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Provider: Northumbria Healthcare NHS Foundation Trust Outstanding

Inspection Summary


Overall summary & rating

Outstanding

Updated 5 May 2016

Northumbria Healthcare NHS Foundation Trust provides services for around 500,000 people across Northumberland and North Tyneside with 999 beds. The trust has operated as a foundation trust since 1 August 2006. The trust manages adult social care services on behalf of Northumberland County Council and it also has General Practitioner services.

The trust serves one of the largest geographical areas of any NHS trust in England, from the Scottish border down to North Tyneside and west across to Tynedale.

We inspected Northumbria Healthcare NHS Foundation Trust as part of our comprehensive inspection programme. This did not include the adult social care services managed on behalf of Northumberland County Council or the General Practitioner services. We inspected this trust between 9 and 13 November 2015 and 2 December 2015.

Overall, we rated it as outstanding. We rated it outstanding for being effective, caring, responsive and well-led, and good for safe.

Our key findings were as follows:

  • The trust covered a large geographical area that managed four acute hospitals, a large community service and various other smaller community hospital sites. It was a very geographically diverse and complex trust. We rated all four hospitals and community services as outstanding.
  • The trust had undergone a major transformation and change during the previous four months before our inspection with the reconfiguration of the acute care pathways through the Northumbria Specialist Emergency Care Hospital (NSECH).
  • The opening of NSECH in June 2015 had resulted in a new model of care and different patient pathways in emergency, maternity and medical and surgical care at this hospital. This had resulted in different ways of working for some staff.
  • Inspirational leadership and strong clinical engagement had ensured that this change had been managed extremely well and effectively.
  • Staff felt fully informed about all the changes which had taken place and were proud of the trust and the care it provided to the local community and beyond.
  • Strong governance structures were in place across the trust and there was a systematic approach to considering risk and quality management. Senior and site level leadership was visible and accessible to staff. Leadership was encouraged at all levels and staff supported to try new initiatives.
  • Managers at all levels understood the challenges of the new model of care and were actively addressing any issues that this had presented, specifically around nursing and medical staffing and patient acuity.
  • There was total integration of all services between the hospital and community.This was particularly apparent in end of life care services.
  • Staff and patient engagement was seen as a priority with several outstanding and effective systems in place to obtain feedback.
  • When we spoke with managers and staff throughout the trust, the “Northumbria Way”, which incorporates the trust’s values, behaviours and culture was evident.

  • Staff delivered compassionate care, which was polite and respectful and went out of their way to overcome obstacles to ensure this. All patient feedback was extremely positive.
  • There were excellent processes to ensure patients were cared for in the right place at the right time. Patient flow was a priority, and the trust proactively managed this.
  • For all performance measures relating to the flow of patients the trust was performing the same or better than the England average.
  • The transfer of patients between NSECH and the ‘base’ hospitals was still being configured and embedded at the time of inspection and staff were working flexibly to accommodate patient needs.
  • The trust had infection prevention and control policies in place, which were accessible, understood and used by staff.
  • Patients received care in a clean, hygienic and suitably maintained environment.
  • The trust routinely monitored staff hand hygiene procedures and at the time of inspection, compliance was high.
  • Between June 2014 and June 2015, there were 2 cases of MRSA, one in January 2015 and one in February 2015.
  • There were 30

    cases of Clostridium difficile with peaks in June and November 2014 and

    February and May 2015. This was an average of around 2 each month.

  • Nurse staffing was maintained at safe levels in most areas. The trust had implemented a ‘Safer Nursing Care Tool’ (SNCT) to assess the staffing requirements across wards.
  • The ratio of consultants was better than the England average.
  • The trust utilised advance nurse practitioners to support doctors.
  • Community services staffing levels and caseloads were meeting national recommendations.
  • Mortality and morbidity meetings were held at least monthly and were attended by representatives from teams within the clinical business units.
  • Patients were assessed regarding their nutritional needs using the Malnutrition Universal Screening Tool (MUST).
  • Nutritional assistants were employed to provide patients with eating and drinking assistance if required within the hospital sites.
  • The trust followed the ‘well organised ward’ model to ensure that equipment storage was standardised and consistent across the trust.

We saw several areas of outstanding practice including:

In medical care:

  • The joint working by the falls team, which has raised the profile of falls and engaged staff, patients and their relatives in trying to reduce falls.
  • The role of nutritional assistants and the focus on the nutritional needs of patients which had improved the patient experience.
  • The ‘real time’ data collected on patient experience to assess how each ward is performing.
  • The inclusion of a psychological assessment for patients who require isolation for infection prevention reasons.
  • The development of comfort care packs for relatives.

In surgery services:

  • North Tyneside General Hospital is rated in the top five hospitals in the country for the treatment of emergency hip fractures.
  • North Tyneside General Hospital was recently recognised by the General Medical Council as the best in the country for the quality of training for orthopaedic surgeons of the future.
  • The service had developed a day case mastectomy service. This was proposed to save 201 bed days each year. Average length of stay had also reduced to between 2.7 and 4.2 days (depending on patient risk at the time of surgery). This compared to a national average of around 4.8 days.
  • The development of the ‘block room’ had resulted in a streamlined approach to the recovery of patients following surgery.
  • Guidelines for oncoplastic breast reduction and guidelines for best practice in reducing surgical site infections had been developed.
  • A dedicated team contacted patients by telephone following discharge to gather information about any immediate concerns the patient may have and provide advice and guidance.

In critical care services:

  • Over 300 days without an avoidable pressure ulcer and the overall safety thermometer results.
  • Patient outcomes and the access and flow data were adjusted internally to monitor the standardised mortality ratio following the trust’s change to the model of delivery of care.
  • A member of staff had been nominated for multiple awards for their compassionate care: The NHS FAB stuff awards; patient champion of the year: North East and they came second in trust experience nationally.
  • The pit stop handover for all admissions to the unit had been developed with human factors training using formula one pit-stop models, to facilitate a structured handover and improve patient safety.
  • The culture of everyone was valued and 'had a voice' seemed embedded in the daily multidisciplinary safety huddle.
  • Staff considered patients individual preferences and evidently went out of their way to exceed expectations to meet their wishes particularly in end of life care.
  • Staff had adapted the “This is me” booklet and used it for long term patients where they included information from relatives and visitors about the patients personal preferences.
  • The rehabilitation after critical illness service.
  • Leadership of the service was excellent particularly in relation to the planning, preparation and the move to NSECH. Time was taken to engage staff in cross-site working prior to the move and work undertaken to standardise guidelines, procedures and equipment.

In acute children and young people's services:

  • Planning for the new model of care and facilities in the hospital was excellent. Managers had fully engaged staff in planning which resulted in a smooth transition into the new build and services being quickly up and running. Following a training needs analysis, staff had received additional training to ensure they had the correct skills to deliver the new model of care. There was ongoing work to further support staff in adjusting to the new services especially in the Children’s Unit.
  • The volume of information collected from service users was outstanding. The trust had innovative ways of engaging with patients and used a number of different methods for collecting information. This was shared with managers and clinical staff in order to improve services for children and young people.
  • A mother told us that while she was in recovery following the birth of her baby, a member of staff from the special care baby unit brought her a picture of her baby. She was extremely happy with this, as she was upset that she had to be separated from her new born baby. We thought this was extremely caring and responsive to her needs.
  • A parent passport was in place in the special care baby unit. This was held and completed by parents to increase their involvement in caring for their baby. The passport summarised the parents confidence and competence in carrying out this care. Following discharge, it provided a record for other healthcare professionals to understand the continuing needs of the parents in caring for their baby.
  • The trust was supporting a Consultant Clinical Psychologist in a longitudinal study to address the question of how health services could contribute most effectively to facilitating successful transition of young people with complex health needs from childhood to adulthood. The study involved young people from the conception of the research idea and throughout the course of the programme. Information from the study was fed into the National Institute for Care Excellence (NICE) as part of a consultation on draft guidelines on transition. The trust had a robust trust policy, which included transition and transfer of young people with long-term conditions and disabilities, which was being rolled out across business units. We thought the work on transition was outstanding.

In end of life care:

  • The model of end of life care services working alongside acute services at NSECH and out into the community was an innovative and pioneering approach to care.
  • Specialist palliative care was aligned with emergency care to ensure patients received specialist palliative care at the earliest opportunity.
  • The trust had responded to a higher than anticipated number of referrals to the specialist palliative care team by increasing the specialist palliative care resource within the hospital.
  • The trust had adopted an innovative approach to providing an integrated person-centred pathway of care in partnership to provide services that were flexible, focused on individual patient choice and ensured continuity of care.
  • The trust had taken positive action to increase the number of patients who were dying in their usual place of residence.
  • The leadership, governance and culture were used to drive and improve the delivery of high quality person-centred care through collaboration and partnership working. The trust had clear leadership for end of life care services that was supported at the top of the organisation.
  • Investment in end of life and palliative care services was apparent and staff we spoke with consistently told us they felt that end of life care was a priority for the trust.
  • Innovations were seen in relation to a focus on spiritual support and an assessment model that aimed to increase staff understanding of spirituality and confidence around assessment.
  • Partnership working with Marie Curie and joint management and nursing posts enabled the trust to provide prompt support and continuity of care for patients being discharged to their preferred place of care in the community.
  • The development of a tool for the assessment of patients spiritual needs that focused on providing staff with prompts that would make it easier for them to have this discussion with patients. The tool also helped staff to engage in a clearer way to ensure patients understood.

In outpatient and diagnostic imaging services:

  • NSECH provided a seven day a week consultant led outpatient trauma service for people from across Northumberland and North Tyneside to access, as well as a teleconference clinic for patients who lived in Berwick, almost 60 miles away.

