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Provider: The Newcastle upon Tyne Hospitals NHS Foundation Trust 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
  • The Freeman Hospital
  • Dental Hospital
  • Centre for Ageing and Vitality
  • Community services including adult community services, community services for children, young people and families, community dentists and community end of life care

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 trust as outstanding. We rated effective, caring, responsive and well led as outstanding and safe was rated as good. We rated the Royal Victoria Infirmary, Freeman Hospital and the Dental Hospital as outstanding and community services as good.

Our key findings were as follows:

  • The trust had infection prevention and control policies, which were accessible, and used by staff. Across both acute and community services 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 and some wards were minimal.
  • 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:

Royal Victoria Infirmary

  • 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 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 totake partin 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.

The Freeman Hospital

  • There was an integrated model of care between the Specialist Palliative Care Team and the Cardiothoracic Transplant Team. The teams worked alongside patients with advanced disease including those waiting for transplant and those with ventricular assist devices.
  • A sleep checklist was developed for patients in critical care to optimise sleep. This included measures such as environmental factors, noise, temperature and light in patient areas.
  • Hydrotherapy rehabilitation after critical illness had been developed for patients who were ventilated which enabled them to move their limbs supported by water. This gave psychological support to patients and helped them engage with their rehabilitation programme.
  • Radiology facilities were adapted to meet the needs of patients with dementia or learning difficulties. This included distraction aids and mood lighting to help patients relax.
  • The trust Falls and Syncope Service was the largest of its kind in Europe and undertook research and treatment for patients presenting with a range of problems such as balance disorders, dizziness, low blood pressure or unspecified lack of co-ordination and falls.
  • The Northern Centre for Cancer Care (NCCC) in partnership with Macmillan was providing chemotherapy in three community health centres enabling access for non-complex treatments closer to home. Chemotherapy nurses from the NCCC ran this service.
  • The perioperative care team at the Freeman were national leaders in pre-operative assessment, cardiopulmonary exercise testing and outcome prediction after major intra-abdominal surgery (including shared decision making in the pre-operative counselling process).
  • The pancreatic service had developed a remote care service to assist clinicians in outlying hospitals to manage their patients. This was to avoid transferring ill patients to Newcastle when they could be managed at their base hospital. This service was coordinated by a nurse specialist and saved patients from being unnecessarily transferred to Newcastle but also ensured that those patients who may require specialist care were transferred at the correct time.

Dental Hospital

  • The service had introduced computer based virtual surgery in the planning of jaw excision and reconstruction. The dental hospital was considered the leaders in this field with experience in using this state-of-the-art package in the UK. It also demonstrated cross specialty multidisciplinary working between Oral and Maxillofacial Surgery and Plastic Surgery.
  • The dental multi-disciplinary team (MDT) worked with other departments such as oncology, cleft palate unit, orthodontists and cranial facial clinic. A MDT (nursing, anaesthetic, surgical) project was introduced to reduce the length of stay, use of high dependency beds and analgesic requirements for orthognathic (straightening of the jaw) cases. An MDT for headache or orofacial (mouth, jaw, face) pain met each month with neurology, to decrease the number of visits for patients with comorbid problems and improve the effectiveness and efficiency of care.
  • The teaching for sedation was nationally recognised as working to the gold standard within the UK.

Community health services for adults

  • The community Chronic Obstructive Pulmonary Disease (COPD) team worked closely with the North East Ambulance Service. When a patient exacerbated, the ambulance staff could contact the COPD team and they attended the patient within the hour.
  • A seamless, comprehensive and inclusive service to all patents had been developed by identifying four distinct service pathways for mild, moderate, severe types of stroke as well as one for long-term support and management. Each pathway within the model was tailored to meet patient need with optimum use of resources to maximise individual’s post stroke health maintenance, promote independence and quality of life as well as reducing re-admission to hospital and social services care requirements.
  • The community team had developed a pressure ulcer care plan and pressure ulcer checklist for housebound patients nursed at home. The care plans detailed essential assessments required and involved family and carers in the delivery of care in order to reduce the incidence of pressure ulcers.

Community health services for children, young people and families

  • The paediatric nutrition team consisted of a gastroenterologist, surgeon, pharmacist, dietician and specialist nurse. This team saw a high number of home patents with very good results. Outcomes of success were demonstrated in a reduction in morbidity, mortality and decreased costs.
  • The School Nursing Team offered pop-up’ interactive health stalls in the school environment. This new approach had received national recognition winning the Cavell Nurses’ Trust Award for School Nursing Innovation.

Community End of Life Care

  • There was nurse specialist input into 10 care homes that were taking part in the care homes project in Newcastle. The aim was to support care homes to deliver excellent end of life care.
  • Specialist Palliative Care Rapid Assessment was in place where a rapid assessment (within 1 hour) was offered to patients at home or in a care home to try to prevent unnecessary admission to hospital. The service ran 7 days a week. There was also capacity to work into the Emergency Department and the Assessment Suite at the RVI to facilitate rapid discharge home again if required.

Community Dental Services

  • The senior dental officer led on mental health issues and had developed with the trust’s mental health team a ‘best interests’ meeting agenda for use with patients who were unable to provide consent to treatment. Carers, social workers and other health professionals or interested persons were invited to the meeting to input into best interest decisions.
  • The service took part in an outreach-training programme for fourth and fifth year students; the programme ran for a whole year rather than a few weeks, which was the only programme of its type in the North East.
  • 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.

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 health visitors and school nurses receive safeguarding supervision every three months.
  • 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 that there are appropriate adaptations for patients with hearing difficulties in the community walk in centres.
  • Ensure that there is a formal escalation procedure for staff to follow in the event of patients deteriorating at the walk in centres.
  • 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

Good

Updated 6 June 2016

We rated safe as good because:

  • There were systems in place for incident reporting and staff received feedback and action taken to reduce the risk of reoccurrence. There was evidence of learning from incidents across all services. The requirements of Duty of Candour were followed and trust processes were open and transparent.
  • The trust scored higher than the England average in the Patient led Assessments of the Care Environment (PLACE) 2015 for cleanliness (Trust 100, England Average 98). All areas we inspected across the trust were clean and there were robust processes for the prevention and control of infection.
  • Despite staffing challenges, staffing levels were managed effectively. Escalation processes were well defined and embedded throughout the organisation to ensure safe staffing.
  • Processes were in place to manage and assess patient risks. Risk assessment tools were used to identify deteriorating patients and action taken appropriately. Plans were in place to respond to emergencies and major situations. All relevant staff understood their role and the plans were tested and reviewed.

However

  • Checks for the storage of medicine and resuscitation equipment were not consistently completed in some areas in line with trust policy and guidance
  • Information written in clinical notes about the care patients received in the Emergency Department and on some wards was minimal.
  • There were some infection control issues relating to mattresses in the Emergency Care Department. Staff removed the mattresses, which required condemning, during the inspection.
  • The majority of staff had received the appropriate level of safeguarding training however, health visitors and school nurses did not consistently receive safeguarding supervision every three months in line with national guidelines.
  • Although improvements had been made to ensure patients received antibiotics within one hour to treat sepsis, the latest audit showed compliance of 55%, which was still low.

Duty of Candour

  • The trust was aware of its obligations in relation to the Duty of Candour requirements. The trust’s ‘Being Open’ policy and serious incident reporting and management policy set out roles and responsibilities of staff to ensure the duty of candour requirements were met.
  • We received a few patient comments, which indicated that there had been inconsistencies and a lack of transparency in the information provided to them following incidents. However, we reviewed 10 serious incident investigation reports and saw examples of where the trust had informed the patient or relative of the harm, and provided an apology.
  • Staff were aware of the duty of candour requirements and could explain the principles of being open and transparent with patients, families and carers.
  • The trust published an ‘Open and Honest Care’ report on its website every month. This provided information on: safety performance; patient experience and details of improvement when lessons had been learnt from incidents.

