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Northumbria Specialist Emergency Care Hospital Good

Inspection Summary


Overall summary & rating

Good

Updated 16 October 2019

  • Patients and families were involved in decision making of their care, staff cared for patients with compassion and we observed positive, kind and caring interactions between staff and patients.
  • There were systems for reporting, investigating, acting and learning from adverse events and there were clear safeguarding processes in place.
  • Patients with a learning disability, those living with dementia, and bariatric patients accessed appropriate emergency services and patients needing care and treatment for mental health needs accessed co-ordinated services.
  • The emergency department had designated mental health assessment rooms that met best practice guidance for a safe mental health assessment room.

  • Staff identified patients at risk of nutritional and dehydration risk or requiring extra assistance and patients were offered support when required. Staff assessed and monitored pain and gave pain relief in an appropriate and timely way.
  • Nurse staffing was managed using recognised tools and professional judgment to maintain safe staffing levels.
  • Leadership teams had a clear vision for the future of the hospital and staff were fully engaged in improving services. The hospital vision continued to develop with involvement from staff patients, and key groups representing the local community.
  • The hospital had stable management structures in place, with clear lines of responsibility and accountability. Managers at all levels in the hospital had the right skills and abilities to run a service providing high-quality sustainable care.
  • Senior managers and operational teams worked together to identify and manage risks, information and lessons learned.
  • Within urgent and emergency care there was a robust triage process in place that used qualified and experienced staff to carry out initial assessment.
  • There was a clear governance framework within maternity services and quality performance and risks were recognised and managed.
  • The risk of child abduction had been mitigated within maternity services through robust security arrangements.
  • Maternity services planned and provided care in a way that met the needs of local people and the communities served and worked well with others to plan care. There were clear and robust policies in place to ensure that patients were seen at the right place at the right time.
  • We saw evidence of learning, continuous improvement and innovation.

However:

  • Mandatory training was not always completed by medical or nursing staff in a timely manner and we lacked assurance how the hospital would improve compliance rates.
  • Annual appraisals were not always completed by medical staff and nursing staff in a timely manner and we lacked assurance how the hospital would improve compliance rates.
  • Patient group directions (PGDs) were past their review date and there was no clear governance process in place to ensure they were reviewed and updated before they expired.
  • Oxygen prescribing did not follow trust policy, best practice and national guidance and medicines had been administered to patients in an emergency, without a clear or retrospective record.
  • Trust policy did not adequately describe the process for initiation and ongoing monitoring of patients receiving non-invasive ventilation treatment, particularly when moved between clinical areas.
  • Patient observations were not consistently monitored in line with alerts on the electronic system.
  • Although fluid balance information was consistently recorded, totals were missing on most charts we viewed.
  • Not all emergency resuscitation trollies had been checked regularly with dates missing from checklists.
  • Paper records were not always securely bound within notes folders and we found some pages or parts became detached.
  • Infection control procedures were not always followed.
  • Patient identifiers were not consistently used, for example entries were not always signed and dated, alterations to records were not appropriately made with a single line, countersigned, timed or dated.
  • In urgent and emergency care the department was not meeting most national standards, for example national clinical audit standards, initial assessment and ambulance handover times. We requested evidence from the department to demonstrate improvement in standards however this was not sent to us.
  • It was unclear how senior management evidenced board to ward information, such as clinical governance dissemination and staff awareness.
Inspection areas

Safe

Requires improvement

Updated 16 October 2019

Effective

Good

Updated 16 October 2019

Caring

Outstanding

Updated 16 October 2019

Responsive

Outstanding

Updated 16 October 2019

Well-led

Good

Updated 16 October 2019

Checks on specific services

Medical care (including older people’s care)