In Community health services for adults:

  • The immediate response team (IRT) provided urgent support for people in a time of crisis. The IRT team joint worked across adult social care between Northumbria Healthcare NHS Foundation Trust and the local authority. The partnership working had developed a range of integrated services to support care closer to home for patients and avoid unnecessary hospital admissions. The fully integrated team of community health and social care staff aim to make contact with the person in need within two hours of the first call for assistance, and could provide equipment to help people move around their house, arrange emergency short term care support to enable them to remain at home, and help people to regain their confidence and independence.
  • Community Adult Services ran a free of charge ‘Inspired Carer Masterclass’ for staff from local residential care and nursing homes to improve care for patients receiving care in care homes. This was a one day course for care home managers and staff. The training covered dementia care, falls prevention, infection prevention and control, swallowing assessment, depression, skin integrity, and supporting families. The training was delivered by a variety of CAS staff including community matrons, SALT, and physiotherapists.
  • Community Adult Services had specialist community research nurses that were funded by the trust’s research and development team. For example, the Tissue Viability Service (TVS) research nurse was involved in a clinical trials study with a university into pressure ulcer mattresses. The TVS service had also conducted research for a large corporate company who specialised in providing products for advanced wound management.
  • The TVS had introduced a SSKIN bundle and ‘reminder note’ for pressure ulcer care. This had resulted in the trust moving from being a national outlier in pressure ulcer care, to performing better than the national average.

In Community Services for Children, Young People and Families:

  • Patient outcomes were consistently high and better than the England average. For example, the immunisation rate for measles, mumps and rubella (MMR) vaccine in children aged two was 96% in Northumberland and 96% in North Tyneside, both better than the national average of 93%. The health visiting service ensured all new mothers received a Maternal Mood review and the family nurse partnership exceeded their fidelity stretch goals.
  • There were excellent arrangements to support young people with complex needs and learning disabilities transitioning to adult services. Specialist school nurses supported the transition process for 17 to 19 year olds and the trust had recently appointed a dedicated specialist nurse to review current practice and identify any gaps in the service.
  • Staff from all community services for children and young people went beyond the call of duty to provide compassionate care and emotional support. Parents were unanimously positive about the care they and their children received. We heard and observed examples of outstanding practice that demonstrated staff were caring, compassionate, understanding and supportive.
  • Community services for children and young people had proactively participated in the 'You’re Welcome' toolkit, which was a quality criteria highlighted in the National Service Framework for Children. The toolkit sets out a number of principles to ensure young people aged 11 to 19 (including vulnerable groups) were able to access services better suited to their needs. The toolkit covered 10 key areas assessed, including accessibility, publicity, confidentiality/consent, the environment, staff training, skills, attitudes and values.
  • Services contributed to addressing the public health needs of children and young people. For example, the family nurse partnership had identified an increase in the number of teenage mothers who had returned to smoking once they had given birth. The team sought support from the trust’s Stop Smoking Team who, in turn, trained the nurses to identify triggers and deliver appropriate intermediate care and treatment. This included the use of smoking monoxide monitors and prescribing patches to help sustain the level of reduction.
  • The trust involved and engaged with local communities in planning services for children and young people. Community services in Northumberland had developed a participation strategy and were actively training young people as part of the reaccreditation programme for the You’re Welcome initiative. There were also two participation groups: the Northumbria Healthcare Young Apprentices gathered feedback about services for children and young people provided by the trust; while the Northumberland College Partnership Health Reference Group offered consultation on literature, materials and resources to ensure they were age appropriate, and met the needs of children and young people.
  • Young people were an integrated part of the sexual health service. The service had a very proactive health promotion team who involved young people to promote the delivery of sexual health messages. For example, young people from the YMCA Young Health Champions and the Young People’s Health and Wellbeing Group worked with the health promotion specialist to develop a ‘One2One DVD’. The aim of the DVD was to inform and encourage young people to access appropriate services when they needed to.

In community dental services:

  • The service had developed an orthodontic service to meet the needs of vulnerable children who would not normally be able to access general dental practice due to their physical, sensory, intellectual, mental, medical, emotional or social impairments or disabilities.
  • The service had also co-developed with colleagues in the North East Oral Health Promotion Group, a comprehensive resource pack to support oral health maintenance in elderly care home residents of care homes across Northumbria. The resource folder contained information that oral health promotion teams, commissioners of services, care home managers and their staff could use to deliver key oral health messages. For example, the information for care home staff included learning outcomes, a training session, and quiz and power point presentation detailing key oral health messages. The service has successfully implemented the award scheme in care homes across Northumberland, assuring improved health in their setting.
  • The service oversaw the dental care of all looked after children in the North Tyneside area. This work began several years ago and involved a consultation process with children, young people carers and professionals. They developed a multidisciplinary approach and created a defined dental care pathway for looked after children within North Tyneside. Northumbria Dental Services received an award by the Patient Experience Network National Award for this pioneering work.
  • The oral health promotion team was instrumental in developing innovative resources for patients with learning disabilities. One resource was a patient information booklet that shows a typical journey through the service for patients with learning disabilities. Patients collaborated on the project and took and modelled in the booklet’s photographs. Another dental resource was developed by the oral health promotion team as part of the ‘Jack and Josephine’ initiative. Jack and Josephine are life size cloth models that act as learning aids for men and women’s groups in Northumberland. As part of this project the oral health promotion team developed a leaflet resource about a dental visit using Jack and Josephine to support care provision to patients with learning disabilities.
  • The oral health promotion team was developing a dental component for the Trust’s young peoples ‘You’re Welcome’ project which supports and encourages younger people to access health services in a timely manner.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • Complete a comprehensive gap analysis against the recommendation made for the University Hospitals of Morecambe Bay NHS Foundation Trust in relation to maternity services.
  • Ensure that the maternity and gynaecology dashboard is fit for purpose, robust and open to scrutiny.
  • Ensure that the entry and exit to ward 16 in Maternity services at Northumbria Specialist Emergency Care Hospital are as safe as possible to reduce the risk of infant abduction.
  • Ensure that the storage of emergency drugs, within maternity services at Northumbria Specialist Emergency Care Hospital, are stored safely in line with the trust’s pharmacy risk assessment.
  • Ensure risk assessments in relation to falls, pressure ulcers, VTE and nutrition are consistently completed for all patients within medical care services at NSECH.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Good

Updated 5 May 2016

We rated safe as good because:

  • Nurse staffing was maintained at safe levels in most areas. However, there were times when rosters indicated that registered nurse staffing levels did not meet planned levels, particularly at Northumbria Specialist Emergency Care Hospital (NSECH). When staffing levels fell below planned this was proactively managed and senior staff regularly reviewed ward establishments following the collation of patient dependency data. The trust were in the process of carrying out a phased review of ward establishments and staffing to ensure acuity levels are met with the right staffing levels. Staffing levels were improving.
  • The trust met the national benchmark for midwifery staffing as set out in the Royal College of Obstetricians and Gynaecologists (ROCG) guidance (Safer Childbirth: Minimum Standards for the Organisation and Delivery of Care in Labour) at most hospitals across the trust. The national recommendation was 1:28.
  • However, at NSECH site-specific data provided by the service identified a 1:36 ratio based on 3000 births a year.
  • 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 the business units. 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.
  • Checks on resuscitation equipment were not consistently completed in some areas within medical care services.
  • On inspection placentas were stored appropriately within the birthing unit at NSECH, however, we found inappropriate non-clinical items stored in the placenta freezer. We raised concerns with staff, and the items were removed immediately by senior staff.
  • The storage of emergency drugs on the birthing centre and ward 16 were not in line with the trust’s pharmacy July 2015 risk assessment, and the service was not using tamper evident boxes in which to store drugs required in ward areas. We found the infant abduction policy had not been tested since the move to the new birthing unit at NSECH, despite an incident reported by a member of the public who was able to leave and enter the unit unchallenged.
  • At NSECH, we found varying degrees of completeness across all medical wards in relation to both nursing and medical records, specifically in relation to pressure area, falls and nutritional risk assessments. VTE assessment was also variable on the medical wards.

Cleanliness, infection control and hygiene

  • The trust had infection prevention and control policies in place, which were accessible, understood and used by staff.
  • Across both acute and community services patients received care in a clean, hygienic and suitably maintained environment.
  • The trust routinely monitored staff hand hygiene procedures across all areas and at the time of inspection, compliance was high. There was an infection control accreditation process in place. We reviewed data for June 2015 and July 2015 which showed high levels of compliance (95% to 100%) across a range of clinical areas.
  • 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).
  • From June 2014 to June 2015 there were 2 cases of MRSA, one in January 2015 and one in February 2015.
  • There were 30 cases of Clostridium difficile with peaks in June and November 2014 and February and May 2015. This was an average of around 2 each month.
  • There were 21 recorded cases of MSSA with a peak in May 2015, an average of just below 2 each month.
  • The trust had hydrogen peroxide vapour (HPV) technology for the disinfection of patient rooms and bays within the trust which could be used. During our inspection we saw rooms being cleaned using this method. It was available 24 hours each day

Duty of Candour

  • The trust was aware of its obligations in relation to the duty of candour requirements.
  • The trust had executive leads for duty of candour; these were the Executive Director of Nursing, Executive Director of Operations, Executive Director of Community Services, and Executive Director of Performance and Governance.
  • The trust has updated its 'Being Open policy' to include the CQC duty of candour regulations.
  • The trust utilised the incident reporting within the Datix incident management system to record and monitor any notifiable safety incidents which invoke the duty of candour regulations. We observed examples of this in practice.

  • We reviewed 9 serious incident root cause analyses 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. At clinical governance meetings throughout the trust, discussions about duty of candour included how to apply it in practice and examples of application.
  • Training was available to provide staff with a clear understanding of the duty of candour. Recently appointed members of staff told us they had received information about duty of candour as part of the trust induction programme.
  • 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 together with stories of patient experience.

