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Provider: The Newcastle upon Tyne Hospitals NHS Foundation Trust Outstanding

On 29 May 2019, we published a report on how well The Newcastle upon Tyne Hospitals NHS Foundation Trust uses its resources. The ratings from this report are:

  • Use of resources: Outstanding  
  • Combined rating: Outstanding  

Read more about use of resources ratings

Inspection Summary


Overall summary & rating

Outstanding

Updated 29 May 2019

Our rating of the trust stayed the same. We rated it as outstanding because:

  • We rated effective, caring, responsive and well-led as Outstanding and safe was rated as good. All five ratings stayed the same as our previous inspection in 2016.
  • In rating the trust, we took in to account the current ratings of the services that we did not inspect during this inspection but that we had rated in our previous inspection.
  • We rated well led for the trust overall as outstanding. This was not an aggregation of the core service ratings for well led.
  • Our full inspection report summarising what we found and the supporting evidence appendix containing detailed evidence and data about the trust is available on our website.
Inspection areas

Safe

Good

Updated 29 May 2019

  • There were enough medical and nursing staff employed by the trust 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.
  • 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.
  • The end of life 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.
  • 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.
  • All areas we visited were visibly clean and we saw members of the team taking appropriate infection control measures. For example, the mortuary was clean and tidy, and trust cleanliness audits confirmed high standards of cleanliness in all areas.
  • The trust 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.
  • The trust-controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection.

However;

  • Mandatory training levels were below the trust’s 95% target for all staff, however, data provided showed the year to date which was April 2018 to December 2018. However, staff were meeting the trajectory to complete mandatory training by end of March 2019 and could easily access training as required.
  • In diagnostics 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.

Effective

Outstanding

Updated 29 May 2019

  • The trust 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.
  • There was strong evidence of different disciplines of staff from across the trust working well together throughout the trust.
  • The end of life team was 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.
  • Staff were well supported to develop in their role, acquiring new skills and sharing best practice. New team members were given extended protected time to enable them to become fully embedded within the team and staff spoke very positively about how they felt ‘invested in’. The team’s extensive skills and knowledge were effectively cascaded to wider hospital staff through numerous training opportunities.
  • All staff were actively involved in monitoring quality and outcomes for patients. The service took part in local and national benchmarking and was one of the pilot organisations developing the national palliative care dataset. Patients had positive and consistent outcomes as a result.
  • Staff, teams and services were working collaboratively and were using innovative ways of delivering joined up care. People’s discharge was discussed and planned at the earliest stage possible and patients received the same quality of care seven days a week.

Caring

Outstanding

Updated 29 May 2019

  • 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.
  • 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.
  • Patients and those closest to them were active partners in their care. They knew what the plan was for their care, and where appropriate, had discussed their preferred place of death with staff.
  • Staff ‘went the extra mile’ to support patients and we heard of multiple examples of additional support such as arranging emergency accommodation for vulnerable patients’ pet dogs. They also voluntarily provided extra touches such as providing and arranging flowers for the mortuary viewing rooms.
  • There was a chaperone policy and chaperones were available to patients as needed. In diagnostics staff were aware of patients who may be anxious of claustrophobic and supported patients as needed. Patients could visit the department before an appointment to reduce anxiety if required.

However:

  • While privacy and dignity were maintained in the diagnostics 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 in diagnostics had access to communication aids to enhance communication with people with additional needs where required.

Responsive

Outstanding

Updated 29 May 2019

  • The emergency department was mostly meeting the target for patients to be admitted or treated and discharged within four hours, although this was a challenge.
  • The emergency department 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 views and opinions of patients were important, and the trust engaged with hard to reach patient groups to improve their patient journey experience.
  • People’s spiritual care was well catered for, and the chaplaincy team could accommodate the preferences and needs of people from all faiths, or no faith.
  • Families of people nearing the end of their life in hospital were very well supported by the team’s specialist healthcare assistants. They provided reduced fees for car parking, comfort packs, shared diaries and respite breaks for those at the bedside as well as hot drinks and a chance to talk.
  • People knew how to give feedback about their experiences and could do so in a variety of ways. The end of life service received very few concerns and complaints, but treated these seriously, investigated them and learned lessons from the results.

However:

  • The diagnostics service did not meet the 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 diagnostics service did not always meet the two-week urgent waiting time targets.