Requires improvement

Updated 16 October 2019

  • We found a number of issues surrounding patient safety, risk of re-admission, access and flow, and the governance, oversight and quality monitoring of the medical care service.
  • The service did not monitor nurse staffing levels for patients receiving acute non-invasive ventilation and could not assure us that patients were nursed according to British Thoracic Society guidelines surrounding one nurse to two patients.
  • The policy surrounding non-invasive ventilation (NIV) did not adequately describe the process for initiation of NIV on base sites.
  • Patients were not continuously monitored when patients were moved between clinical areas while receiving non-invasive ventilation. We escalated this to the business unit management team. As a result, they assured us a business case had been be submitted to purchase additional monitoring equipment.
  • Although the electronic track and trigger system indicated when patients should be observed, we found that patient observations were not consistently monitored according to the flag alert on the system. In the four weeks prior to inspection, out of 77,350 observations recorded only 44,610 had been completed within 15 minutes of need.
  • Although patient records contained comprehensive information, patient identifiers were not consistently used, entries were not always signed and dated, alterations to records were not appropriately made with a single line, countersigned, timed or dated, and fluid balance charts were not always totalled.
  • We lacked assurance surrounding clinical governance dissemination in some instances due to the use of wipe clean boards for weekly ward meetings. There was no record of staff attendance at these meetings.
  • The risk register did not evidence a robust process surrounding review dates or target dates.
  • The model of care separated emergencies from planned care at base sites, however access and flow was impacted due to bed pressures at Northumbria Specialist Emergency Care Hospital and ward closures at base sites.
  • During our last inspection we were assured that patients were not transferred between wards at night. However, at this inspection, from January to December 2018, 927 patients moved wards at night. Senior management told us patients were moved to other wards within the hospital due to bed pressures.
  • The service had a higher than expected risk of readmission for elective admissions in gastroenterology and respiratory medicine and a higher than expected risk of readmission for non-elective admissions in general and respiratory medicine compared to the England average.
  • Two specialties were below the England average for admitted referral to treatment times within gastroenterology and rheumatology.
  • The service used systems and processes to prescribe, administer, record and store medicines. However, patient group directions had not been reviewed in line with the review date set by the trust and oxygen was not prescribed or recorded in line with national guidance on all wards that we inspected. Medicines had been administered to patients in an emergency without a clear or retrospective record.
  • Overall mandatory training compliance, including safeguarding training, Mental Capacity and Deprivation of Liberty Safeguards training did not meet the trust target. Staff were not given protected time to complete mandatory and safeguard training.
  • Although senior leadership were aware of training non-compliance surrounding mandatory, safeguarding and Mental Capacity Act & Deprivation of Liberty Safeguards. We lacked assurance of how the service would improve upon this.
  • Not all staff received appraisals to assess their work performance and promote their professional development. Appraisal compliance did not meet the trust target.

However:

  • The service-controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection.
  • Nurse staffing was managed using recognised tools and professional judgment. To maintain safe staffing levels, the service monitored staffing levels and reviewed these daily using nationally recognised tools alongside clinical judgment.
  • The service had enough nursing 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 identified patients at risk of nutritional and dehydration risk or requiring extra assistance at pre-assessment stage. Patients were offered support when required.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. We observed positive, kind and caring interactions on the day units and between staff and patients.
  • The service had stable management structures in place, with clear lines of responsibility and accountability. We saw evidence of learning, continuous improvement and innovation within medical services at the location.
  • Patients we spoke to felt involved in their care and had been provided with information to allow them to make informed decisions.
  • The trust had systems and processes in place to ensure that the needs of local people were considered when planning the service delivery.
  • Managers at all levels in the trust had the right skills and abilities to run a service providing high-quality sustainable care.
  • The trust had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff, patients, and key groups representing the local community.

Services for children & young people

Outstanding

Updated 5 May 2016

We rated services for children and young people at NSECH as outstanding because:

Access to the Children’s Unit and 24 hour care was excellent with patients reporting they were seen by relevant staff and treated quickly. The performance for children being seen and either discharged or admitted within 4 hours in the Children’s unit was 99%. A triage assessment tool was in place to identify clinical acuity and fast track children when necessary. There were robust arrangements for the transfer of babies and children needing a higher level of care. Other organisations and the local community had been involved in the planning and delivery of this service. There was a proactive approach to understanding the needs of children and young people to ensure that care was delivered to meet their needs. The new facilities were excellent, met national standards and the needs of children and young people.