Safeguarding

  • The trust had appropriate safeguarding policies and procedures were in place for both adult and children. The policies and procedures were supported by staff training.
  • The trust’s director of nursing was the executive lead for safeguarding adults and children.
  • There were effective processes for safeguarding mothers and babies. The trust had dedicated midwives responsible for safeguarding children.
  • The trust had an action plan in place in response to the Savile Inquiry.
  • We found the infant abduction policy had not been tested since the move to the new birthing unit at NSECH, despite an incident reported by a member of the public who was able to leave and enter the unit unchallenged.
  • Community adult services had a named lead district nurse specialist for adult safeguarding.
  • Appropriate staff across both acute and community services received one-to-one child protection supervision sessions from the safeguarding team at least every six months (sometimes more frequently), complying with trust policy.
  • Health visitors, school nurses and looked after children nurses received one-to-one child protection supervision sessions from the safeguarding team at least every six months, in accordance with trust policy. Most staff told us these sessions often took place more frequently, around every three months. Outcomes from each session were recorded on SystmOne, the trust’s electronic records system, so staff could easily access the advice and feedback for future reference. Compliance was measured using a performance dashboard and when we reviewed this data, we saw 100% of staff had received the required supervision by 30 June 2015.
  • The safeguarding children named nurse and senior nurses had a high profile across the community children and young people’s services.
  • Staff had access to the Patient Administration Systems (PAS), which alerted staff to identify any child subject to a child protection plan, or who was looked after, or where a Multi-Agency Risk Assessment Conference (MARAC) had occurred.
  • There was a designated doctor and designated nurse for looked after children. The named nurse attended monthly safeguarding meetings, run by the local authority, to discuss cases and issues involving missing, sexually exploited and trafficked children and young people.
  • The Children’s Unit at NSECH used a quality assessment tool to assess if injury was accidental or non-accidental. The tool recorded condition, witness, incident, location, time, escort, and description (CWILTED).
  • The trust had a safeguarding strategy and monthly safeguarding board meetings were held. Minutes and action plans were in place and meetings were attended by senior staff from across the trust. This meeting provided a forum for staff to discuss safeguarding concerns and share learning across the trust. Local safeguarding leads had been appointed.

Incidents

  • Between July 2014 and July 2015, there were 15,397 incidents reported trust wide. Of these 8,139 (73%) were reported as no harm and 22 (0.20%) reported as severe harm.
  • The number of reported NRLS incidents is higher than the England average at 10.6 per 100 admissions for the same period data was requested.
  • The ‘2014 National NHS Staff Survey’ rated the trust at 28% for witnessing potentially harmful errors, near misses or incidents. This was lower than the national average of 34%.
  • In the same survey, staff reporting potentially harmful errors, near misses or incidents was 92%, which was better than the national average of 90%.
  • Never events are serious incidents that are wholly preventable. There had been one such event in 2015 which related to a dental extraction error within community dental services. The community dental service had carried out a thorough investigation of the event and as a result a very robust safe site check list protocol had been developed by the service. We saw this system in operation during our visit at Wansbeck Hospital where we observed patients having teeth removed. We observed staff adhering to the system in full with great care taken over each step of the process and backed up with meticulous record keeping.
  • There were no active Care Quality Commission mortality outliers for this trust.
  • In the NHS 2014 staff survey, 56% of staff believed that staff who were involved in an incident, error or near miss were treated fairly. This was better than the national average of 48%.
  • 57% of staff said they agreed or strongly agreed that they received feedback about changes made in response to incidents, errors, or near misses. The national average was 44%.
  • Between April and June 2015 the trust recorded five avoidable grade two pressure ulcers (two in April, two in May, and one in June) and two avoidable grade three/four pressure ulcers (one in April and one in May). No avoidable pressure ulcers were reported at Hexham.
  • During our inspection we attended the weekly incident reporting meeting (IR1 meeting). At this meeting all incidents that had been reported during the previous week were discussed. Matrons and ward managers from all medical wards attended and discussed the incidents pertaining to their areas of responsibility including detailing the actions that had been implemented. Matrons advised of any further requirements and also tracked any ongoing incidents and updates were provided. We saw the minutes of these meetings.
  • We reviewed nine serious incidents and 5 significant learning events and the associated root cause analyses.We saw clear timelines and detailed action plans. There were processes in place through the safety panels to review progress against the action plans.

Environment and Equipment

  • In all services we found that there was adequate equipment to support the delivery of care.
  • The trust scored higher than the England average in the Patient Led Assessments of the Care Environment (PLACE) 2015 for facilities (Trust 96, England average 90).
  • At the Northumbria Specialist Emergency Care Hospital (NSECH) we found the infant abduction policy had not been tested since the move to the new unit, despite an incident reported by a member of the public who was able to leave and enter the unit unchallenged.
  • Within maternity services at NSECH, we also found inconsistent practices in the checking of rooms and equipment.
  • The storage of emergency drugs on the birthing centre and ward 16 at NSECH were not in line with the trust’s pharmacy risk assessment, and the service was not using tamper evident boxes in which to store drugs required in ward areas.
  • There were processes in place for the checking of resuscitation equipment. However, on medical wards at Wansbeck General Hospital resuscitation checks were not consistently completed on a daily basis.
  • On inspection placentas were stored appropriately within the birthing unit at NSECH, however, we found inappropriate non-clinical items stored in the placenta freezer. We raised concerns with staff, and the items were removed immediately by senior staff.
  • The environment for older people with psychiatric illness was no longer fit for purpose however the trust had commissioned a new purpose built facility which was due to open in March 2016.

Assessing and responding to patient risk

  • Trust data showed between April and July 2015, there was 100% compliance with the World Health Organisation (WHO) safer surgery checklist (‘Safe surgery saved lives’, 2008. This is a tool for clinical teams to improve the safety of surgery by reducing deaths and complications).
  • The strategy and processes for recognition and treatment of the deteriorating patient, including staff use of National Early Warning Scores (NEWS), was embedded. Staff gave examples where escalating a sick patient and transferring them safely to NSECH had worked well.
  • The trust used a ‘pick and retrieve’ system, whereby an anaesthetist was on-call from NSECH and, in emergencies, was able to attend base site hospitals immediately to stabilise patients and transfer them to critical care facilities at NSECH.
  • Risk assessments, handover processes and safety briefs were observed and we saw all staff worked and communicated well as a team. We observed that ward staff used, on a daily basis, the ‘risk approach’ handover sheets. Also they used a trust developed document, called the Treatment Escalation Plan (TEP), to support effective decision making for those patients at risk of deteriorating.
  • Maternity services used the Modified Early Obstetric Warning Scoring system (MEOWS) to monitor any deteriorating patients. Audits performed by the trust indicated that the system had been used 100% correctly from January to July 2015.
  • Staff across the trust used a variety of different tools such as risk assessments for nutrition, pressure area care and falls.
  • A handover process to the wards and community nursing teams was known as SBAR. (This is used to describe the patients medical Situation, Background, Assessment and Recommendations). It enables staff to clarify what information should be communicated between members of the team and enhanced patient safety.
  • All wards at the trust used Sepsis 6. (A tool designed to identify sepsis in the early stage and to enable prompt treatment). Each ward at the hospital displayed sepsis safety crosses which monitored the recognition of sepsis. This was audited daily by a team within the hospital with high levels of compliance.
  • The trust had implemented the Safety Thermometer and displayed information about performance on wards and clinical departments across the trust. This performance information was discussed at staff meetings.
  • Safety thermometer information from across the trust showed that a total of 172 pressure ulcers were recorded from July 2014 to July 2015.
  • Falls with harm are currently at their highest and showed an upward trend between May 2014 and July 2015. A total of 161 were recorded during this 13 month period at an average of 12 eac month. The trust was aware of this and work was in progress to reduce the number of falls.
  • VTE assessment was variable on the medical wards at NSECH. The lowest compliance was 55% on one ward in September; a second ward also reported only 60% compliance in assessment in August 2015. Data received from the trust indicated that, when VTE assessment compliance was low, this corresponded with lower percentages of patients receiving prophylactic treatment in some areas, for example, when the assessment was identified at 55%, only 86% of patients received the appropriate preventative treatment.
  • There were a total of 100 recorded catheter acquired urinary tract infections (CUTIs) between July 2014 and July 2015 at an average of nearly 8 each month. There is no discernible trend.
  • In community services for children, young people and families, risks within the family nurse partnership were identified through various means including DANCE (Dyadic Assessment of the Naturalistic Caregiver Experience) assessments. DANCE helps to enhance the relationship between the parent and child and educates the parent on the benefits of reciprocal interaction. It is also a means to identify risk in the relationship between the new mother and her baby. The health visiting service also used the Tynedale Assessment Tool to identify potential risks they may have missed during previous visits such as, for example, deep parental psychological issues.
  • There were systems to monitor and track looked after children. Once the local authority notified the team of a new child, an appointment was made for the initial health assessment. This took place within 28 days.

Nurse and Midwifery Staffing

  • The trust utilised the Safer Nursing Care Tool, an acuity and dependency tool endorsed by NICE as part of its approach to review staffing levels. At the time of the inspection this tool was not rolled out on every ward. A roll out of Stage 2 of this programme was planned. This had been phased due to the reconfiguration of acute services which had resulted in changes to a large number of wards across all of the acute sites and the new emergency care hospital.
  • Internal bank staff were used to manage absences and annual leave.
  • The trust had its own bank staff to cover any shortages and did use agency staff; however this usage was very low. The trust had a policy on the use of agency staff which set out the training and induction requirements for agency staff.
  • There were escalation procedures in place to address any staffing shortfalls.
  • Planned and actual numbers of staff were displayed in each ward area.
  • On some medical wards at NSECH the actual qualified staffing was less than the planned qualified staffing numbers. This was supplemented with an unqualified member of staff. Qualified staff were moved from other wards to assist during these periods.
  • The service met the national benchmark for midwifery staffing as set out in the Royal College of Obstetricians and Gynaecologists (ROCG) guidance (Safer Childbirth: Minimum Standards for the Organisation and Delivery of Care in Labour) at most hospitals across the trust. The national recommendation was 1:28.

  • However, at NSECH site-specific data provided by the service identified a 1:36 ratio based on 3000 births a year. The service used Birthrate Plus® to establish staffing numbers.Staffing at NSECH was being reviewed and nine additional midwives were going through the recruitment process. We were told births at the new NSECH site had exceed expectations as more women were choosing to deliver at the birth centre than anticipated.