Safeguarding

  • The Nursing and Patient Services Director on the Newcastle Safeguarding Adults Board and the Newcastle Safeguarding Children’s Board represented the trust at Executive level. Trust safeguarding professionals were proactive on all Board subgroups ensuring the trust was linked into all levels of multiagency developments and assurance processes.
  • The team worked closely with multi-agencies and represented the trust by attending multi-agency sexual exploitation reviews in Newcastle, domestic homicide reviews, Multi-Agency Police Protection Arrangements (MAPPA) and PREVENT – a government counter terrorism strategy which focuses on the potential radicalisation of staff or patients.
  • A Domestic Abuse Champions’ network had been developed.
  • The service had a dedicated, midwife responsible for safeguarding children, who worked alongside the named nurse for safeguarding children.
  • A safeguarding nurse advisor worked with Sexual Health Services to implement the under 18’s pro-forma which identified whether the young person was at risk of harm or abuse including child sexual exploitation.
  • The Looked after Children’s (LAC) Health Team worked in line with legislation for children and young people who were ‘looked after’. The LAC team assessed and identified the physical and emotional needs of children and young people placed in care.
  • There was a named doctor for adult and children’s safeguarding.
  • The trust was compliant with the recommendations of the Lampard Report following the Savile inquiry.
  • The majority of staff had received the appropriate level of safeguarding training however, health visitors and school nurses did not consistently receive safeguarding supervision every three months in line with national guidelines.

Incidents

  • There were 82 serious incidents reported between August 2014 and July 2015, 38 (46%) related to slips, trips and falls.
  • The number of reported NRLS incidents was lower (worse) than the England average (6.5 per 100 admissions compared to the England average of 8.4) however, there had been a slight increase in incident reporting.
  • There was one never event (a serious incident that is wholly preventable). This was in the Dental Hospital and related to wrong site local anaesthetic block. The service had carried out a thorough investigation of the event and actions to prevent recurrence were implemented.
  • The 2014 National NHS Staff Survey rated the trust at 29% for witnessing potentially harmful errors, near misses or incidents. This was better than the national average of 33%.
  • In the same survey, staff reporting potentially harmful errors, near misses or incidents was 91%, which was similar to the national average of 90%.
  • The trust had an incident reporting policy and staff reported incidents of harm or risk of harm using the trust risk management reporting system. Medical and nursing staff told us they felt confident reporting incidents and near misses.
  • Staff were trained in basic incident reporting as part of their initial trust and local induction. Incident investigators received specialist training which included the principles of root cause analysis (RCA), report writing and completing the investigation on the trust incident reporting system.
  • Staff discussed incidents at monthly quality and safety meetings attended by medical and nursing staff and senior managers. Staff also discussed current incidents, any actions, learning from previous incidents or changes to practice at daily safety handover briefings and team meetings.
  • Medical and nursing staff discussed mortality and morbidity at monthly governance meetings. Clinicians discussed recent cases, outcomes and actions, and the information was shared across staff groups.
  • We reviewed 10 serious incidents and the associated RCA reports. There were clear timelines and detailed action plans. There were processes through patient safety panels to review progress against action plans.
  • There was a process for managing safety alerts from the Central Alerting System (CAS). The details of alerts (received, closed and ongoing) were presented at the Corporate Governance Committee, along with drug alerts received from the Medicines and Healthcare Products Regulatory Agency (MHRA).

Cleanliness, infection control and hygiene

  • The trust had infection prevention and control (IPC) policies, which were accessible, understood and used by staff.
  • Health Care Associated Infections (HCAI) action plans were reviewed regularly by the Infection Prevention Control Committee (IPCC). HCAI was a standing agenda item at the trust main forums and directorate communication and governance meetings.
  • Across both acute and community services patients received care in a clean, hygienic and suitably maintained environment. However, there some infection control issues in the emergency care department relating to mattresses.
  • Results of the Patient-Led Assessments of the Environment (PLACE) 2015 showed that the trust scored, for cleanliness: 100, (the England average was 98).
  • Between August 2014 and August 2015, there were 7 cases of Methicillin Resistant Staphylococcus Aureus infection (MRSA) and 95 cases of clostridium difficile. The number of cases per 10,000 bed days was consistent over time and similar to the England rate.
  • There were 75 cases of MSSA in the same period. The rate per 10,000 bed days was generally above the England figure. The trust had focussed on areas where patients were at a higher risk of MSSA. A new root cause analysis to look at the source and contributory factors of MSSA in the trust was being developed.
  • Following each case of MRSA bacteraemia a rapid review and post infection review toolkit was completed. Lessons for learning were shared trust-wide.
  • Matrons completed monthly checks to monitor cleanliness. This included patient bed space, treatment rooms, the uniform and appearance of staff, environment and facilities.
  • The trust routinely monitored staff hand hygiene procedures and compliance at the time of inspection was high.
  • There was an in-house rapid response cleaning team who were available 24 hours a day 7 days a week across all sites.
  • Antibiotic stewardship was a standing agenda item at the IPCC. There were antibiotic leads appointed in the majority of medical specialities who attended the Antimicrobial Steering Group to have input into the audit process.

Environment and Equipment

  • There were processes in place for the checking of resuscitation equipment; however, in the emergency care department and on some medical wards, resuscitation checks were not consistently completed on a daily basis.
  • Some resuscitation trollies on medical wards did not have the medication drawers secured with a tamper proof seal, which meant there was a risk that medications were accessible.
  • In critical care at the RVI (Ward 38) there was a number of environmental and facilities issues. This was highlighted in the critical care risk register and in a trust gap analysis report to the Trust Board in 2015. Critical care was managing risks consistently well to ensure safe care.
  • In all services, there was adequate equipment to support the delivery of safe care. The trust scored better than England averages in the Patient Led Assessment of the Care Environment (PLACE) 2015 for facilities (Trust 100: England average 90).

Records

  • There was minimal information recorded in the nursing records in the Emergency department. For example, none of the 18 records looked at showed that risk assessments such as falls, skin pressure care or nutrition and hydration had been documented.
  • On some of the medical wards, it was not always clear due to illegible written entries who the name/grade of the nurse/clinician/other healthcare professional was who had made the note.
  • All nursing notes used in medicine included a core care plan identifying care needs however these were not always individualised to identify specific patient care needs.

Assessing and Responding to Patient Risk

  • The strategy and processes for the recognition of the deteriorating patient, including staff use of the National Early Warning Score (NEWS) was embedded. Records showed NEWS scores were completed correctly and staff were aware of the escalation process when a patient deteriorated.
  • The trust ensured compliance with the Five Steps to Safer Surgery through application of the World Health Organisation (WHO) surgical checklist. The WHO checklist audit showed note completion at 98%, sign in at 95.6%, time out at 94.1%, and sign out at 90.7%. Audits showed that 98% of the entire team attended the surgical briefings. We observed that theatre staff followed the ‘Five Steps to Safer Surgery’, and completed the World Health Organisation (WHO) checklist appropriately.
  • WHO documentation prior to surgery was fully completed. We also observed correct surgical site marking on a patient immediately prior to their surgery. The WHO surgical checklist was also used for radiological interventions.
  • Children’s services used the paediatric early warning scores (PEWS), an early warning assessment and clinical observation tool. This included a clinical observation chart, coma scale and additional information such as the pain score tools with an assessment table to assist clinical staff in determining what action nursing and medical staff should take for a sick child. We spoke with medical staff and nurses who demonstrated a clear awareness of how to assess patient risk and what action they would take in response. Senior nurses audited PEWS data through the Clinical Assessment Toolkit (CAT).
  • The trust took part in the National Audit of Inpatient Falls. This showed that the number of falls per 1000 patient days was in line with national averages, with the rates of falls resulting in harm being lower (better) than the national average.
  • The Fall and Syncope Service (FASS) based at the RVI was the largest unit of its kind in Europe. FASS undertook research for patients presenting with a range of problems such as balance disorders; dizziness; low blood pressure; gait; or unspecified lack of co-ordination and falls. New patients underwent a series of investigations to establish the cause of their condition and clinicians assessed, identified and treated risk factors for falls, blackouts, dizziness and osteoporosis.