There was a clear vision for this service with strong leadership. The management team were very positive about their services and very proud of their staff. They sought to make continual improvements and were passionate about and strived to deliver high quality patient care. Staff told us that managers were both visible, approachable and open to new ideas. Robust and effective governance arrangements were in place to protect patients from harm. Governance arrangements and the risk register were proactively reviewed. There was a high level of staff engagement and excellent team working. Staff felt proud of the services they delivered to patients and there was a culture of continual improvement. There were inventive ways of engaging the public and service users in order to improve the patient experience. The service supported and encouraged innovation.

There were arrangements in place to protect patients from abuse and avoidable harm. There was a positive culture of reporting and learning from incidents. The clinical environment and equipment was clean and staff observed good infection control practices. Medicines, including controlled drugs, were stored securely and dispensed safely. Safeguarding systems were robust in protecting children and young people from harm. Staffing levels were safe although further work was being undertaken to ensure staffing levels in the Children’s Unit could meet future demand. There were effective measures in place to assess and respond to a child whose condition was deteriorating.

Services for children and young people were effective. Clinical practice was based on local and national standards and was regularly audited to ensure standards continually improved. There was involvement in regional networks to learn and share good practice. Staff were competent to deliver care. Additional training needs were being identified and training planned as the new service continued to develop. Policies and procedures were in place, up to date, and staff knew how to access them.

Staff provided compassionate care and treated children and parents with kindness and respect. We heard consistent praise from children and parents who told us they felt well informed and involved in decisions about their care. Both the Children’s Unit and the Special Care Baby Unit (SCBU) scored highly in patient surveys. In the Special Care Baby Unit, we saw that staff gave special attention to siblings to help them feel included. They also gave parents a call 48 hours after discharge to offer advice and support. Emotional support was good with the availability of specialist bereavement midwives in SCBU and easy access to in-reach mental health services in the Children’s Unit.

Critical care

Outstanding

Updated 5 May 2016

We rated critical care as outstanding because:

People’s individual needs were central to the planning and delivery of critical care services. The service involved patients and stakeholders in the new model of care and the build of the unit to ensure it provided an innovative approach to integrated person-centred care. The management team worked with leads in the trust to plan service delivery.

Governance and performance metrics were proactively reviewed. Governance arrangements enabled the effective identification of risks and monitored these risks and the progress of action plans. There was evidence that controls were in place to mitigate these risks.

An experienced and cohesive team managed the service. They demonstrated a clear understanding of the challenges of providing high quality, safe care. Continuous improvement was driven with the involvement of frontline staff that felt valued and who were engaged in service development. The leadership team motivated staff to succeed. It was clear that staff had confidence in the leadership at all levels and spoke highly of the culture within the unit. There were high levels of staff satisfaction.

All staff considered patients individual preferences and evidently went out of their way to exceed expectations to meet their wishes. Staff were motivated and inspired by leaders to deliver person centred, holistic care. One visitor told us the staff made them feel like their relative was the only patient on the unit and nothing was too much trouble. Staff had been nominated for awards for their compassionate care. Formal feedback from patients and relatives was continually positive about all aspects of their care.

Care was led 24 hours a day, seven days a week by a consultant in intensive care medicine and staffing was in line with Core Standards for Intensive Care (2013). Patient outcomes were the same as or better than the national average and care and treatment was planned and delivered in line with current evidence based guidance and standards. There was evidence of excellent joint and patient centred multidisciplinary team working. The culture of ‘everyone had a voice’ was embedded.

Governance

arrangements enabled the effective identification of risks and monitored these

risks and the progress of action plans. There was evidence that controls were

in place to mitigate these risks.