  • All adult district nursing teams were skill mixed, comprising of one Band 6 and a number of Band 5s, based on the practice population size and geography. Teams also had access to Band 3 time, which might be shared between two teams. Information on the skill mix and district nurses’ caseloads was routinely collected and reviewed by operational managers. Caseloads were managed using SystmOne patient records. The care plan and visit schedule provided details of acuity and the number of home visits that needed to be allocated.
  • Locality leads and operational managers assessed the level and acuity of caseloads, and allocated staff resources to meet the needs of all teams. Community matrons completed a ‘caseload analysis’ form to assess their activity. These were monitored by operational leads. Workload and the complexity of the caseload were discussed and where necessary staff, or patient visits were reallocated to ensure patients needs would be met.
  • Northumberland and North Tyneside had a combined district nursing staffing level of 401.Thirty four was the established whole time equivalent (WTE) figure for district nurses. This was the number of staff the trust has assessed the service as requiring to provide services based on the needs of the population being served.
  • The trust’s WTE spreadsheet recorded that in September 2015 there were 393 WTE district nurses working across Northumberland and North Tyneside. This meant the Trust had 8 WTE unfilled district nursing posts. There were 1.41 Bank district nurses being used against an established figure of 0.8. Staff confirmed that flexible staffing and reallocating resources was an option that was used to maintain safe district nursing caseloads.
  • According to guidance produced by the Community Practitioners and Health Visitors Association, caseloads should be, on average, 250 children for one WTE health visitor. This should vary according to deprivation indicators, with a maximum of 400 in the most affluent areas and less than 200 in the most deprived areas. We found health visitor caseloads in Northumberland and North Tyneside were managed well and followed this guidance. Health visitors looking after children with a high number of child protection and safeguarding concerns had a lower overall caseload than colleagues who were managing less complex cases. This meant some localities had higher caseloads than others. This was reviewed regularly to ensure caseloads were managed safely and teams worked together to ensure the distribution of work was equitable.
  • The children’s community nursing team covered Northumberland and North Tyneside as one unit. There were 10 WTE qualified nurses and four WTE healthcare assistants. The service was led by a modern matron who had recently appointed a band seven nurse to manage the nursing team, following a service review. Caseloads were managed collectively across the team; however, each child or young person did have a named nurse.
  • Family nurse partnership caseloads were below the national recommendation of 25. Supervisors told us this had been planned deliberately to ensure there was some flexibility built into the system. This flexibility enabled the teams to support some young mothers who lived outside of the immediate locality. The limit was set at 23 young mothers for each family nurse and the current staffing levels enabled the service to deliver the healthy child programme and meet its fidelity measures.

Medical staffing

  • At this trust the proportion of junior doctors and consultants was higher than the England average (44% against an England average of 39%).
  • Consequently the proportion of middle graded staff was lower at 36% compared to the England average of 47%.
  • The medical staffing mix for the maternity and gynaecology service across the trust was better than the England average, with 38% consultant grade staff compared to the England average 35%. Middle grade staff, that is doctors with at least three years as a senior house officer or at a higher grade, was 0% at the trust and the England average was 8%. The trust had higher than the England average for registrar level staff, which formed 58% of the staff, against an England average of 50%. Junior doctors, those in foundation years one or two, made up 4% of staff, with the England average at 7%.
  • The delivery suite had consultant cover 84 hours each week. This was in line with the Royal College of Obstetrics and Gynaecology (ROCG) recommendations for the number of births.
  • The consultant obstetricians provided acute daytime obstetric care on the birthing centre 08.00 – 20.00 and participated in out-of-hours work when they were on call for the obstetrics and gynaecology unit.
  • The trust had processes in place for consultants to be able to fulfil revalidation requirements.

Effective

Outstanding

Updated 5 May 2016

We rated effective as outstanding because:

  • The trust used a wide range of data to monitor and measure clinical outcome information. This included clinical audit (local and national), external and internal information systems and service specific improvement projects. This data was reported through local and corporate governance arrangements.
  • Patient outcome measures showed the trust performed mostly within or better than national averages when compared with other hospitals. Stroke pathways and outcomes were particularly effective. 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 across acute and community settings. 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.
  • Policies and procedures for care and treatment were based on National Institute of Clinical Excellence (NICE), national and Royal College guidelines. These were accessible to staff across the trust through the trust’s intranet site. Staff were aware of the local policies and procedures and there were mechanisms to update policies as guidance changed.

Evidence based care and treatment

  • Policies and procedures for care and treatment were based on National Institute of Clinical Excellence (NICE), national and Royal College guidelines. These were accessible to staff across the trust through the trust’s intranet site.
  • Staff were aware of the local policies and procedures and there were mechanisms to update policies as guidance changed.
  • The trust had a system in place to audit its performance and participated in national clinical audit programmes. The trust participated in 97% of all national audits it was eligible to take part in.
  • The tissue viability service (TVS) used the SSKIN bundle.This was a five step model to reduce incidents of pressure ulcers and endorsed by NHS England. The service had gone further in pioneering their own pressure ulcer and skin integrity ‘reminder notes’ for staff to assist in identifying patients at risk of developing pressure ulcers. This had resulted in the trust moving from being a national outlier for pressure ulcer care to consistently performing better than the national average.
  • In end of life care, the trust used the Northern England Strategic Clinical Networks guidance on caring for the dying patient and care planning document (CDP). The guidance included identifying patients at the end of life, holistic assessment, advance care planning, coordinated care, involvement of the patient and those close to them and the management of pain and other symptoms. This document had included national guidance from sources such as the Leadership Alliance for the Care of Dying People, the Department of Health End of Life care Strategy, and the National Institute of Clinical Excellence (NICE).
  • All health visitors, school nurses and the family nurse partnership nurses followed the national initiative called the Healthy Child Programme. This is a Department of Health programme of early intervention and prevention for health visitor contacts with babies and children. It offers regular contact with every family and includes a programme of screening tests, immunisations and vaccinations, development reviews and information, guidance and support for parents. The programme was delivered across the 0-19 age range.
  • Health visitors and the family nurse partnership used Ages and Stages Questionnaires (ASQs) as part of their assessment of children. This is an evidence based tool to identify a child’s developmental progress, readiness for school and provide support to parents in areas of need.
  • Staff from the health visiting teams in Northumberland and North Tyneside had achieved accreditation from the United Nations Children’s Fund (UNICEF) Baby Friendly Initiative.

Patient outcomes

  • Hospital Standardised Mortality Ratio (HSMR) compares the number of deaths in a trust with the number expected given age and sex distribution. HSMR adjusts for a number of other factors including deprivation, palliative care and case mix. HSMR’s are usually expressed using 100 as the expected figure based on national rates. In 2013-2014 the trust were reported to be an elevated risk for HMSR.
  • The Summary Hospital-level Mortality Indicator (SHMI) reports on mortality at trust level throughout NHS hospitals in England. The SHMI is represented as a ratio and indicates the number of patients who died following being in hospital, compared to the England average of the number who would be expected to die looking at the characteristics. The figures are represented at trust level and the trust has a ratio between the control limits, meaning its SHMI is as expected. This was discussed at the Mortality and Outcomes data group meeting in May 2015 where the SHMI was noted to be 106. This was noted to be as expected and reducing.
  • There were no active CQC outliers across the trust.
  • The Sentinel Stroke National Audit Programme (SSNAP) is a programme of work that aims to improve the quality of stroke care by auditing stroke services against evidence based standards. The SSNAP results for 2015 showed that, for NSECH and North Tyneside General Hospital , both hospitals were rated A. This is the highest score possible. At Wansbeck General Hospital the SSNAP results for 2015 indicated an overall level of B. In the Sentinel Stroke National Audit Programme (SSNAP) 2014, Hexham General Hospital had an overall level of D. There were no results available for 2015.

  • Wansbeck General Hospital scored better or the same for the England average on 3 measures of the 4 in the 2014 Heart Failure Audit. North Tyneside General Hospital scored in patient care better than the England average on 3 measures of the 4 in the 2014 Heart Failure Audit.
  • The Myocardial Ischemia National Audit Project (MINAP) showed that Wansbeck General Hospital was worse in two and improved in one of the three measures compared to the previous audit. This hospital was below the England average in two measures and above in one.
  • The National Diabetes Inpatient Audit (NaDIA) showed that results were mixed for this site. Hexham General Hospital was better in 12 and worse in 6 of the 21 measures compared to the England median in the 2013 audit.
  • The Myocardial Ischemia National Audit Project (MINAP) showed that Hexham General Hospital had improved in two and worsened in one of the three measures compared to the previous audit. This hospital was below the England average in two measures and above in one measure.
  • The Myocardial Ischemia National Audit Project (MINAP) showed that North Tyneside General Hospital has improved in three and worsened in one of the four measures when comparing data from 2012/2013 and 2013/2014. This hospital was below the England average in two measures and above in two measures.
  • The National Bowel Cancer Audit (2014) showed better than England average results for multi-disciplinary team discussion, clinical nurse specialist involvement and scans undertaken; 68 % of patients undergoing major surgery stayed in the trust for an average of more than five days (lower than the England average of 69%).
  • The trust participated in the National Hip Fracture Audit. Findings from the 2014 report showed the hospital was better than the England average in areas such as: patients being admitted to orthopaedic care within 4 hours (63%, England average 48%); surgery within 48 hours (91%, England average 74%); patients receiving a bone health medication assessment (100%, England average 97%); and falls assessment (100%, England average 97%).
  • The Patient Reported Outcome Measures (PROMs) in the North East and North Cumbria report (September 2015) showed the trust had significantly better performance compared to the national average in the ‘Oxford Hip Score’ and also the ‘Oxford Knee Score’ and were comparable to England averages in surgery.
  • Results from the National Joint Registry (NJR) audit showed 100% of patients (benchmark 95%) had consent confirmed prior to procedure (January 2015). Revision rates for hip replacement were above the NJR total at one, three and five years; the revision rates for knee replacement were below the NJR total at one, three and five years.
  • The rate of deep surgical site infections (June 2015) was in line with the national target for both hip replacements (0.8% compared to 0.7%) and knee replacements (0.7% compare to 0.6%).