  • The trust had signed up to the three year national ‘Sign up to Safety’ Campaign, which aims to save 6000 lives and reduce avoidable harm by 50%. The trust was carry out work in five patient safety domains sepsis, surgical safety, deteriorating patient, obstetrics and medication safety. Although improvements had been made to ensure patients received antibiotics within one hour to treat sepsis, the latest audit showed compliance of 55%, which was still low.

  • There was an established 24/7 critical care outreach team available on both hospital sites. The outreach team were involved in developing safer care of patients with tracheostomy. A number of approaches were being introduced as part of the National Confidential Enquiry into Patient Outcome and Death (NCEPOD, 2014) ‘on the right trach’ recommendations. Designated wards in respiratory medicine had been identified for all patients discharged from critical care as part of a trust approach.
  • The trust used the safety thermometer. This looks at four harms, pressure ulcers, falls, blood clots, and urine infections for those patients who have a urinary catheter in place. The scores for December 2015 showed 94.9% of patients did no experience any of the four harms whilst inpatients, 97.7% of patients did not experience any of the four harms whilst being treated in the community, overall 95.6% of patients did no experience any of the four harms in the trust.
  • Venous thromboembolism (VTE) assessment for 2014/2015 was 95.7% against a trust target of 95%.
  • Midwifery staff identified women as high risk by using an early warning assessment tool known as the Maternal Early Warning System (MEWS) to assess their health and wellbeing. This assessment tool enabled staff to identify and respond with additional medical support if necessary. Internal audit data for November 2015 showed good compliance with the MEWS tool.

Nursing and Midwifery Staffing

  • There was a monthly staffing paper to the Trust Board, reported in line with National Quality Board guidance. Nursing establishments were reviewed using the Safer Nursing Care Tool, planned and actual staffing data and other metrics including the judgement of the sister, matron and senior nursing team.
  • Inpatient areas underwent a six monthly nurse staffing review to ensure safe and effective staffing levels across the trust. Midwifery used ‘Birth Rate’ plus as a tool to review staffing. Nursing “Red Flag” events continued to be recorded on the Nurse Day Count Web page; validation of the information in the application was currently taking place.
  • The overall fill rates in October 2015 were 88.9% for registered nurses (day duty) which showed an increase for the third month in a row. Night duty, fill rates had also increased in October 2015 to 93%. The HCA night duty, fill rates continued to be over 100%.

  • The service did not meet the national benchmark for midwifery staffing set out in the Royal College of Obstetricians and Gynaecologists guidance (Safer Childbirth: Minimum Standards for the Organisation and Delivery of Care in Labour) with a ratio of 1:30 across both community and hospital staff against the recommended 1:28. However, records showed that women received 1:1 care in labour. For example, data for the Birthing Centre showed 1:1 care was 100%.

  • The nursing establishment in critical care at the RVI corresponded to Royal College of Nursing (RCN) and British Association of Critical Care Nurses (BACCN) national guidance and could provide 1:1 care for level 3 patients and 1:2 care for level 2 patients.
  • The neonatal unit did not meet the staffing levels recommended by the British Association of Perinatal Medicine (BAPM). This was a risk on the directorate risk register. BAPM recommends that the nurse to baby ratio for intensive care should be 1:1 (one nurse to one baby). For high dependency care, the ratio should be 1:2 and low dependency care should be 1:3. This was 54% of the time. However, staffing levels were reviewed daily and to ensure the safety of the infants, the matron and clinical lead made decisions to close some cots or infants were transferred to other special care baby units in the region. Following a staffing review, recruitment was on going to ensure the unit complied with BAPM.
  • The community children’s services were well staffed. Health visitors caseloads were within the caseload limit recommended in ‘The Protection of Children in England: A progress Report (March 2009).
  • The Trust Board continued to show commitment to provide substantive funding to support the full time role of the Lead Nurse for End of Life/Bereavement Care.

Medical Staffing

  • The proportion of consultants was better than the England average. The proportion of junior doctors and middle grade doctors was worse than the England average (Junior doctors 10% against and England average of 15%; Middle Grade doctors 6% against an England average of 9%)
  • There was 24/7 consultant cover in the emergency department.
  • The delivery suit had consultant obstetric cover 98 hours per week. This was based on an onsite consultant presence for 14 hours a day seven days a week.
  • The skill mix for children’s services was in line with the England average for junior doctors, registrars, middle grade doctors (doctors with at least three years’ experience as senior house officer or at a higher grade) and consultants.
  • The neonatal unit followed the British Association of Perinatal Medicine (BAPM) recommendations and adopted a tiered approach to medical staffing. Junior doctors and two consultants supported two parallel rotas, one for the ward and the other supporting the neonatal transfer service.
  • Ward 38 and 18 at the RVI met all of the requirements of the Core Standards for Intensive Care (2013) for medical staffing, with the exception of standard 1.1.3, for ratio of consultants to patients out of hours.
  • The trust performed within expectations for all questions on the 2015 General Medical Council (GMC) National Training Survey.

Medicines

  • The trust had an effective medicines governance and incident reporting structure. The Medicines Safety Working Group clearly focused on the areas identified in the medicines arm of the Trust’s ‘Sign up to Safety Campaign’.
  • A new protocol for the investigation of medicines incidents had been piloted with greater focus on reflective practice and sharing learning, this was being rolled out across the trust.
  • A regular patient safety bulletin was issued to all staff to help ensure awareness of any current themes or alerts. Additionally, a medicines dashboard was being developed to look at progress towards agreed medicines optimisation targets including medicines reconciliation; take home medicines turnaround times, community pharmacy referrals and for targeting pharmacist support to agreed priority areas.
  • An internal audit of medicines security was completed in November 2015 and an action plan was being developed against the issues identified.
  • The trust had identified that the pharmacy service had “reached a critical point where demand appears to outweigh capacity”. There was only a limited seven-day clinical pharmacy service, focused on the assessment wards. Additionally, levels of specialist pharmacist cover to critical care were lower than the recommended minimum. This had not affected service delivery but had reduced the time available to support for example, education sessions and capacity to cover absences.
  • A pharmacy strategy review was underway focusing on pharmacy skill mix and effective ways of working. Trust figures showed that completion of 24-hour medicines reconciliation across the trust was less than 30% against their own target of 70%. Action was being taken to try to improve this through the pharmacy skill mix review and future adoption of an electronic healthcare gateway, providing quicker and easier access to patients’ medicines information on admission. The figures also demonstrated that pharmacy support was being effectively directed to patients identified as a high priority, with 75% of priority pharmacy tasks being completed.
  • The trust had also exceeded its targets for patient referral to local pharmacies on discharge. This referral programme was designed with the North of Tyne Local Pharmaceutical Committee to reduce the level of patients having problems with medicine after discharge from hospital.
  • Pharmacy provided ongoing support for the development of the Trusts Electronic Prescribing and Medicines Administration [EPMA] system. The EPMA had been in use for several years with roll out to the Children’s ward planned for the financial year April 2016. Consideration was also being given to implementing electronic interaction alerts for prescribers. We saw that updates to the system were monitored to help manage changes effectively. The children’s wards demonstrated lower compliance with the trust’s antibiotic prescribing policy than areas of the trust using EPMA. A recent audit showed that the number of reported medicines incidents on children’s ward had increased over the last five years. The lead clinician was consulting with other providers about this trend and it was envisaged that implementation of the EPMA should help to reduce medicines incidents.

Effective

Outstanding

Updated 6 June 2016

We rated effective outstanding because:

  • The trust was actively involved in local, national and international audit activity and followed recognised guidance that provided a strong evidence base for care and treatment. New evidence-based techniques and technologies were used to support the delivery of high quality care.

  • There were opportunities to participate in benchmarking, peer review, accreditation and research which staff proactively pursued.
  • 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. Where outcomes were worse than the national average, the trust ensured measures were in place to make improvements.
  • The trust had a clear policy to provide guidance for obtaining consent from patients within the organisation.
  • There were excellent examples of multi-disciplinary working to secure good outcomes and seamless care for patients. Staff in all disciplines worked well together for the benefit of patients. There were trust wide multidisciplinary teams with established links to local speciality teams across acute and community settings.