The service had a good track record in safety. There had been no never events or serious incidents reported. Between July and October the unit achieved 100% harm free care on three out of four months and it had been over 300 days since there had been an avoidable pressure ulcer.

End of life care

Outstanding

Updated 5 May 2016

We rated end of life care as outstanding because:

We found that the hospital was providing high quality end of life care services using innovative approaches and effective partnership working. There had been significant investment in palliative and end of life care services and the trust was responsive to addressing issues as they arose with flexibility in relation to staffing and resources. There was a clear vision, strategy and leadership at all levels of the organisation with a focus on good quality end of life care. Patients were cared for using a truly holistic approach and staff teams were committed to working collaboratively to meet individual needs. The structure of the hospital liaison service that had been developed in partnership with Marie Curie provided additional flexibility to enable specialist palliative care staff to provide support to patients at the end of life irrespective of the complexities of their condition. This was sometimes in the form of supporting a rapid discharge to the patients preferred place of care in the community and as such involved a very hands on approach to ensuring as straightforward a transition as possible with hospital staff accompanying the patient in order to handover to community staff.

We saw evidence of the use of national guidance and appropriate anticipatory prescribing of medicines at the end of life. Multidisciplinary working was apparent between different disciplines and across services within the hospital and the community. The hospital liaison palliative care team worked well alongside the acute teams at NSECH to provide palliative and end of life care specialist support at the earliest appropriate opportunity. There was an emphasis on working to increase the confidence and competence of ward based staff to ensure all patients had access to good quality end of life care. Patients and their families were involved in care and we saw a number of initiatives in use to record patient wishes including advance care plans, emergency healthcare plans and treatment escalation plans.

There was consistent evidence that staff were motivated to go the extra mile. Spiritual care was seen to be important with initiatives having been developed in supporting staff in the assessment of spiritual needs through training and the use of an internally designed assessment tool. Chaplaincy support saw multi-denominational ministers and faith leaders available for patients, relatives and staff.

The leadership, governance and culture were used to drive and improve the delivery of high quality person-centred care through collaboration and partnership working. The trust had clear leadership for end of life care services that was supported at the top of the organisation. There was a clear proactive approach to seeking out and embedding new and more sustainable models of care. Staff we spoke with consistently told us they felt that end of life care was a priority for the trust.

Outpatients and diagnostic imaging

Outstanding

Updated 5 May 2016

We rated outpatient and diagnostic imaging at NSECH as outstanding because:

The service was flexible and ensured continuity of care. People accessed services in a timely and convenient way. The hospital provided a seven day a week consultant led outpatient trauma service for people from across Northumberland and North Tyneside to access, and a teleconference clinic for patients in Berwick, almost 60 miles away. Trauma clinics and related services were organised so patients only had to make one visit for investigations and consultation or, if possible did not have to return to hospital for unnecessary appointments. It also provided patients with timely advice on the management of their injuries while at home. Radiology reporting was swift with an emphasis on “results within minutes” for trauma patients. This enabled medical teams to complete assessments and manage risks quickly. Reporting times for urgent and non-urgent procedures consistently met or were better than national and trust targets for all scans and x-rays for emergency patients, inpatients, and outpatients. There was widespread involvement with the local population, primary care, and commissioners to plan this new model of emergency care to ensure that the service met people’s needs. Since the departments opened in June 2015, there had been no formal complaints. However, the department teams recorded any concerns and informal complaints and used patient feedback proactively to prevent recurrence that might affect others.

Staff and managers had a clear vision for the future of the service. They knew the risks and challenges the service faced. Staff we spoke with at all levels felt supported by their line managers, who encouraged them to develop and improve their practice. Staff embraced change and there was a real focus on patient experience and leaders and managers drove this. There were well embedded systems and processes for gathering and responding to patient experiences and the results were well publicised throughout the departments. Early feedback provided by patients for the virtual trauma service was very positive. There were effective and comprehensive governance processes to identify, understand, monitor, and address current and future risks. These were proactively reviewed. There was an open, honest and supportive culture where staff discussed incidents and complaints, lessons learned and practice changed. All staff were encouraged to raise concerns. The departments supported staff who wanted to work more efficiently, be innovative, and try new services and treatments and ways of engaging with the public.