  • The rate of infection for fractured neck of femur surgery was lower than the national average (1.2% compared to 1.5%).
  • The rate of all recorded surgical site infections during this period was below the national average.
  • In adult community services, the service benchmarked patient outcomes against the, ‘adult social care outcomes framework’ (ASCOF). We viewed the trust’s ASCOF monitoring spreadsheet dated October 2015. The trust was doing better than the North East region and England national average in 43 of the 48 ASCOF outcomes.
  • The immunisation rate for the measles mumps and rubella (MMR) vaccine in children aged two was 96% in Northumberland and 96% in North Tyneside, both better the England average of 92%. The immunisation rate for diphtheria, tetanus, polio, pertussis and Hib in children aged two was also better than the England average of 96%. The rate was 98% in Northumberland and 99% in North Tyneside.
  • The immunisation rates for children in care were 90% in Northumberland and 93% in North Tyneside. This was better than the England average of 87%.
  • The health visiting services used the national Programme Delivery Assurance Tool (quarterly area team dashboard) to record and monitor patient outcomes. The trust provided data recorded in Quarter 1 (April 2015 -June 2015) which showed performance targets were met.

Nutrition and hydration

  • Patients were assessed regarding their nutritional needs using the Malnutrition Universal Screening Tool (MUST). This was confirmed in the notes that we looked at.
  • Nutritional assistants were employed by several of the wards throughout the trust to provide patients with eating and drinking assistance.
  • Mealtimes within the hospitals were protected, however visitors told us that there was flexibility to support relatives with their meals.

  • The trust had a Newborn Feeding policy and this included support and care for breastfeeding mothers. There were breastfeeding support groups across Northumberland and North Tyneside.

Multidisciplinary working

  • There were excellent examples of multi-disciplinary working to secure good outcomes and seamless care for patients across acute and community settings. 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.

Consent, Mental Capacity Act & Deprivation of Liberty safeguards

  • The trust had a policy in place that detailed the procedures for obtaining consent. This included the process for obtaining consent, recording and responsibilities. The policy included advance directives, the use of independent mental capacity advocates (IMCAs) and the use of mental capacity assessments.
  • Clinical staff had a good understanding of mental capacity issues and were able to describe the process they followed to assess a patients capacity to make decisions or to be involved in decisions.

Caring

Outstanding

Updated 5 May 2016

We rated caring as outstanding because:

  • Feedback from patients and their relatives was consistently positive about all aspects of their care. All staff consistently communicated with patients in a kind and compassionate way and treated them with dignity and respected their privacy. We saw and were told of many examples of staff at all levels going the extra mile to meet patients needs.
  • We observed a commitment to providing care that was of a consistently high standard and focused on meeting the emotional, spiritual and psychological needs of patients as well as their physical needs. This was apparent through the development of a tool to help staff better assess the spiritual needs of patients and elements of spiritual care being incorporated into end of life care training. There was a strong visible person-centred culture within the trust.
  • We saw examples where staff went above and beyond expectation in the ways they cared for patients.
  • 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

  • In the Cancer Patient Experience Survey 2013/14 the trust was in the top 20% of trusts for 22 out of 34 indicators and the middle 60% for the other 12 measures.
  • The results of the CQC A&E Survey 2014 showed that the trust performed better than other trusts for eight of the 24 questions relevant to caring and about the same as other trusts for the remainder.
  • Results from the Maternity Service Survey 2015, showed the service scored better than other hospitals in five of the 19 questions about labour/birth. For antenatal and postnatal care, the service scored the same as other trusts.
  • Results of the Patient-Led Assessments of the Environment (PLACE) 2015 showed that the trust scored for privacy, dignity and wellbeing: 95 (the England average was 86).
  • The trust’s response rate to Friends and Family Test (FFT) was consistently above the England Average between June 2014 and July 2015.
  • 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.
  • The trust interviewed 6,489 patients during 2014. Results showed that 99% of patients felt they had been treated with kindness and compassion and 99% of patients had been treated with respect and dignity at all times.
  • The trust had developed a Shared Purpose Programme in partnership with a charity involved with older people to improve compassionate and dignified care. This has resulted in the recruitment of nutritional assistants to support elderly patients, increased staff training and improvements in facilities and the ward environments across the trust.
  • A member of staff within critical care services had been nominated for multiple awards for their compassionate care: The NHS FAB stuff awards; and patient champion of the year: North East. They also came second in trust experience nationally.

Understanding and involvement of patients and those close to them

  • In the A&E patient survey 2014, the trust scored better than other trusts to questions about staff explaining decisions about treatment and care, explaining test results in a way that is easy to understand, and being given enough time and opportunity to talk to patients.
  • Results from the CQC Children and Young People’s Inpatient and Day Case Surgery Survey 2014 showed that the trust scored the same as other trusts to questions about involvement in decisions about care, treatment and obtaining answers about care in a way patients were able to understand.
  • Patients receiving end of life care had the opportunity to discuss their wishes for their future in terms of resuscitation, preferred place of death at end of life and decisions to refuse treatment.

  • The trust had a carers’ task group, involving family carers, community and acute professionals, which had been set up in 2014. This group was founded primarily to support the Shared Purpose Programme to ensure that carer issues were integral to the improvement of compassion and dignity in care on the elderly care wards.

Emotional support

  • Spiritual care and support was seen to be important throughout the trust. The chaplaincy team had developed a spirituality assessment tool for staff to use on the wards and in the clinical areas. The tool involved identifying if a person had a belief system, how important it was to them and how they wanted their spiritual and emotional support to be a part of their care plan.
  • A chaplaincy service was available, with ministers from a variety of denominations employed. There were 16 ministers within the chaplaincy team and included Church of England, Roman Catholic, Muslim, Sikh, Hindu and Jewish Rabbi chaplaincy support. Comfort and support was available 24 hours a day through the service and was available for people of diverse faiths or no faith.
  • Volunteers worked with ministers to provide listening for patients who wanted to talk.
  • A bereavement service was available across the trust for the families of patients who had died.
  • Chaplaincy staff told us that a lot of time and resource had been invested in meeting the spiritual needs of patients and their relatives. They had spent time working on what spirituality means to people and had developed a tool to assess people’s spirituality and emotional needs on admission. Staff training had included aspects of spiritual distress and the provision of support.
  • The lead chaplain told us they had felt overwhelmed by the investment the trust had made in meeting people’s spiritual needs.
  • Specialist bereavement midwives were available to give support to women and their families following the loss of a baby.
  • In surgical services, the Surgical Site Infection Surveillance Team (SSI team) offered a follow up service to all postoperative patients. Patients received a follow up phone call at two and 30 days post discharge from hospital.
  • Specialist nursing teams also offered follow up for patients post discharge and across site when patients were transferred for rehabilitation and further recovery.

Responsive

Outstanding

Updated 5 May 2016

We rated responsive as outstanding because:

  • People’s individual needs were central to the planning and delivery of all services across the trust. The development and subsequent opening of NSECH in June 2015 and introduction of new patient pathways across the trust followed many years of discussion and planning with local stakeholders. It also included widespread public engagement.

  • People could access services across the trust in a timely way and there were innovative approaches to provide flexibility, choice and continuity of care. The trust’s effective use of telemedicine was an example of this.

  • There was a proactive approach to understanding and meeting the needs of different groups of people. The trust made sure services could meet every patients individual needs, but in particular, those with conditions such as dementia, people with learning or physical disabilities, or those whose first language was not English. Staff, including reception and portering staff, knew how to support people living with dementia and had completed the trust training programme.

  • The trust was performing better than the England Average in most of the national waiting time targets.
  • Complaints were actively reviewed in terms of how they are managed and responded to, and improvements were made as a result across the trust.

Service planning and delivery to meet the needs of local people

  • Business units were responsible for developing their own service capacity and demand plans which were then reviewed at the Clinical Policy Group. Annual plans were also developed and submitted by each business unit and these were monitored on a quarterly basis. The trust planned on an annual, five year and ten year basis from service to board level. We reviewed the community business unit annual plan for 2015 – 16.
  • NSECH was a vanguard site. These sites will take a lead on the development of new care models which will act as the blueprints for the NHS. The NHS England vision for vanguard sites such as this is that they will make health services more accessible and more effective for patients, improving both their experiences and their outcomes.
  • The development and subsequent opening of NSECH in June 2015 followed many years of discussion and planning with local stakeholders. It also included widespread public engagement.
  • NSECH was the first purpose built hospital of its kind in England dedicated to providing specialist emergency care. The impact of this resulted in the transfer of all emergency care services from other hospital sites within the trust to a state of the art emergency care department in Cramlington.
  • We saw evidence of ongoing engagement with external stakeholders such as local authorities, health and wellbeing boards, and clinical commissioning groups.
  • The trust involved and engaged with local communities in planning services for children and young people. Community services in Northumberland had developed a participation strategy and were actively training young people as part of the reaccreditation programme for the You’re Welcome initiative. There were also two participation groups: the Northumbria Healthcare Young Apprentices gathered feedback about services for children and young people provided by the trust; while the Northumberland College Partnership Health Reference Group offered consultation on literature, materials and resources to ensure they were age appropriate and met the needs of children and young people.
  • The trust also held a series of Young People’s Health roadshows in locations across South-East Northumberland where there were higher levels of deprivation, teenage pregnancies and mental health issues across the young people demographic. The purpose of the roadshows was to gather feedback from young people about the types of health issues they have and where they find information and advice. Following the events, the trust reported it was updating young people’s health information resources and ensuring current approved literature was advertised throughout young people’s settings to promote positive Mental Health messages. The sexual health promotion team in North Tyneside involved young people to promote the delivery of sexual health messages. For example, young people from the YMCA Young Health Champions and the Young People’s Health and Wellbeing Group worked with the health promotion specialist to develop a ‘One2One DVD’. The aim of the DVD was to inform and encourage young people to access appropriate services when they needed to.

