of the patients who we spoke with were complimentary about, and satisfied with, the care and treatment they received. Comments included, �My care is spot on � I can�t find a fault, all of the staff are really good�; and, �Nothing is too much bother for the staff�.

Patients described how their care was delivered in a way that ensured their safety and well being. For example, �I asked one of the nurses for some pain relief and they brought it to me quickly�.

We received mixed feedback from patients on the assessment suite unit regarding the meal provision which they told us consisted of sandwiches, bread and jam or biscuits.

Patients described how they felt safe and said they would speak to the ward manager or staff if they were ever unhappy about anything.

Other comments included, �I�ve no concerns over staff attitude, they�ve all been lovely to me and very patient� and, �The staff attitude towards me has been fantastic�.

Patients told us that they felt confident about the knowledge and abilities of the staff. Their comments included, "The staff can answer my questions�; "I find the staff are capable and skilled�; and, �The staff understand what my needs are�.

Inspection carried out on 22 March 2012

During a themed inspection looking at Termination of Pregnancy Services

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.