Evidence based care and treatment

  • During 2014/2015, the trust participated in 100% national clinical audits and 100% of the national confidential enquiries of the national clinical audits and national confidential enquiries, which it was eligible to participate in.
  • The Corporate Governance Committee monitored recommendations by external agencies and the actions, which arose from these, so that compliance was assured. The services reported a total of 15 visits, inspections and accreditations during the period 1 April – 30 September 2015. Of the 15 visits, inspections and accreditations, final reports had been received for 13 of the visits, inspections and accreditations. Of the 14 reports received, the results showed that in five cases all outstanding actions had been completed / or there had been no actions identified following the visit, inspection or accreditation. In the reports, which did have ongoing actions, these were added to the trust’s action plan.
  • Each clinical directorate was required to present an Annual Clinical Audit Report to the Clinical Effectiveness, Audit and Guidelines Committee, detailing all audit activity both national and local.
  • There was evidence of improvements from audits, for example, two consultants had provided extra on call to contribute to the rating of the Sentinel Stroke Audit Programme (SSNAP) improving.
  • In acute kidney injury, the trust had expanded the outreach service and put new protocols and training for junior doctors in this area.
  • Radiation protection supervisors for each modality led on the development, implementation, monitoring, and review of the policy and procedures to comply with Ionising Radiation (Medical Exposure) 2000 regulations IR(Me)R.
  • There was adherence to NICE CG50 for acutely ill patients in hospital. Work included, bi-monthly audit, improvements in general, neurological and spinal charts and a clear NEWS policy.
  • Patients at risk of VTE were risk assessed and prescribed prophylaxis in accordance with NICE QS3 Statement 5. Audit and monitoring was carried out to ensure compliance targets were maintained.
  • The children’s bone marrow transplant unit was accredited with JACIE, a joint initiative of theEuropean Group for Blood & Marrow Transplantation(EBMT) and theInternational Society for Cellular Therapy (ISCT), Accreditation to JACIE meant the unit had undergone a rigorous inspection process and was working in line with international standards.
  • Community children’s services were effectively delivering the Healthy Child Programme (HCP). The HCP is an early intervention and prevention public health programme offered to every family and is an opportunity to identify families in need of further support.

Nutrition and Hydration

  • Patient-led assessments of the care environment (PLACE) audit scores were consistently higher than the England average. Statistics showed quality of food scored 99% (England average 88%).
  • There was a nutrition policy, which included the need for screening for malnutrition 24 hours of admission and weekly thereafter (adults and children). The matrons audited screening rates as part of the trust wide nutritional audit. Data was collected using a Nutritional Care Tool.
  • A range of menus were available to meet a diverse group of patients including cultural, religious, dementia/older adults, learning difficulties, large print and pictorial.
  • Dieticians left feeding plans on each surgical ward for patients requiring nasal gastric feeds required out of hours, which allowed nurses to commence feeding regimes.
  • The trust had implemented United Nations Children’s Fund (UNICEF) Baby Friendly Initiative standards. The maternity unit was awarded full UNICEF baby friendly accreditation in October 2014, and were due for reassessment in October 2016.
  • There was a screening tool for the assessment of malnutrition in paediatrics to assess and monitor a child’s nutritional status.

Patient outcomes

  • The level of mortality calculated using the standard Summary Hospital-level Mortality Indicator (SHMI) showed the trust to have death rates within expected levels.
  • Data from the most recent Health and Social Care Information Centre SHMI release covering the period October 2014 - September 2015 showed for the majority of cancer types the trust performed better than expected with a smaller number of deaths observed than expected. There was only one cancer type (rectum) where there were a greater number of deaths than expected but the numbers were small with only one additional death to the expected figure.
  • The trust performed better than the England average for half of the indicators in the 2015 Hip Fracture Audit.
  • In the 2014, Bowel Cancer Audit the trust performed better than the England average for all indicators.
  • The trust performed better than the England average for two out of three indicators in the 2014 Lung Cancer Audit.
  • The RVI stroke service performed well in the Sentinel Stroke National Audit Programme (SSNAP) recording a level B at trust level and at team level, a C overall (where A is the best and E is the worst) rating during July - September 2015.
  • The trust performed better than the England average in each of the three indicators in the 2013/2014 Myocardial Ischaemia National Audit Project.
  • The trust performed better in nine of the 11 indicators in the 2012/2013 Heart Failure Audit, although proportionally fewer patients received an echocardiogram when compared to the national average (38% compared to 91%).
  • The majority of indicators in the National Diabetes Inpatient Audit were better than the England average.
  • The 2013/2014 Intensive Care National Audit and Research Centre (ICNARC) showed that the RVI performed as expected; ward 38 performed better than expected on mortality. The Freeman Hospital performed worse than expected on two ICNARC indicators on hospital mortality.
  • The trust achieved four of the seven organisational key performance indicators (KPIs) and performed better on all but one of the 10 clinical KPIs in the 2013/2014 National Care of the Dying Audit.
  • Trauma Audit Research Network (TARN) information showed 99% of patients with a head or spinal injury and 98% of patients with a chest or abdomen injury were seen by a consultant within five minutes of arrival.
  • The health visiting teams were performing within targets in relation to the Healthy Child Programme. Figures provided by the trust showed that 89.4% of birth visits were done between 10-14 days, 88.5% had a review by eight weeks, 85% had a 12-month assessment and 87% had a two to two and a half year assessment.
  • The rates for babies breastfeeding at six weeks was 46.3%, which was slightly above the England, average of 45.2%.
  • The College of Emergency Medicine (CEM) audit for mental health in the emergency department showed that the department was better than the England average for the two fundamental standards and identified some work for the department to do to ensure that the results for the developmental standards improved.
  • The results of the CEM audit, assessing for cognitive impairment in older people in the emergency department showed that the department was failing to meet the fundamental standard that all patients over 75 should have an early warning score completed. This result had been discussed with staff and staff were reminded of the importance of recording assessments. A new paperless system was in development. This would not allow staff to progress without completing an early warning score.
  • The CEM audit, initial management of the fitting child showed that the emergency department was better than the national average for all but two standards.
  • There were no risks identified in maternal readmissions, emergency caesarean section rates, elective caesarean sections, neonatal readmissions or puerperal sepsis and other puerperal infections (Source: HES 2014/15; Intelligence Monitoring Report May 2015).
  • Emergency caesarean section rates between April and December 2015 were 15%, which was comparable with the England average of 15%. For elective sections, the service achieved 14%, which was worse; than the England average of 11%, however, this was comparable with other regional trusts.
  • The laboratory services maintained full United Kingdom Accreditation Service (UKAS) clinical pathology accreditation (CPA) and the Medicines and Healthcare Products Regulatory Agency (MHRA) compliance for its transfusion service.
  • The most recently published BMT annual report (2014) showed clinicians had performed 35 transplants on children and young people. Of these, 10 were haematology-oncology patients and 25 were immunology patients. The overall survival rate was 89%.
  • Data provided to us by the trust showed the five-year survival rate for children and young people between 0 and 19 years was over 82%. This was higher than the national average and indicated the North of England Cancer Network was the best performing network out of 28 across the country.

Multidisciplinary working

  • There were excellent examples of multi-disciplinary (MDT) working to secure good outcomes and seamless care for patients across acute and community settings.
  • Staff teams and services found innovative and efficient ways to deliver more joined-up care for patients.
  • There were effective MDT processes throughout the stroke care pathway at the Centre for Ageing and Vitality where patients received MDT involvement on the stroke rehabilitation unit.
  • There were clear internal referral pathways to therapy and psychiatric services. Additionally, staff confirmed external referral to community services also flowed well and community services would attend MDT meetings.
  • The Burns Service was run by a highly skilled multi-disciplinary team made up of specialist surgeons and nurses, together with psychologists who provided emotional support during a very difficult time for patients and their families.
  • The dental multi-disciplinary team (MDT) worked with other departments such as oncology, cleft palate unit, orthodontists and cranial facial clinic. A MDT (nursing, anaesthetic, surgical) project was introduced to reduce the length of stay, use of high dependency beds and analgesic requirements for orthognathic (straightening of the jaw) cases.
  • The trauma and orthopaedic department worked closely with a range of disciplines to maximise outcomes for patients. MDT ward rounds took place including physiotherapy, and occupational therapy input alongside the surgeon.