Meeting people's individual needs

  • The trust had developed a Shared Purpose programme in partnership with a charity involved with older people to improve compassionate and dignified care. This has resulted in the recruitment of nutritional assistants to support elderly patients, increased staff training and improvements in facilities and the ward environments across the trust for patients living with dementia.
  • Some patients with learning disabilities had patient passports. When the patient or carer presented this at the department, staff used the information to assist them in making decisions about patient needs and wishes.
  • If patients had specific needs, alerts were put on to the electronic record system to alert staff. The electronic records system had a built in alert system that highlighted any patients attending the department who were at risk of self-harm, or of harming others. This made sure that staff were aware of safety risks to patients and to themselves.
  • On Ward 9 at Wansbeck General Hospital, domestic staff created a social dining area from a bay no longer in use to enable patients to dine together at mealtimes.
  • There were very good networks of support for looked after children within the trust. Staff worked closely with them and developed close working relationships to ensure they met their needs. For example, following an assault, one young person felt vulnerable leaving their home therefore the team arranged to meet the young person in a place of their own choosing and ensured they received the right care and support.
  • There were dedicated specialist school nurses to support children and young people with complex needs. To strengthen the transition process for 17 to 19 year olds with complex needs and learning disabilities, the trust had recently appointed a specialist nurse to review current practice and identify any gaps in the service. Consideration was being given to the introduction of a hospital passport as well as more involvement with families.
  • The trust had a learning disability specialist nurse. This nurse worked with departments in advance of patients with special needs attending for procedures.
  • The community dental service had developed an orthodontic service to meet the needs of vulnerable children who would not normally be able to access general dental practice due to their physical, sensory, intellectual, mental, medical, emotional or social impairments or disabilities.
  • The community dental service had co-developed with colleagues in the North East Oral Health Promotion Group, a comprehensive resource pack to support the maintenance of oral health of elderly residents in care homes across Northumbria. The resource folder contained information that oral health promotion teams, commissioners of services, care home managers and their staff could use to deliver key oral health messages. For example, the information for care home staff included learning outcomes, a training session, and quiz and power point presentation detailing key oral health messages. The service has successfully implemented the award scheme in care homes across Northumberland, assuring improved oral health in their setting.
  • The community dental service oversaw the dental care of all looked after children in the North Tyneside area. This work began several years ago and involved a consultation process with children, young people carers and professionals. They developed a multidisciplinary approach and created a defined dental care pathway for looked after children within North Tyneside. Northumbria Dental Services received an award by the Patient Experience Network National Award for this pioneering work.
  • The oral health promotion team was instrumental in developing innovative resources for patients with learning disabilities. One resource was a patient information booklet that shows a typical journey through the service for patients with learning disabilities. Patients collaborated on the project and took and modelled in the booklet’s photographs. Another resource was the redeveloped ‘Jack and Josephine’ initiative. Jack and Josephine are life size cloth models that act as learning aids for men and women’s groups in Northumberland. As part of this project the oral health promotion team developed a leaflet resource about a dental visit using Jack and Josephine to support care provision to patients with learning disabilities.
  • The oral health promotion team was developing a dental component for the Trust’s young peoples ‘You’re Welcome’ project which supports and encourages younger people to access health services in a timely manner.

Dementia

  • The trust had a dementia strategy. There were robust policies and procedures to ensure people living with dementia were identified.
  • There were dementia champions on many of the wards who provided support and advice to staff and relatives.
  • All staff, including reception and portering staff, knew how to support people living with dementia and had completed the trust training programme.
  • The trust had implemented the ‘This is me’ tool which supports patients and their families with dementia. (A tool for people with dementia to complete that lets health and social care professionals know about their needs, interests, preferences, likes and dislikes).

Access and flow

  • Since the opening of the new accident and emergency department at NSECH, the target of seeing 95% of patients within four hours was consistently met throughout July 2015 to September 2015.
  • Between July 2015 and September 2015, 99% of patients who attended Wansbeck General Hospital ECC were seen within four hours.
  • At Wansbeck General Hospital the unplanned re-attendance rate for July 2015 to September 2015 was 0% (only one patient). This was significantly better than the threshold of 5% set by the trust.
  • At Wansbeck General Hospital only 1.7% of patients left the department before a clinician saw them. This was significantly better than the 5% standard set by the trust.
  • Between July 2015 and September 2015, 99% of patients who attended Hexham General Hospital were seen within four hours.
  • Since June 2015, at Hexham General Hospital, 95% of patients waited less than 60 minutes for treatment.
  • At Hexham General Hospital the un-planned re-admission rate for July 2015 to September 2015 was 3.7%. This was better than the threshold of 5% set by the trust.
  • At Hexham General Hospital only 1% of patients left the department before a clinician saw them. This was significantly better than the 5% standard set by the trust.
  • Patients were usually admitted from NSECH following initial assessment. However, admissions were also accepted through GP and consultant referrals. The bed management team would transfer patients coming from NSECH and ward staff from the base hospitals were contacted with basic patient details in the first instance.
  • The trust had a dedicated bed management team. The matron’s held the bleep for this and there were daily team telephone calls three times each day to look at pressures across the medical directorate. Bed data was captured at 09.30 and 16.00 each day. The nurse practitioner within urgent care at NSECH had bed management responsibility out of ours. This arrangement was in place seven days a week.
  • The trust had 33,909 surgical spells between January 2014 and December 2014.
  • At the end of November 2015, the trust was meeting (93%) of the NHS operational referral to treatment target (RTT) of 92% of patients waiting less than 18 weeks for treatment.
  • RTTs had steadily improved since the opening of NSECH and were met within general surgery (94%), urology (96%), plastic surgery (93%) and oral surgery (96%).
  • Trauma and orthopaedics was the only area where this target was not met although there had also been improvement from 86% (September 2015) to 87% (November 2015) and 92% of patients were waiting less than 21 weeks.
  • The trust’s performance against the NHS 18 week referral to treatment target had been above the England average since January 2014.
  • Within outpatients departments the trust had a low level of patients who failed to attend with a ‘Did Not Attend’ (DNA) rate (6%) which was lower than the 7% national average. Managers monitored this continually to enable adaptations and staff told us that the rate had improved since the onset of the automated voice system to remind patients seven days and again one day before attendance attheir appointments. Clinicians made all decisions and actions for patients who DNA based upon their care needs.

  • The trust’s new to follow up ratios were similar to the rates of the majority of trusts at 1:2.2.
  • The percentage of appointments cancelled by the trust within 6 weeks of an appointment date was consistently low with an average over the previous 12 months of 1% which was much better than the England average of 6%. The main reasons given for cancellations were medical staff annual leave, on-call commitments, attendance at clinical and business meetings, study leave, research, training, and sickness.
  • Referral to Treatment (RTT) waiting times April 2013 to May 2015 showed that the trust consistently performed at or above the national average of 95% of (non-admitted patients) starting treatment within 18 weeks (apart from September 2015 when it was 94%) and above the national average of 92% for patients waiting to start treatment (incomplete pathways).
  • The trust performed continually better than the England average in all three measures for cancer targets. Where individual speciality targets dipped below the national standard operational service managers were proactive in working with specialist teams to meet capacity and demand for patient referrals.
  • The trust had missed the national 62 day target for upper gastrointestinal (GI) for June, August, September, November and December. Senior managers told us this was due to capacity problems caused by a sudden increase of patients through choose and book from another local area. Managers monitored all targets and reported to the trust board through their overall performance reports. These were escalated to the surgical risk register and actions assigned to improve the target. They did achieve100% in July 2015 and had continued to achieve this to date.
  • The percentage of non-admitted patients seen within 18 weeks of referral over the previous 12 months ranged between 95% and 97% and was continually higher (better) than the operational standard of 95% and the England average (apart from September 2015 when it was 94%). However, for the period between April and August 2015, general surgery, urology, Trauma and orthopaedics, oral surgery and plastic surgery dipped just below the national standard (95%) at 94%.
  • The percentage of patients with incomplete care pathways who had started their consultant-led treatment ranged between 92% and 94%. The operational standard in England is 92%. However, results for trauma and orthopaedics had declined from 91 to 86%. Managers had recorded these as a governance risk. Outpatient’s staff had checked the results and found there were no delays in the appointment systems and this target was failing further along the patient pathways for treatment.
  • The trust had a high number of active pharmacist prescribers; one of which had started to write discharge prescriptions at the time that a consultant had informed the patient they can go home. This meant the time taken for these patients to be discharged home had now been reduced.
  • In Adult community services, services were organised to ensure that patients were seen in a timely way and in a way to help prevent unnecessary admissions into hospital. These services included the Immediate Response Team (IRT), the Short Term Support Service (STSS) and the Hospital 2 Home (H2H) Team.
  • Matrons in community adult services had a target time of 72 hours for new referrals. They were achieving 100% of their target times for new referrals.
  • The adult community continence service provided assessment for patients with bladder or bowel problems, as well as a home delivery service which provided continence products direct to patients homes. We viewed the continence service triage and referral to treatment spreadsheet. The service was achieving 100% of their two day triage targets and 100% of their target for patients being seen at a clinic within eight weeks of referral.
  • Referrals to paediatric therapy services within the community were triaged and prioritised according to need. For example, children and young people deemed as high priority saw a therapist within 13 weeks while the waiting time for non-urgent cases was the standard 18 weeks. Some referrals received an immediate response, for example, urgent dysphagia referrals were actioned within 10 working days. There were local systems within each service to monitor waiting times. Staff discussed their caseloads and the subsequent impact this had, if any, on waiting times at supervision sessions and at locality meetings. Senior managers within the service and business unit received assurance or were alerted to significant issues at clinical lead management and governance group meetings.
  • There were no breaches to current waiting time targets within community services for children and young people. We reviewed data between April 2015 and August 2015. The average wait for a non-urgent occupational therapy appointment within the community was 13 weeks and 10 weeks within education. We also reviewed referral to treatment time data in May and June 2015 for speech and language therapy and saw they achieved 100% compliance against target.
  • The trust used telemedicine very well to meet patients needs in a timely way that suited them. For example, NSECH provided a seven day a week consultant led outpatient trauma service for people from across Northumberland and North Tyneside to access, as well as a teleconference clinic for patients who lived in Berwick, almost 60 miles away.
  • Also latest digital technology to help treat fractures was being used at urgent care centres in Berwick and Alnwick. Specifically trained staff at each infirmary conducted a live video conferencing linkup to specialist doctors in Wansbeck General Hospital. This saved patients from travelling long distances for appointments and meant the rural population could receive treatment locally. This benefitted patients of all ages and increased multidisciplinary joined-up working with other hospital locations. We observed the telemedicine service provide real-time information across teams and services resulting in quicker treatments times and outcomes.