The hospital had good systems and processes in place to protect patients and maintain their safety. The departments were clean and hygiene standards were good. Medical records were stored and transported securely. Staff followed professional best practice guidelines to plan and deliver good quality care and took part in a wide range of national and clinical audits. Diagnostic imaging provided services for inpatients and emergency patients seven days a week and service availability was increasing and continuously improving. Staff undertook regular departmental and clinical audits to check practice against national standards.

Staff respected patients privacy, dignity, and confidentiality at all times. Staff spent time with patients and those close to them to give explanations about their care and encouraged them to ask questions.

Surgery

Outstanding

Updated 5 May 2016

We rated surgery services as outstanding because:

The hospital provided a new model of elective and emergency care to its population and at the time of inspection NSECH had been open for 5 months. The provision of specialist emergency surgical care, with consultants on site 24/7, as well as consultants in a range of specialties working seven days a week was embedded across the trust and appeared to be working well. The change to the provision of emergency and high risk surgical services centred at NSECH ensured patients received the right care and treatment, support services, nursing and clinical staff at the appropriate time and location. The strategy of the service clearly identified the new model of emergency and high-risk surgery provided at NSECH and the relationship between NSECH and the base hospitals. The new model was under constant review to determine the most effective site to undertake different procedures depending upon risk and safety. Local communities had been engaged in the consultation and development of the strategy for the new model of care. This had a positive effect upon the feedback received from patients and relatives received during the inspection at NSECH and also at the base hospitals.

At the end of September 2015, the trust was meeting the NHS operational target of 92% of patients waiting less than 18 weeks for treatment. Six theatres were available at NSECH, seven days a week. There were innovative approaches to delivering patient care and evidence based practice based on national guidance and benchmarking was evident across the trust. A dedicated team contacted patients by telephone following discharge to gather information about any immediate concerns the patient may have and provide advice and guidance.

Strong governance structures were in place across surgery and there was a systematic approach to considering risk and quality management. Performance data and information was available and displayed at NSECH, albeit limited from the month of opening in June 2015. The trust team had been consistent in its approach to communication, and having good systems and processes in place to protect patients and maintain their safety. Staff we spoke with in surgery at NSECH understood the process for reporting and investigating incidents and there was a good reporting and feedback culture. There had been no serious incidents at NSECH and 150 reported incidents in surgery since June 2015, with very low incidence of minor patient harm being recorded at this site. Senior managers had a clear vision and strategy for the division and identified actions for addressing issues within the division. We were told the service had a commitment to a people centred approach delivering high quality care with robust assurance and safeguarding and saw this in practice during the inspection. Staff told us they were encouraged to challenge existing practices, look for improvements and suggest ways to develop and introduce innovative practice. Staff reflected on the strong leadership and visibility of senior members of the trust board. This motivated staff and they felt that senior leadership reflected the vision and values that they shared with the organisation. Surgical staff we spoke with at NSECH and across all base sites understood the new model of care and consistently spoke of being proud to work for the trust.

The surgical wards were a modern design with majority single room accommodation. They were spacious and visibly clean.We observed new pharmacy technology and new systems for monitoring patient/nurse calls. Staffing levels were good at the time of inspection. Staffing had been reviewed since opening and an increase in both medical and nursing cover had been agreed. Senior and site level leadership was visible and accessible to staff at NSECH. Staff spoke very positively about their immediate line managers and senior leaders and a positive culture was evident during the inspection.

We observed patients being cared for with dignity, compassion and respect in all surgical wards and departments. The 22 patients we spoke with were very positive about the service and staff and surgical services in NSECH had received positive feedback scores and comments for the first few months of delivering services at this hospital site. There was a comprehensive approach used by the trust to capture the patient experience but information was limited at the time of inspection of NSECH. Patients commented they had been treated: ‘…very well, promptly and by staff who were caring and treated them well’, ‘…although staff are busy, they always have time for a chat, couldn’t be better’ and ‘…the service was professional at all times’.