Consent, Mental Capacity Act & Deprivation of Liberty safeguards (DoLS)

  • Records showed patients had consented to surgery in line with Department of Health guidelines. This included the risks, benefits and alternative options of treatment.
  • The trust’s consent policy had a section specifically about children and young people. Staff we spoke with understood the Gillick and Fraser guidelines and gave examples of how they had applied them in practice. Staff explained that the consent process actively encouraged children and young people to be involved in decisions about their care.
  • The trust consent form was being changed so that for patients undergoing elective care where a period of critical care was anticipated explicit consent for this was documented.
  • The trust had over 80 MCA leads in the trust to support staff where mental capacity assessment was a key element of a patients care.
  • Critical care was taking a proactive approach to the management of patient’s assessment of capacity and DoLS. They had developed local guidelines with the lead for the trust and safeguarding team and in consultation with the Intensive Care Society, the trusts appointed solicitor and the Law Commission.
  • Advice provided around mental capacity was reflected in the adult safeguarding dashboard each month.

Caring

Outstanding

Updated 6 June 2016

We rated caring as outstanding because:

  • Feedback from patients and their relatives was continually positive about the care they received.
  • All staff consistently communicated with patients in a kind and compassionate way, treated them with dignity, and respected their privacy. There were many examples of staff at all levels going that extra mile to meet patient’s needs.
  • Staff created a strong, visible, person-centred culture; they were highly motivated and inspired to offer the best possible care to patients. Patient’s emotional and social needs were highly valued by staff and were embedded in their care and treatment.

  • Patients were involved and encouraged to be involved in their care and in making decisions. They received sufficient information in a way they could understand.

Compassionate care

  • The results of the CQC Inpatient Survey 2014 showed the trust performed around the same as other trusts and in four areas, (The hospital and ward, nurses and care and treatment) the trust was amongst the better performing trusts.
  • The Cancer Patient Experience Survey 2013/2014 showed the trust was in the top 20% of trusts for 10 of the 34 indicators and the middle 60% of trusts for the other 24 indicators.
  • Results from the CQC Maternity Service Survey 2015, showed the service was about the same as other trusts for labour and birth and care in hospital after the birth and scored better than other trusts for staff during labour and birth.
  • The results of the CQC A&E Survey 2014 showed the trust was performing about the same as other trusts for all but one of the questions ‘did a member of staff help to reassure you if you were feeling distressed while you were in the A&E department’ which was worse than the national average.
  • The results of the National Children’s Inpatient and Day Case Survey 2014 published in June 2015 showed that overall 91% of parents and 89% of children and young people rated care at 7 or more out of 10.
  • Results of the Patient-Led Assessments of the Environment (PLACE) 2015 showed that the trust scored, for privacy, dignity and wellbeing: 90, (the England average was 86).
  • Between August 2014 and July 2015, the trust had higher recommendation percentages in the NHS Friends and Family Test
  • Patient feedback data across the trust showed a very high level of satisfaction across all care services. Information from 2 minutes of your time survey feedback showed very high levels of satisfaction, with those surveyed stating they would recommend the service, were satisfied overall and were treated with dignity and respect.
  • 32 patients (80%) completed the Colorectal Cancer Patient Information Satisfaction Survey. Of the 32 patients that responded 81% stated that they met with the Stoma Nurse in outpatient’s clinic prior to surgery. Seventy-three percent stated the information provided about their condition was excellent, and 85% rated the service as excellent.

  • The inflammatory bowel disease clinic carried out audits of patient experience. Of the 100 patients surveyed, over 70% of patients rated the service as excellent. The audit also took steps to identify areas for improvement, including increasing awareness of how to contact the team and access to MDT support.
  • Results from the CQC Children and Young People’s Inpatient and Day Case Surgery Survey 2014 showed the trust scored better than other trusts when parents were asked if their child was given enough privacy when receiving care and treatment. Parents, children and young people thought staff were friendly, listened to them and treated them with dignity and respect.

Understanding and involvement of patients and those close to them

  • The trust performed better than other trusts nationally on the CQC inpatient survey question ‘were you involved as much as you wanted to be in decisions about your care and treatment’.
  • According to the 2014 A&E Survey, the department scored about the same as other trusts for questions relating to understanding and involvement.
  • Results from the CQC Children and Young People’s Inpatient and Day Case Surgery Survey 2014 showed the trust scored better than other trusts when parents were asked if a member of staff explained what would be done during the operation or procedure.
  • Responses from teenager cancer patients from a ‘So How Are We Doing’ survey were very positive. 100% of responders said, overall, they were given enough support from the team looking after them and 90% said they were given enough information about their condition at the time they were first diagnosed.
  • In the 2013/2014 Cancer Experience Survey, the trust was in the top 20% of trusts for patients receiving understandable answers to important questions all/most of the time and patients were given a choice of different types of treatment.

Emotional support

  • The Macmillan nursing team offered counselling and support to patients and staff on the respiratory ward.
  • There were clinical nurse specialists across a wide range of services, supporting children and young people with long-term, complex medical conditions, including leukaemia, solid tumours and burns. The Children and Young People Oncology Outreach Nurse specialist team (CYPOON) cared for children and young people receiving end of life care. Feedback from the CYPOON parent experience survey described the service as ‘excellent’.
  • The school nursing service provided group work in school around bereavement. Practitioners used motivational interviewing techniques in order to empower families to manage problems and difficulties.
  • The trust had good provision of spiritual, religious and pastoral support.
  • Annual memorial services were held in critical care. Over 400 relatives of patients who had died within the critical care units attended the service in November 2015
  • Bereavement policies and procedures were in place to support parents in cases of stillbirth or neonatal death; a specialist midwife and a labour ward lead supported this. People’s emotional and social needs were highly valued by staff, for example, the service was developing the butterfly project in partnership with the neonatal unit.

Responsive

Outstanding

Updated 6 June 2016

We rated responsive as outstanding because:

  • The trust worked closely with its commissioners and external stakeholders on service redesign and the transformation agenda.
  • The trust performed overall consistently well with regard to the how quickly patients could access care and receive treatment.
  • There were innovative approaches to providing integrated person-centered pathways of care that involved other service providers, particularly for patients with multiple and complex needs.
  • Services were planned around the needs of local people and there were good relations with local commissioners. Systems were in place for the management of complaints, and there was evidence of improvements following complaints.

However

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

Service planning and delivery to meet the needs of local people

  • The trust worked closely with its commissioners and external stakeholders on service redesign and the transformation agenda.
  • The trust had developed an informal network with local GPs from North of the Tyne to improve communication, identify areas of common interest and focus on areas of development and improvement.
  • In community services, the Community Response and Rehabilitation Team (CRRT) worked with primary care to minimise inappropriate admissions/readmissions to hospital. The team delivered an integrated health and social care model, which centred on short-term support, for vulnerable patients and those with long-term conditions. The aim was to promote their independence health and wellbeing.
  • There was active involvement in the North of England Critical Care Network and good practice and learning was shared across the region.
  • Services were responsible for developing and submitting capacity and demand plans however, standardisation of the capacity and demand process was being developed as we were told that currently it was done differently across the directorates.