Learning from complaints and concerns

  • There was a comprehensive and current complaints policy in place that covered the complaints management process for the NHS services as well as the Adult Social Care services operated by the trust.
  • The Chief Executive had overall responsibility for NHS complaint handling issues, reading complaints and signing off responses.
  • The Director of Operations had delegated responsibility for the same and the Head of Quality Assurance and the Risk Manager were responsible for operational management of complaint handling.
  • Staff knew how to access the complaints policy and procedures. Staff felt the process was open and honest. Staff were aware of actions to take when concerns were raised.
  • The policy sets out the processes by which complaints can be raised and the required responses.
  • We reviewed ten NHS complaints and associated action plans from the period February 2014 to September 2015.
  • These were classified according to severity: None, Minor, Moderate and Major however the definition of classification is not referred to in the policy. Our sample included predominately moderate and major complaints.

  • We found these to be of a good standard in terms of ease of use of the system, effective support from PALS, support for complainants in using the system, standard of documentation and communication with the complainants, including an apology. Evaluation of the risk and of the investigation was excellent.

  • We reviewed the monthly NHS complaints dashboard from July 2015.This report set out numbers of complaints and themes from both open and closed complaints. The trust had audited complaint action plans; this looked at the extent to which individual actions within the sample of action plans had been completed. Of the 12 action plans audited 100% of actions had been completed.
  • Detailed summaries of serious complaints and actions including timelines for the process were reported to the Safety and Quality Committee who escalated issues to the board. Reporting included the outcome of ombudsman investigations.

Well-led

Outstanding

Updated 5 May 2016

We rated well led as outstanding because:

  • The trust had a clear vision and strategy in place which could be described by both executive and non-executive directors and by staff working throughout the trust. The vision sets out that the trust aims to provide local patients with the highest possible set of sustainable healthcare services by achieving the vision ‘To be the leader in providing high quality, caring and safe health and care services’.
  • The levels of clinical engagement and leadership across both acute and community settings were exceptional and there is a strong clinical leadership model in place. There is a clear focus on the approach to quality being built upon the need for leadership at all levels within the organisation.
  • There is a strong focus on developing, integrating and improving services and pathways of care with the community teams. The trust acquired community services and established a partnership agreement with Northumberland County Council for adult social care in April 2011.This has resulted in the trust creating a single point of access for core community services and the development of an integrated community response team to facilitate admission avoidance.
  • There is a safety culture across the organisation which puts the patient first and patient experience is given the highest priority with the implementation of real time patient feedback through the development of patient feedback questionnaires. The trust has appointed a Director of Patient Experience.
  • There was exceptional innovative practice and development of sustainable services across services in both 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 2014 NHS staff survey results as 84% of staff said that care of patients is my organisations top priority:the national average for this is 70%.
  • The five year strategy 2014 – 2019 sets out clearly the six strategic goals for the trust which focus on the delivery of quality and safety while being recognised as a caring organisation. It also outlines the need for maintaining financial stability and the need to recruit and retain staff. Finally the trust wants to develop an internationally recognised brand and build upon strong local and national relationships. The trust had an annual plan that supported the delivery of the five year strategy.
  • The strategic direction of the trust has been demonstrated through the development of the Northumbria Emergency Care Hospital which resulted in the consolidation of and radical transformation of care pathways for the delivery of acute care in a centralised place. This became operational in June 2015 and sets out the direction of travel for the three base sites and the opportunity to reconfigure services with the aim of providing a better environment for patient care. The strategic aim is for the base sites to become centres of excellence for elective care and continue to provide ‘walk in’ urgent care services as well as diagnostics, ambulatory care, elderly care assessment services and outpatients.
  • There is a strong focus on developing, integrating and improving services and pathways of care with the community teams. The trust acquired community services and established a partnership agreement with Northumberland County Council for adult social care in April 2011.This has resulted in the trust creating a single point of access for core community services and the development of an integrated community response team to facilitate admission avoidance.
  • The trust has a Quality Strategy that was launched in 2014 and was led by the Director of Patient Experience. The focus of the Quality Strategy was to provide safe effective care that provided a positive patient experience. The strategy is linked to the trust aims and sets out the key quality objectives for 2014 – 2019. Examples include ongoing reduction in mortality rates, reduction in harm from falls and improvement in sepsis mortality. There was a separate Nursing Strategy.
  • The trust has a robust estates strategy that includes the development of a new hospital on both the Berwick and Alnwick sites replacing existing buildings, which will be developed in conjunction with the Northumberland County Council
  • The trust had an Information Technology (IT) Strategy although a decision had been taken to phase new IT systems in over a longer period.
  • The trust had a Clinical Policy Group that had representation from primary care and the commissioners.
  • A palliative care steering group was in operation to guide the trust in delivering effective palliative and end of life care. Membership of the group included key staff and representatives from a variety of specialities including elderly medicine, general practice and general medicine. This helped to ensure that responsibility for good quality end of life care did not solely sit with the palliative care team.
  • The formal clinical strategy for maternity or gynaecology services which was contained within the surgical business unit annual plan was very generic in terms of outcomes and references to maternity and gynaecological services were minimal. This did not support identification of how the service was to achieve its priorities or support staff in understanding their role in achieving the services priorities.

Governance, risk management and quality measurement

Leadership of the trust

  • There were a range of committees that provided assurance to the Board; these included the Finance, Investment and Performance Committee, Audit Committee, Workforce Committee and Safety & Quality Committee. Non-Executive Directors chaired these committees and formal reports were submitted to the Trust Board.
  • There was a Board Assurance Framework and Corporate Risk Register that identified both strategic and operational risks. We reviewed the corporate risk register which documented actual risk, control measures and residual risk ratings. The Board Assurance Framework is reviewed by the board on a quarterly basis and by the Audit Committee. Risk registers are held at business unit level and there is a clear process for escalation of risk.
  • 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 learning was shared. Safety Panels were held to review Serious Untoward incidents and these were chaired by a medical director (or their deputy) and Non-Executive Directors attend as part of the panel. There is a mechanism for follow up and the business unit director is asked to submit a progress report 6 months after the quality panel. If actions are still outstanding this is escalated to the Executive Management Team (EMT).
  • Business Units held their own governance meetings with services and submitted quarterly integrated governance reports and quarterly governance declarations. We reviewed a sample of business unit governance meeting minutes from 2015 which showed evidence of review of incidents, complaints and risk registers, actions were agreed and there were mechanisms in place for ensuring follow up of actions. The quarterly governance declarations declared compliance with quality, finance and performance standards. Business units reported into the Safety & Quality Committee and Assurance Committee both of which report directly into the trust board.
  • The trust used the 15 Steps programme to inform the on-going monitoring of compliance against fundamental CQC standards and to provide an opportunity for quality improvement and sharing of best practice; this programme provides a framework for quality assessment of clinical areas. We reviewed action plans from 15 steps visits to clinical areas carried out in August 2015. The trust use the CQC ratings in their assessment process and an action plan is produced based upon the findings of the assessment.
  • An external Annual Quality Governance Assessment against the Monitor Framework had been carried in May 2014 and the Board had carried out a self- assessment in February 2015.
  • Service teams attended Quality Panels. Quality panels are chaired by the Clinical Lead for Quality, however a non-executive director does attend each meeting and will chair the meeting in the absence of the clinical lead for quality. Quality Panels were held with services being asked to submit data two weeks prior to the panel.The panels use the five key domains from the CQC. We reviewed a sample of five sets of notes from Quality panels held between April 2014 and September 2015. We observed a Quality panel in October 2015. These meetings were attended by the senior teams from the services and the Business Unit. The Quality Panel asked the five key questions from the CQC framework, identified areas of good practice and areas that required further action. The actions identified who needed to take this forward and had timescales identified. At this meeting, teams were held to account with regard to progress.
  • The trust had an internal audit programme and a clinical audit programme set for 2015 – 2016. The clinical audit programme is approved by the Safety & Quality Committee and is made up of the plans submitted by each of the business units. The Safety & Quality Committee receive quarterly reports on progress against the audit programme.
  • 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 and five monthly assurance reports from 2015. The six monthly staffing reviews were being done in stages due to the recent reconfiguration of services across all of the acute sites. The monthly assurance reports included a range of quality indicators as well as planned and actual staffing levels. The monthly reports also included serious incidents, harm and patient experience data. Where standards were not being met this would ‘trigger’ closer monitoring. The assurance reports would be submitted to the Safety & Quality Committee.
  • The trust had forecast a year end financial position of £14million surplus with a cost improvement programme of £25million and a cash balance of £40million. There was still some shortfall in the cost improvement programme however the executive team were well sighted on the financial position and associated financial risks both of the organisation and the wider health economy.