Urgent and emergency services

Requires improvement

Updated 16 October 2019

Our rating of this service went down. We rated it as requires improvement because:

  • We rated safe and effective as requires improvement. We rated caring, responsive and well led as good.
  • Infection control procedures were not always followed in relation to hand hygiene and we saw staff wearing nail varnish. Used blood transfusion bags were also stored inappropriately in an unlocked room, with unsheathed needles exposed.
  • Patient group directions (PGDs) were past their review date and there was no clear governance process in place to ensure they were reviewed and updated before they expired. Oxygen prescribing did not follow trust policy, best practice and national guidance in the ED.
  • The department had not fully transitioned to electronic patient records and were running a dual system. We identified some discrepancies between the paper and electronic records of some patients.
  • Mandatory training was not always completed by medical or nursing staff in a timely manner and the department needed to improve compliance with mandatory training.
  • The department needed to improve compliance with appraisal rates in the department.
  • National audit results were poor and the department was not meeting most of the standards and were in the lower quartile compared to national performance. There was little evidence of further local audit work underway to ensure that audit compliance improved.
  • The department was not meeting initial assessment and ambulance handover times and had experienced a high number of black breaches (patients waiting more than 60 minutes to be handed over from ambulance staff to hospital staff.

However:

  • Both the adult and children’s departments had a robust triage process in place and used qualified and experienced staff to carry out initial assessment.
  • Clinical policies online were reviewed and up to date.
  • There were good examples of care and compassion witnessed in both the adults and paediatric departments. The caring relationships were valued by staff and promoted amongst staff. There was a strong person-centred culture.
  • Patients and families were involved in the decision making on their care in a way that they understood.
  • Services were planned in a way to meet the individual’s needs.
  • Patients with a learning disability, those living with dementia, and bariatric patients could access emergency services appropriate for them, and their needs were supported. Patients needing care and treatment for their mental health needs could access services in a joined-up way from within the department.
  • The emergency department had designated mental health assessment rooms that met best practice guidance for a safe mental health assessment room.

  • Complaints were addressed in line with the trust’s policy although response timescales were not being met.
  • There was a sense of teamwork within the department and operational staff worked together in partnership to provide effective care and treatment especially at times of pressure.

  • Senior clinical leadership was visible in the department during our inspection and attended the department to support staff during our inspection. Senior staff also supported the department at times of escalation.
  • The leadership team had a clear vision for the future of the department and staff were fully engaged in improving the department and ensuring its sustainability.

