The Newcastle upon Tyne Hospitals NHS Foundation Trust

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

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.

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.

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.

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.