Well-led

Outstanding

Updated 29 May 2019

  • Leaders were experienced and had the right skills and abilities to provide high quality, sustainable care. Service managers were focussed on the quality issues, priorities and challenges for the team.
  • There was an inclusive, learning and supportive culture in the trust for example by the approach the trust took to dealing with incidents and complaints.
  • Staff felt appreciated by their colleagues and managers.
  • The culture in the trust supported staff to deliver good patient care. Staff were encouraged and supported to be innovative and we saw examples of innovative ways of working.
  • Staff felt there was strong supportive, forward thinking, innovative leadership within the trust.
  • The End of Life team were passionate about continuous improvement and had been nominated for and won regional and national awards. Learning from practice, both positive and negative, was central and discussed at each team meeting. The team had made positive improvements since our last inspection and had addressed all the issues previously highlighted.

However:

  • Leadership in the end of life service 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.
Assessment of the use of resources

Use of resources summary

Outstanding

Updated 29 May 2019

Combined rating

Combined rating summary

Outstanding
Checks on specific services

Community dental services

Good

Updated 6 June 2016

Overall rating for this core service Good

We rated the community dental services at this trust as good because:

  • We considered the service was staffed by people who were trained and regularly appraised and who were willing to learn and improve from any incidents and who showed a real commitment to safeguarding their patients.
  • The community dental service had an effective referral based service for the local community, including managing an emergency ‘out of hours’ service and an oral health promotion team which worked with local schools and other agencies.
  • We observed care from caring and committed staff who had chosen to work in a community setting to provide consistently patient focussed and compassionate care.
  • The community dental service was responsive to the needs of its patients who often had complex needs, for example those with a learning disability. Staff spoken with saw complaints as a way to improve and shape the service given to patients and could describe how changes had been made to their practice to deliver better care.
  • The community dental service was led by a consultant in special care dentistry. The service had robust governance arrangements in place which were evidenced in minutes of meetings seen and reported to the Board through the medical director. Staff were engaged and motivated and spoke proudly about the innovations they had achieved, particularly with regard to the dental student programme which ran throughout the year to provide training for future dentists.

Community end of life care

Outstanding

Updated 29 May 2019

  • Staff knew how to report an incident using the trust’s electronic system and were aware of the importance of doing this. There were clear routes for feedback and learning from incidents to be shared and these were being used effectively.
  • Staff understood how to protect patients from abuse. Safeguarding was well understood with comprehensive training delivered to staff.
  • There was evidence of well worked out systems for multidisciplinary working between different staff groups, between different parts of the trust, and with external agencies; such as hospices and the ambulance service.
  • There was good input from general practitioners and pharmacies. Systems for the provision of out-of-hours and anticipatory medicines were in place.
  • Staff assessed risks to patients during their visits and advice from a consultant was always available.
  • The service worked towards a standard based on the principles of the national palliative care ‘Gold Standards’ framework.
  • Evidence from surveys, statements by relatives, and our conversations with patients, and staff, showed the highest degree of compassion, emotional support, understanding and involvement of patients and those close to them.
  • The service linked into a general practitioner risk register used to identify patients who were in need of end of life care input.
  • Consent was informed and discussed with patients. ‘Do not attempt cardiopulmonary resuscitation’ (DNACPR) forms we reviewed were signed and dated
  • We observed compassionate care that met patients’ emotional needs. We saw the team engaging with patients, and understanding their needs, and involving them and those closest to them.
  • There was evidence of a high level of responsiveness in the way the service linked with patients from different backgrounds and facilitated the inclusion of hard to reach groups. The latter being seen clearly in the work done, in collaboration with a local charity, to reach homeless people.
  • The service fully supported patients in helping them choose their final place of care. This included the compassionate way in which they supported a patient who was considering using the Dignitas service.
  • There was an effective referral system from the in-patient hospital team to ensure new patients accessed the community team quickly and effectively. There was a system of triage to ensure patients got the care and support at the right time.
  • There were explanatory leaflets for patients and those close to them that was written in an empathetic and jargon free style. These were also available in different languages.
  • There was a culture of everybody working together in a non-hierarchical manner for a common goal.