Meeting people's individual needs

  • There was a Learning Disability Liaison Team and a dedicated learning disability Nurse.
  • The trust had worked with a Newcastle based community arts organisation to develop short films featuring people with learning disability and their carers as they come into hospital to have an x-ray, CT or MRI scan. The videos were accessed directly from the patient appointment letter.
  • Patients had hospital passports, a personal document containing important health needs information.
  • The learning disability liaison team received alerts using e-records when a vulnerable patient was admitted. The team also emailed the nurse in charge of the ward to ensure their pathway of care was adjusted to meet patient’s needs.
  • The learning disability team collected patient feedback using an easy-read questionnaire or by talking with the patient following attendance.
  • From January 2015, the trust piloted a review of care and treatment of patients who died in the trust and had a clear diagnosis of a learning disability. In the mortality reviews, the learning disability team gave attention to discussion with the MDT, mental capacity assessments and reasonable adjustments.
  • Patients with purely mental health needs received support in the emergency department to wait in a designated room. There was access to the the psychiatric liaison team by telephone and the trust was working towards having the team based in the emergency department in the near future.
  • Speech and Language therapists trained patients with aphasia (inability (or impaired ability) to understand or produce speech, because of brain damage) to ‘befriend’ and support other patients with aphasia for them to return to meaningful activity in the community.
  • Processes were in place to support children, young people and families from different ethnic backgrounds, those with hearing impairment and those from the lesbian, gay, bisexual and transgender (LGBT) community.
  • The GNCH provided the North East Children’s Transport and Retrieval (NECTAR) service, a standalone commissioned service that provided intensive care for children from the point of referral to the handover of care at the receiving unit. It operated 24 hours a day, 365 days a year, triaged all referrals and provided a consultant-led telephone advice service. NECTAR also transported children home for palliative care.
  • Clinicians held outreach clinics across the country for those children who lived outside of the region. For example, consultants from the children’s’ bone marrow transplant unit ran clinics in cities across the UK and Ireland for pre and post-transplant patients.

Dementia

  • The trust dementia strategy provided an overview of the aims and objectives for the care of people with dementia and their families and carers. The strategy had three main themes care and partnership, support and development of staff and assessment and pathways of care.
  • There were policies and procedures to ensure people with dementia were identified. This included the use of red lids and cups at mealtimes to identify the extra needs these patients may have and ‘forget me not’ cards. This provided staff with details about patients, such as social history and favourite foods.
  • A number of wards and areas had been designed as ‘dementia friendly’ with appropriate signage to aid communication, with triggers for reminiscence such as music, photographs and decorations to encourage positive interactions.
  • In conjunction with Age Concern, wards 9 and 18 at the RVI used ‘dementia navigators’ to help signpost and inform patients and family members about dementia services in their location.
  • Staff assessed patients with known or possible dementia, cognitive impairment or delirium. Compliance with these assessments was monitored. Step 1 Dementia Awareness Reporting in medicine for September 2015 was 92.36%; Step 2 was 90.9% and Step 3 83.3%.
  • The trust was supporting ’John’s campaign’ a national campaign for the right of carers to stay with patients with dementia in hospital. This was being rolled out across the trust initially targeting older people’s medicine wards.
  • Progress against the dementia commissioning for quality and innovation target (CQUIN) was being sustained, with the ‘find, assess and investigate’ element of the CQUIN routinely performing well in excess of the 90% target.
  • The trust held focus groups for carers to share stories about being a carer for someone with dementia, what their experience was when their relative was in hospital and what the trust could do to support them. The feedback from focus groups and monthly audits were used to improve patient care.
  • The Community Response and Rehabilitation Team used a patient experience project to improve the skills, knowledge and documentation of the team caring for patients in their home with cognitive impairment. This included early identification of patients with actual or cognitive impairments, access to mental health services, involvement of GPs in decision-making and links with voluntary agencies.

Access and flow

  • Between April and October 2015, 95.3% of patients were seen within four hours of arrival in A&E. However, the 95% target was not met in April, June and September.
  • Between April 2014 and October 2015, no patients waited on a trolley in A&E for more than 12 hours before being either discharged or moved to a ward.
  • Between July 2015 and October 2015, no patients waited longer than 60 minutes to be handed over from ambulance staff to A&E staff.
  • The trust had achieved the 2-week cancer waiting times for a first outpatient appointment in all specialties. Results for the previous 12 months ranged between 95.5% and 96.5%, better than the England Average.
  • The trust had met the overall referral to treatment targets (RTTs) of patients admitted for treatment within 18 weeks of referral up to September 2015 except for trauma and orthopaedics, which achieved a rate of 85.9%. The overall rate for the trust for the 6-month period prior to our inspection ranged between 95% and 96%, slightly better than the England standard of 95%. However, for the six-month period prior to that, the trust had achieved lower results ranging between 91.5% and 95%.
  • According to information supplied by the trust, the percentage of appointments cancelled by the trust over the four months between May and August 2015 ranged between 5 and 8.7%, which was worse than the England average of 6%.
  • The percentage of patients with incomplete care pathways who started their consultant-led treatment ranged between 92% and 94.7%. The operational standard in England is 92%. This rate had dipped in the second half of 2014 but rapidly improved by the end of the year and for the first six months of 2015; the trust had maintained its performance above the England average.
  • The trust was performing consistently similar to or better than the England average for the percentage of people waiting less than 62 days from urgent GP referral to first definitive treatment for all cancers. Between 84% and 89% of patients were seen within 62 days in 2015.
  • The previous 12 months’ appointments showed the RVI outpatient departments booked 1,454,375 appointments with a new to review ratio of 1:2.7 (the number of new appointments compared to the number of reviews) for all appointments which was similar to the England average.
  • Out of 556 cancelled operations over a two-year period, 17 patients were not treated within 28 days (Q2 2013 to Q2 2015/16). There were fewer cancelled operations as a proportion of elective admissions in surgery, compared to the England average.
  • In quarter 2 2014/2015, bed occupancy increased to 89.1%. This had since reduced, and data for quarter 2 (2015/2016) showed bed occupancy of 84%.
  • The trust provided data, which confirmed 36% of delayed transfers of care were due to the patient waiting for further non-acute NHS care. A further 35% of delayed transfers were due to patient or family choice.
  • Every Friday there was a ‘Safe Friday Report’, which enabled plans to be agreed for the weekend and then shared with the Patient Services Co-ordinator to support managing patient flow and staffing out of hours.

Learning from complaints and concerns

  • A comprehensive and current complaints policy covered the complaints management process for the trust.
  • The number of written complaints received had decreased from 0.40 for each 1000 patient contacts in 2014/2015 to 0.34 in 2015/2016, a decrease of 14%.
  • During 2014/2015, 37 complaints were accepted by the Health Service Ombudsman, 14 investigations were fully or partly upheld and 20 investigations were not upheld
  • The Chief Executive had overall responsibility for NHS complaint handling issues, reading complaints and signing off responses. Complaints monitoring information was reported to the Trust Board each month.
  • The complaints panel met monthly and reviewed all complaints summaries to identify issues, trends and themes and address any concerns.
  • Complaints panel scrutiny was by two non-executive directors, two public governors, and other executive and senior staff.
  • Staff knew how to access the complaints policy and procedures and felt the process was open and honest. Staff were aware of actions to take when concerns were raised.
  • We reviewed ten complaints. Each complaint was signed by the Chief Executive and contained a compressive response, apology and where required an action plan.

Well-led

Outstanding

Updated 6 June 2016

We rated well-led as outstanding because:

  • There was a very clear vision and strategy for delivering the highest standards of patient care with quality and safety as a key focus. There was open engagement and involvement of patients, staff and external partners in the successful delivery of the trust’s strategic goals.

  • There were effective reporting arrangements and governance systems up to the board. Financial pressures were managed so that they did not compromise the quality of care. The trust was transparent, open and worked with all relevant stakeholders about performance. There was a strong focus on continuous learning and improvement at all levels of the organization.
  • The trust valued and encouraged public engagement. The trust actively promoted projects to support patient choice.
  • The levels of clinical engagement and leadership across both acute and community settings were strong. Staff were proud of the organisation as a place to work and spoke highly of the culture. There were consistently high levels of constructive engagement with staff. Staff at all levels were encouraged to raise concerns and contribute to service improvement. There was exceptional innovative practice across acute and community settings.