Maternity

Good

Updated 16 October 2019

  • Several areas for improvement had been identified at our previous inspection in 2015. At this inspection we found each of these had been addressed.
  • The risk of child abduction had been mitigated by security arrangements including staff challenging all visitors and a ward clerk stationed immediately outside the ward, monthly drills, a CCTV system and routine security guard attendance on the ward.
  • Infection control procedures and practices were in line with guidance and most equipment checks were completed consistently.
  • Drugs, including emergency medicines were prescribed, stored securely and administered appropriately.
  • There were systems for reporting, investigating, acting and learning from adverse events and there were clear safeguarding processes in place. Records showed pregnancy pathways were clear and risk assessments were completed at each stage of pregnancy. There was consistent handover from one team to another.
  • The service provided care and treatment based on national guidance and best practice. Staff monitored the effectiveness of care and treatment using an electronic maternity dashboard.
  • There were sufficient medical and midwifery staff for the number of babies delivered on the unit. Doctors, nurses and other healthcare professionals worked together as a team to benefit women. They supported each other to provide good care. Staff were competent for their roles. Managers appraised staff and held supervision meetings to provide support and development.
  • Staff supported women to make informed decisions about their care and treatment. They followed national guidance to gain patients’ consent. They supported women experiencing mental ill health and used measures that limit women's liberty appropriately. Staff assessed and monitored pain and gave pain relief in an appropriate and timely way. Staff gave women enough food and drink to meet their needs and improve their health.
  • Staff treated women with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. Feedback from women and families was positive with good patient survey results. Staff provided emotional support to women, families and carers to minimise distress. They understood patient's personal, cultural and religious needs. Staff supported women, families and carers to understand their condition and make decisions about their care and treatment. Staff gave women practical support and advice to lead healthier lives.
  • Key services were available seven days a week to support timely care. The service planned and provided care in a way that met the needs of local people and the communities served. It also worked with others in the wider system and local organisations to plan care. There were clear and robust policies in place to ensure that patients were seen at the right place at the right time. There was a pregnancy assessment unit (PAU) available from 8am to 10pm daily with plans in place to open the unit 24 hours a day.
  • Women could access the service when they needed it and received the right care promptly. The service was inclusive and took account of women’s individual needs and preferences and coordinated care with other services and providers.
  • Women and their families provided feedback and raised concerns about care received. The service treated concerns and complaints seriously, investigated them and shared lessons learned with all staff.
  • Leaders had a clear strategy and plans for the future of the service. Leaders supported staff to achieve the service priorities. Staff were aware of the trust’s vision and were committed to embedding the changes and improvements in maternity services and as part of the trust as a whole. Senior managers and operational team worked together to identify and manage risks, information, and to share lessons learned.
  • Staff worked together, supported each other and felt very positive about leadership within the service. The senior team were visible and approachable and staff valued the vision, support and leadership of matrons and the clinical lead. Line managers worked as role models and were part of the team. Staff were offered opportunities for training and progression.
  • There was a clear governance framework and quality performance and risks were recognised and managed. The service used the maternity dashboard as a clinical performance and governance scorecard and helped to identify patient safety issues in advance. Staff followed duty of candour appropriately.
  • Women and staff had access to information and informative literature. Copies of the delivery summary were sent to the GP and health visitor.
  • Staff sought opinions of those who used the service and feedback was positive. There was a maternity services user forum to gather experiences from women and improve standards of maternity care.
  • Staff felt very engaged and involved in the development of the service and its aims to provide good quality care for women. Staff took part in fundraising initiatives. We saw encouragement and recognition were given to staff for fostering innovation or improvements to the service across different levels within the teams.

There was evidence of innovative practice throughout the service and by staff at all levels including:

  • Home inductions
  • A health psychology team which supported women who had experienced a previous traumatic birth
  • A continuity of care model in Hexham MLU
  • Sharing of information regarding safeguarding including partners (SIRS)
  • A ‘Rotation Toolkit’ to demonstrate and document maintenance of competency
  • A monthly skill drill for all staff in all clinical areas
  • A ‘Listening Buddies’ system
  • Quarterly staff away days for multidisciplinary team (MDT) development
  • Teaching clinics
  • Antenatal fetal DNA testing for Rhesus negative mothers
  • The use of Episcissors and obstetric anal sphincter injuries (OASIS) bundle
  • Extended use of NATSSIPS.

However:

  • The emergency resuscitation trolley had not been checked regularly with several dates missing from checklists.
  • Midwifery and Medical staff failed to meet trust mandatory training and safeguarding training compliance targets of 95% for the majority of modules, although the service had identified this and had plans in place to address compliance.
  • Records were not always securely bound within notes folders and we found some pages or parts became detached.
  • At our last inspection we found incomplete fluid balance charts. At this inspection fluid balance information had been recorded on all charts, although totals were missing on most charts we viewed.
  • Review dates for Patient Group Directions (PGDs) used by midwives had been exceeded. This meant that medicines were being administered or supplied without an appropriately reviewed authority document. This is not in line with regulation or NICE guidance. Following feedback to the trust after the inspection the pharmacy reviewed PGDs and expedited their approval.