However:

  • The trust had a mandatory training target of 95%. In the case of qualified nursing staff ten out of fourteen training modules exceeded the target with a compliance rate of 100%. Although the target was not achieved in the training modules of; anti-bribery and corruption, fire safety, health and safety, and Prevent (Prevent is part of the UK's Counter Terrorism Strategy that works to stop individuals from getting involved or supporting terrorism or extremist activity). These latter areas had a compliance rate of 89%.
  • Staff were aware of the principles of cleanliness and infection control. However, because of the nature of the work being undertaken in patients’ homes we could not observe staff providing clinical care to patients that required a clean or aseptic environment. Staff did not always keep detailed records of patients’ care and treatment. A review showed that not all paper records had signatures and that conversations with patients were not always recorded.
  • Although we saw evidence that consent was being sought it was not recorded in all the records that there had been a full discussion with the patient and their family.
  • We saw one record where the use of bed sides was not recognised as a possible use of restraint.
  • There was a lack of provision of end-of-life care provision for children although this was a commissioning issue outside of the responsibilities of the service. It was noted that one of the consultants worked pro-bono in their own time to help the service meet patients’ needs.
  • There was no operational manager post within the team, that was jointly consultant and nurse led. The team recognised that this role would further strengthen their leadership, and conversations had taken place at an executive level with a view to implementing this.

Community health services for adults

Good

Updated 6 June 2016

Overall, we rated this service as good because:

  • Staff knew how to report incidents and most received feedback when requested. Lessons learnt from incidents were found to be shared by distribution of team meeting minutes. Pressure ulcers were the most commonly reported incident.

  • We found that staff had a good understanding of safeguarding and how to report concerns.

  • Medicines were managed appropriately and equipment was checked and serviced. Waste management and disposal information and guidance was in place.

  • Records viewed were accurate and complete. There was some duplication of work in community services due to paper records being used alongside the electronic patient system.

  • Recruitment to community staffing was highlighted as a concern and managers were using different strategies to address this. Staffing was on the risk register. Staff we spoke to felt caseloads were manageable. Therapy staffing had few vacancies and the actual staffing levels versus planned was good. Community nursing staffing data showed the whole time equivalent against the planned staffing levels to be similar.

  • Staff base buildings were highlighted on the risk register and staff told us of the challenges of being based in such buildings. Lack of access to IT was found to be an issue in some areas of community services. This was highlighted as a risk and managers were actively seeking a mobile solution to allow access to the required systems.

  • There was good evidence based care and treatment using national and local guidance. We saw person centred care and the use of risk-based tools through the electronic patient system. Patient outcome data was collected and community services participated in a number of audits.

  • Staff had received the appropriate training and development. Learning needs were identified during annual appraisals, staff told us they had access to further training, and development was good.

  • Patients received compassionate care and their dignity and privacy was respected. Staff interacted with patients and provided the emotional support required. We found staff had a strong sense of patient understanding and staff involved patients, families and carers where appropriate.

  • Feedback from patients and carers was consistently positive. Community services sought feedback from patients and carers and the walk in centres actively engaged with the public.

  • The culture in the community teams was one of teamwork and supporting each other. Management were found to be visible and supportive. There was a clear strategy in place for community services for adults. The strategy had yet to be implemented fully. Governance arrangements were in place and a clinical governance data pack included a clinical assessment tool, care summary data and patient outcome data.

Community health services for children, young people and families

Good

Updated 6 June 2016

We rated this service as good overall because:

  • Staff were aware of their responsibility to report incidents, they knew how to report incidents, near misses and accidents and were encouraged to do so. Learning from incidents was shared between teams and across the organisation.
  • There were safeguarding systems in place to protect children from harm, although some staff in the health visiting and school nursing teams were not receiving recommended amounts of safeguarding supervision. There was a dedicated safeguarding team in place.
  • Staff received mandatory training, although it was not clear whether all staff were up to date due to differences between recorded data held by the trust and individual practitioner’s records.
  • Staff received regular supervision and appraisals, although it was not clear whether some staff were up to date with their appraisal as figures provided by the trust indicated that they were not meeting the target for appraisals.
  • The service had sufficient numbers of staff and had appropriate sized caseloads in line with national guidance.
  • Care and treatment was evidence based with policies, procedures and pathways available to staff. There was good evidence of multi-disciplinary working and good transition arrangements were in place. Staff were aware of their responsibilities with regards to obtaining consent.
  • We observed staff treating people with compassion, kindness, dignity and respect. Feedback from children, young people and their families was positive.
  • Services were planned to meet people’s needs and the needs of different people were taken in to account. There were systems in place to make sure that children, young people and their families could access care at the right time and services were flexible enough to fit in with individuals needs. There were examples of innovative practice that aimed to make the services more accessible to people such as those with a learning disability. Feeback from service users was taken in to consideration when developing services.
  • Leaders were approachable, supportive and encouraged staff engagement. Staff knew the trust vision and values. Governance systems were in place to ensure delivery of good quality care.
  • While most of the services had their own strategy, the community directorate strategy did not incorporate children’s services within it.