Vision and strategy

  • There was a very clear vision of delivering the highest standards of patient care with quality and safety as a key focus. Staff from all areas we visited were aware of the vision of promoting safe and effective care to improve patient experience. This was reflected in the National Staff Survey 2014, 84% agreed or strongly agreed that care of patients was the trust’s top priority, compared to 67% nationally.
  • The trust had a nursing and midwifery strategy 2013-2016. It identified five sections reflecting the trust’s priorities for the next three years and these linked into the national and local initiatives and policy.
  • There was a quality strategy 2015-2018, which outlined key priorities for patient safety, clinical effectiveness and patient experience. The clinical strategy further underpinned the delivery of safe, high quality care.
  • Research was an integral part of clinical practice to improve patient experience. The research strategy and innovation framework supported this.
  • The organisations objectives were linked through to service performance targets.
  • The trust was part of the urgent care vanguard for the North East and was part of two accountable care organisations.
  • Services developed annual action plans that were in line with the priorities set out in the trust strategy.

Governance, risk management and quality measurement

  • The trust had a well-established governance framework that supported delivery of safe and high quality care from ‘ward to board’. At a service, level across both acute and community there were processes in place for teams to review incidents and ensure shared learning.
  • A Board Assurance Framework and Corporate Risk Register identified strategic and operational risks. We reviewed the corporate risk register, which documented actual risk, control measures and residual risk ratings. The Assurance Framework was under regular review by the Audit Committee and the Trust Board.
  • There were a number of committees that provided assurance to the board; non-executive directors chaired these. All assurance committee chairs attended the Clinical Governance and Quality Committee. The chair of the Clinical Governance and Quality Committee however was unable to attend the meeting consistently and we raised concerns regarding the impact on the effective functioning of this committee.
  • We reviewed a sample of clinical governance and quality reports that formed part of the board papers, there were no concerns raised from this review.
  • Services had clinical governance leads and held their own governance meetings. We reviewed a sample of governance meeting minutes from 2015, which showed evidence of review of incidents, complaints, and risk registers. Actions were agreed and there were mechanisms for ensuring follow-up actions.
  • Services held local risk registers and there was a clear process for escalation of risk. However, in emergency care and end of life care the risks discussed with senior managers during the inspection did not accurately reflect all the risks identified on directorate risk registers.

  • We reviewed 10 root cause analysis reports from serious incident investigations. The reports included contributory factors although some did not clearly identify the root cause. Action plans were concise and effective and changes to reduce the risk of recurrence was evidenced. Duty of candour was addressed with specific details of when the patient and/or family were communicated with and an apology given.
  • The Patient Safety and Quality Reviews monitored national audits where a data pack was presented containing audit compliance. Each service presented an Annual Clinical Audit report to the Clinical Effectiveness and Guidelines Committee detailing the local and national audits they had undertaken.
  • Clinical audit leads identified any potential risks of compliance with National Confidential Enquiries or NICE and evidenced these onto the trust risk register.
  • The clinical director for patient safety sat on the Clinical Effectiveness and Audit group as well as the serious incident and complaints panel, which showed a good cross over of audit needs.
  • The trust had a business continuity policy. This described the roles, responsibilities, and processes to ensure continuity of services, protection of patients and staff and the reputation of the organisation. Each service had a business continuity lead. Staff were aware of the process for identifying and escalating an incident that was causing service disruption.
  • The trust had signed up to the three year National ‘Sign up to Safety’ Campaign. During April to September 2015, project leadership was established, including clinical experts and multi-disciplinary teams.
  • The Health & Safety Team had developed a Health and Safety Compliance Audit Tool to measure compliance with new trust Health and Safety requirements. Questionnaires were completed on a quarterly basis, returned to the Health and Safety Team and a quarterly report provided to the Trust Health and Safety Committee.
  • A monthly Clinical Assurance Tool (CAT) provided clinical assurance to the Trust Board in the form of an overview of performance against a wide range of clinical and environmental measures for each ward and service. The aim of the CAT was to measure and demonstrate compliance with the published documents and national drivers such as High Impact Actions, Saving Lives. Feedback and, where necessary, reports on improvement actions were provided to the Corporate Governance Committee.
  • There were patient safety briefings led by clinical directors for patient safety and quality, the Director of Quality and Effectiveness and heads of nursing. The briefings were designed to keep staff up to date with current best practice and ensure that lessons were learnt from incidents and near misses that happened in the trust.
  • A serious incident panel met each month, which included, the medical director, director of nursing, heads of nursing, clinical directors and head of patient safety and risk. The panel discussed new serious incidents, Duty of Candour, monitored on-going investigations, ensured actions were implemented and trust wide learning. The panel reported to the Clinical Governance and Quality Committee.
  • Nurse staffing levels were reviewed in line with the National Quality Board guidance 2013. We reviewed a six monthly staffing review report to the Board.
  • Services had a performance and accountability framework and they were held to account by the Executive Director with lead responsibility. The trust had detailed performance reports; we reviewed a performance report, which provided information on finance, performance, workforce, quality and risk. Formal performance reviews were held every six months and chaired by the Executive Director aligned to the service.
  • If services were performing below expectation there, were processes to ensure that additional support was provided so that improvements were made.
  • There was a cost efficiency programme (CIP) for 2015-2016, which was reviewed by the Cost Improvement Operational Group. The Associate Medical Director and Head of Nursing reviewed all service plans for CIP achievement to ensure that these did not increase clinical risks or adversely affect patient experience. There were no breaches with Monitor relating to financial sustainability.
  • There were effective processes for learning from complaints. A monthly complaints panel mailer was sent to all staff, complaints were discussed in patient safety briefings and clinical governance meetings. Service level, patient experience dashboards included complaints analysis by theme and department. Evaluation of the complaints handling process was through patient satisfaction surveys and sent with all final responses.
  • Governance and quality measures for Harm Free Care were reported to the Board through the Quality Accounts and themed board reports. This included Falls Task Force – ‘No falls on my Patch’ and Pressure Ulcer Task Force – ‘Time to Turn’. Task forces were multidisciplinary, chaired by the Deputy Director of Nursing and reported to the Clinical Risk Group. Dashboards supported directorate analysis.
  • When considering developments to services or efficiency changes, the trust undertook trials and audits prior to a full roll out of a new system or procedure. The relevant Board committees sanctioned all innovation through review, monitoring and subject to approval.
  • The annual governance declarations declared compliance with quality, finance and performance standards.

Leadership of the trust

  • There was a well-established senior executive team which was highly visible, challenging and with a commitment to the delivery of a high quality service and improvement agenda.
  • Staff were proud to work for the trust and felt supported to work at the organisation; staff described leadership at a local level as supportive.
  • In the 2014 NHS Staff Survey, the percentage of staff reporting good communication between senior management and staff was better than the national average.
  • Executive and non-executive directors would walk round clinical and non-clinical areas on a monthly basis and would talk to staff. The chair told us that he would often go out into the clinical areas and sit in waiting areas to observe services. Although there was no fixed agenda, there were ‘rules’ to support the process.
  • Non-Executive Directors had annual appraisals by the trust committee responsible for their appointment (Nominations Committee) to ensure that they carried out their roles effectively.
  • We found examples of effective leadership throughout the organisation. A Clinical Director, and a Directorate Manager supported by a Matron led each of the services.
  • Leadership programmes were in place to support the development of leadership across the organisation, for example the trust had a ward sister’s development programme
  • The Council of Governors expressed a strong commitment and enthusiasm about the trust. Minutes of governors meetings showed presentations by directors, senior managers and staff. Governors were consulted on various trust operational and strategic plans, including financial, clinical and quality performance measures and attended various committees for example Complaints Committee.
  • Governors said they visited ward areas to listen to patient and staff concerns and were encouraged to give feedback to the Board about quality of patient care and felt this was taken seriously and acted on by the Board. Minutes showed a number of governor visits to wards and departments.
  • The trust had developed expectations and core behaviours expected by all staff in their ‘Professional and Leadership Behaviours’ Guide.

Culture within the trust

  • We were told that the culture of the trust had been changing to a more open culture in which staff were able to raise concerns in a no blame culture.
  • The trust had a ‘Freedom to Speak up’ action plan in response to the Francis Report, which was monitored by the Trust Board. There was a ‘freedom to Speak Up Guardian’ that was independent from the organisation. Staff could raise concerns through email that was not part of the trust.
  • The trust had introduced Schwartz Rounds, an initiative that arose from discussions with trust staff post the report of the Mid Staffordshire NHS Trust Public Enquiry. Schwartz rounds provide a confidential forum for staff reflection and support. Seven Schwartz rounds were held up to November 2015; almost 600 staff had attended the first seven rounds. Feedback from staff was very positive.
  • Following listening events with staff, the trust agreed to support the piloting of ‘Speak in Confidence’ an online anonymous dialogue system. The system was launched in March 2015. Twenty senior staff were identified as ‘points of contact’ and since the system went live, 52 dialogues were initiated. The most frequently used categories related to patient /staff safety, improvement ideas and leadership.
  • In September 2015, the trust appointed a Freedom to Speak Up (FTSU) Guardian to enable staff to raise concerns in an appropriate and supported way. In addition, the trust has continued to develop its ‘Speak up we’re Listening’ brand to ensure support and resources are accessible to staff. All relevant information was centralised on to a single webpage on the trust intranet. This included details of how to contact the FTSU Guardian.
  • The trust used a values based recruitment process.
  • Sickness absence rates were similar to the national average.

Fit and Proper Persons

  • The trust was prepared to meet the Fit and Proper Persons Requirement (FPPR) (Regulation 5 of the Health and Social Care Act (Regulated Activities) Regulations 2014). This regulation ensures that directors of NHS providers are fit and proper to carry out this important role.
  • We looked at employment files, which were completed in line with the FPPR regulations. However, in one case a new NED was appointed in December 2015. The trust policy requires pre-employment checks in line with the regulations. In this case, these were not done, the HR department confirmed they were not engaged in the appointment and have been asked to do the checks post-employment.

Public engagement

  • The trust Patient, Carer and Public Involvement Strategy and Plan 2015-2017 set out involvement at all levels to ensure services were planned around the needs of patients and that continuing improvements in the patient experience was achieved.
  • A monthly patient experience report went to the Trust Board. Following the appointment of a Head of Patient Experience, work was continuing to integrate patient carer and public involvement (including Family and Friends), equality and diversity, and complaints management.
  • The trust regularly sought the opinions of patients and received feedback from a number of National Patient Experience Surveys. Locally the trust had implemented the Friends and Family test and a real time patient feedback system across acute and community services.
  • There was a well-established and proactive Community Advisory Panel, which consisted of patients using or who had used trust services and /or their relatives. The panel met each month to hear from speakers on various issues and consider requests for involvement. The panel sat on a number of groups such as the Patient Carer and Public Involvement Group, Nutrition Steering Group and Outpatient User Group. The panel provided an annual report to the Chief Executive.
  • Outpatients had implemented a work placement programme for young adults with learning difficulties. Following successful work placements, the trust had employed three young people. Project Choice had won the Workforce Award at the 2015 HSJ Awards.
  • Eye Clinic Liaison service staff had won a Healthwatch Award in October 2015 for their work with the charity Action for Blind people. This provided an improved link between medical and social care teams and studies carried out by staff had shown that there had been a reduction in patient falls and consultations.
  • In response to feedback from patients, requiring infusion therapy to treat multiple sclerosis (MS) related symptoms, this service had now moved permanently to private cubicles in the neurosciences short stay unit.
  • Young people from the Teenage Cancer Unit were involved in making a DVD, designed to welcome new patients to the unit, which included information ranging from what to eat and taking your own temperature.
  • Children and young people were involved in the assessments to achieve ‘You’re Welcome’ accreditation.

Staff engagement

  • There was strong clinical engagement and input in to the development of services and efficiency changes. The consultant focus group were very positive about the support they received from executive directors, they all said that they were listened to, supported and encouraged to make changes to improve the quality of patient care.
  • The NHS Staff Survey 2014 showed that the trust was in the top 20% for staff engagement. The number of staff recommending the trust as a place to work was higher than the national average.
  • The trust had introduced ACE Awards (Acknowledging Continuous Excellence) which recognised consistent achievement in five areas, cleanliness, patient experience, assurance measures, clinical assurance and staff knowledge. A number of wards and staff had received this award.
  • There were monthly safety briefings across the trust led by the senior nursing and medical teams. Nurses, midwives and AHPS of all grades attended a multi-professional forum.
  • The trust had an active Lesbian, Gay, Bisexual and Transgender service, a Black, Asian and Minority Ethnic Staff Network and was a Stonewall Diversity Champion. Patients of the trust had been influential in supporting and moulding these groups, for example, the service incorporated gender identity awareness into nurse preceptorship training.
  • The trust had a programme of visits for Non-Executive Directors to the clinical areas.

Innovation, improvement and sustainability

  • New evidence-based techniques and technologies were used to support the delivery of high quality care. All staff were actively engaged in activities to monitor and improve patient outcomes and there were many opportunities to participate in benchmarking, peer review, accreditation and research.
  • All staff members had access to the trust’s ‘Innovations Portal’. The portal allowed staff to log their innovative idea, which was considered for implementation. Once logged, all ideas were assessed and considered by a wide range of professionals and departments in the trust. To date over 70 ideas have been put forward (portal launched April 2015).
  • 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 totake partin national and international breast cancer treatment trials, as well as reconstruction studies.
  • The school nurses won a Cavell Nurses’ Trust Award for School Nursing Innovation and a trust award for their pop up interactive health stalls.
  • The stroke service was nationally recognised as a centre for innovation and excellence. Examples of this included: being part of eight sites in the country that carry out complex hyper-acute stroke research; being one of only two sites in the country to successfully implement a trial in providing stem cell intravenous therapy (PISCES); and receiving a national award from the stroke research network for being the top recruiter in commercial clinical trials.
  • The neurology department had developed numerous pioneering services such as videoconferencing complex clinic allowing case discussions with clinicians across the UK and the establishment of care standards for patients with mitochondrial disease that have been adopted throughout the UK and internationally.
  • Rheumatology innovations had seen the service develop the first specialist spodyarthritis nurse in the UK and the early arthritis clinic which was shortlisted for a ‘Best Practice Award’ by the British Society for Rheumatology and had excellent results in National Clinical Audit for Early Arthritis (HQiP).
  • The home ventilation service delivered care to around 500 patients in their own home in 2014/15. The service led the way for patients who need 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 dental hospital had introduced computer based virtual surgery in the planning of jaw excision and reconstruction. The dental hospital was considered the leaders in this field with the experience in using this state-of-the-art package in the UK. It also demonstrated cross specialty multidisciplinary working between Oral & Maxillo-facial Surgery and Plastic Surgery.
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 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.

End of life care

Good

Updated 6 June 2016

Overall rating for this core service Good

Overall, we rated community end of life care as good because:

  • Incident reporting was effective across the service. Staff were aware of their reporting responsibilities and there was evidence of learning from incidents.
  • Risks to patients were assessed and managed to ensure safe delivery of care. Staff responded appropriately to safeguarding concerns. There were systems and processes for the monitoring of medicines and infection control.
  • Staffing levels were adequate to meet patient demands; these were monitored and reviewed daily.
  • Documentation and care records were completed appropriately. Do not attempt cardio-pulmonary resuscitation (DNACPR) forms were completed consistently. Equipment was available for patients and appropriate safety checks were in place. There was equipment available in patients’ homes and use of anticipatory prescribing of medicines at the end of life.
  • The Community Specialist Palliative Care Team provided effective end of life care to patients. The trust had implemented the Care of the Dying Patient document within the community, which was being used as a guide to deliver high quality end of life care.
  • The feedback from people who used the service and those who were close to them was extremely positive about the care received by patients nearing the end of life. Staff always considered personal, cultural, social and religious needs when delivering care.
  • Care and treatment was planned and delivered in line with current legislation. There was a multi-disciplinary approach to care and treatment within community services.
  • Improvements had been made to fast track the discharge of patients at the end of life and all staff were aware of and involved in, supporting patients to be cared for in their preferred place of care.
  • There were innovative approaches being implemented to achieve the joined up service within acute and community end of life teams. Local managers were proactive and demonstrated an understanding of the current issues facing the service.