  • Cost improvement programmes and business cases were reviewed for impact on quality and we were provided with examples of cases that had been declined due to potential negative impact on quality. All business cases had equality impact assessments.
  • The trust had a performance framework and assurance to the board was provided by the Finance and Performance Committee. Business Units had their own operational boards which held service teams to account and monitored performance at a service level. A performance update was provided to the Clinical Policy group. There was a monthly performance meeting with the deputy directors of the business units. If business units were not succeeding there was a process of providing support and objective setting to improve performance.
  • The trust participated in the Sign up to Safety Campaign with a focus on reduction in mortality rates from sepsis.
  • The maternity and gynaecology service used the maternity dashboard recommended by the RCOG. The dashboard was a clinical performance and governance scorecard and helped to identify patient safety issues in advance. We found the dashboard contained inaccuracies, for example the number of instrumental, operative and vaginal births did not equate to 100%.This meant we were concerned with the accuracy and monitoring of the dashboard at all levels within the service.
  • In the maternity and gynaecology service there was no alignment between the risk register and the senior team worry list. Through discussion with the senior team we learnt that there was concerns about staffing levels at NSECH, as the demand had exceeded expectations. The senior team also stated high on their list of priorities was the relocation of pregnancy assessment services at NSECH. Neither of these concerns were documented on the directorate risk register.
  • The maternity and gynaecology service had only assessed itself against the Kirkup recommendations applicable to the wider NHS and not against the recommendations made for the individual service named in the report.

  • There was a well-established senior executive team that was highly visible, challenging and with a commitment to delivery of high quality services and the improvement agenda. However, the Chief Executive had been seconded and the Medical Director had been appointed as the interim Chief Executive Officer.
  • Community services were represented at Board level with an Executive Director post that sat across both the trust and local authority boards. This post had responsibility for an integrated budget and could focus on developing services that had the patient at the centre.
  • The levels of clinical engagement and leadership across both acute and community settings were exceptional and there was a strong clinical leadership model in place. There is a clear focus on the approach to quality being built upon the need for leadership at all levels within the organisation.
  • In the NHS staff survey 2014, 87% of staff trust wide, knew who their senior managers were. This was better than the national average of 84%.
  • The management structure was based upon Business Units which were led by a clinician as Business Unit Director and supported by a senior manager in a deputy role. The Business Units had a Chief Matron and General Managers. Each service had a Clinical Director, Matron and an operational service manager.
  • There were three Executive Directors identified as leads for one or more business units and they were responsible for holding the teams to account and providing leadership support.
  • Staff described a very visible Board of Directors and a Chief Executive who was well respected and very visible across acute and community services. The board undertook leadership walk rounds.
  • Nursing leadership was provided by the Executive Director of Nursing and a Deputy Director of Nursing.Each business unit has a Chief Matron who supports a Matron in each of the services. The Matrons have responsibility for several ward managers.

  • There was end of life care representation/leadership at trust board level and we saw evidence of active engagement in end of life care at board level.
  • The trust’s palliative care steering group was chaired by one of the trust’s executive medical directors which meant that the overall responsibility for monitoring of end of life care did not sit entirely with the specialist palliative care team.
  • Leadership programmes were available for staff at all levels.​

Culture within the trust

  • There was a ‘can do’ culture that is evident across the organisation with staff encouraged at all levels to make changes to services that would improve the quality of care to patients.
  • Staff described ‘The Northumbria Way’ which was evident at all levels throughout the organisation. This focussed on engagement; patient and staff experience; trust values and communication. Staff told us about the Northumbria Way in focus groups, during interviews and while visiting clinical areas. This is linked to the importance within the trust of ‘brand’, and there is a standardisation of the trust brand across both acute and community, for example, on the community cars there is the trust logo.
  • The trust had been working with NHS Employers to look at organisational development in relation to organisational culture.In the workforce committee minutes of December 2014 it was identified that the trust had been identified as a ‘beacon trust’ for this work.
  • Wards had begun piloting a scheme called ‘Board to Ward’ which encourages staff to develop safety and quality priorities specific to them and lead on improvements.
  • The trust had a ‘Freedom to Speak Up’ action plan in response to the Francis Report; the action plan showed that the trust had implemented many of the recommendations.
  • The trust had a values based recruitment process and staff have been trained in values based interviewing techniques.
  • In critical care services, staff had been involved and engaged with the development of the new unit and it was clear that the leadership team had prepared staff well for the change. Two teams of staff had been brought together by introducing cross-site working and work streams to standardise equipment and practices in preparation for the move to NSECH. All staff spoke of a seamless transition from the base sites to NSECH.

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.
  • The trust policy on pre-employment checks (2011) covered criminal record, financial background, identity, right to work, employment history, professional registration and qualification checks. It was already part of the trust’s approach to conduct a check with any and all relevant professional bodies (for example, medical, financial and legal) and undertake due diligence checks for senior appointments. This for example, would exclude candidates who could not demonstrate they were capable.
  • The trust was introducing additional checks for non-executive directors (NEDs) to ensure references were obtained from substantive employees, and routine checks on the Companies House website to identify any disbarment from running a business.
  • The board agreed the FPPR for executive and NEDs in November 2014. They also decided to widen the spectrum of posts required by the Regulation to include executive team members who are not board members.
  • We reviewed the personnel files of three directors on the board. One was appointed since the Regulation came into force and two were appointed prior. The trust informed us that they had proceeded as if the requirement was in place. The files provided evidence that relevant checks had been done.
  • All NEDs had received a disclosure and barring (DBS) check.

Public engagement

  • The trust had a Director for Patient Experience who had developed the capture of real time patient feedback regarding services provided by the trust called ‘Two Minutes of Your Time’, which included obtaining feedback during the patient stay and three months following discharge.
  • There was evidence of extensive engagement with patients and the public and the trust actively sought their views and opinions.
  • Information about real time patient experience was displayed on all wards and clinic areas we visited. Staff we spoke with told us that the patient experience team collated the views of ten patients twice a month and the results were then used to produce statistical graphs and posters for individual wards. Ward managers told us that they reviewed the data and fedback the data at team meetings. Themes and trends were also looked for and highlighted if necessary. All information including patient comments, good and bad, were displayed in wards and clinics.
  • The trust actively promoted projects relating to patient experience. An example of this was the 15 steps challenge. It was developed by various staff groups, patient and volunteers to help capture what good quality care, looks, feels and sounds like. They used the Care Quality Commission's five domains as a basis to look at all aspects of care and the environment.
  • The trust had developed projects to support patient choice. This included the post discharge service from pharmacists to patients who were at high risk of readmission. Patients were telephoned by a pharmacist who would explain medication changes and to answer any questions the patient or carer would have.
  • The trust proactively engaged with children, young people and families and took appropriate action based upon the feedback they received. For example, following feedback from a teenage mother, the family nurse partnership was preparing to hold its first client user group meeting. The purpose of the meeting was to encourage peer support and develop relationships amongst the teenage mothers who accessed the service. In addition, the service has identified a number of young women who had requested to participate in ‘breastfeeding peer support’ training.
  • The Children’s Unit hosted meetings every Tuesday for the Child Health Action Team (CHAT). CHAT was a children’s service user group who met regularly to suggest and develop ideas to improve local services. We were told that members of CHAT had recently been involved in staff interviews and had developed a child friendly hospitals information book, which included blood investigations.
  • The looked after children team ran an annual event for children and young people in their care, celebrating their achievements. Children were actively encouraged to participate in the planning and organisation of the celebration.
  • The trust had an active council of 71 governors and the Chair held regular breakfast meetings across the geographical patch to discuss local issues with the governors.
  • There was an innovative and proactive approach to external communication from the trust examples of this include ‘Hoops for Health’ a local basketball team that visits schools to promote a healthy lifestyle. Social media is used effectively to ensure public views are incorporated into the delivery of care.

Staff engagement

  • Results from the 2014 NHS Staff Survey showed that the trust performed well, with 26 positive findings, six findings within expected levels, and no negative findings. Based on staff survey results, the trust was within the top 20% of trusts in England.
  • The trust had various effective processes in place to ensure that all staff were kept informed and engaged. These included a weekly e-bulletin (staff update) to all employees, monthly team brief, quarterly staff magazine and all staff emails from the chief executive.
  • The trust has bi-annual chief executive roadshows to update staff on major developments and provide opportunities to ask questions. Information is provided on the trust intranet for those who could not attend.
  • The trust had a workforce committee and we reviewed a sample of minutes from meetings of the committee. There was evidence of staff engagement at a time of significant change within the organisation due to the transformation of the emergency care pathways and the opening of the Northumbria Emergency Care Hospital. Minutes showed that the trust had implemented an organisational change process prior to the service reconfiguration. Themes had been identified and actions agreed.
  • The trust recognised the contribution of staff and celebrates their achievements and improvements to quality patient care and innovation through annual staff awards. These awards had been running since 2012, with over 200 nominations received last year.
  • Throughout our inspection staff consistently told us they were encouraged to challenge existing practices, look for improvements and suggest ways to develop and introduce innovative practice. Staff reflected on the strong leadership and visibility of senior members of the trust board. This motivated staff and staff felt that senior leadership reflected the vision and values that they shared with the organisation.
  • Staff from all services within the trust consistently told us they felt encouraged to contribute to service development. For example, the Chief Executive promoted an ‘open door’ policy where staff could contact him at any time to discuss any concerns they had or suggestions for improvement. A member of staff told us that she had emailed the chief executive with an idea to support young people leaving the looked after children service and those who had learning disabilities. She suggested the trust apprenticeship scheme could look at ways to actively recruit those young people and offer them the opportunity to gain sustainable work experience. She received a very prompt response with an assurance her suggestion would be considered.
  • There were health and well- being advocates across the trust and the trust had been identified as an exemplar organisation for health and wellbeing.

Innovation, improvement and sustainability

  • The trust had been awarded the 'Overall best trust' and awarded five other accolades at the Patient experience network national awards 2014.

  • The trust was awarded the British Medical Journal's patient safety award for improving quality of care for hip fracture patients.
  • The trust was awarded Provider Trust of the Year, National Health Service Journal Awards 2013 for continuous improvement in the quality of care delivered to patients in hospitals and in the community and for its commitment to listening to, and acting on, the feedback of patients and relatives.
  • Northumbria Healthcare NHS Foundation Trust was appointed as one of nine ‘integrated primary and acute care system vanguards’, with the intention of joining up GP, hospital, community and mental health services. This was being supported through: the opening of the Northumbria Specialist Emergency Care Hospital (NSECH); an extension of primary care to create ‘hubs’ of primary care provision across the county seven days a week; and the redesign of community and acute services to ensure patient care was increasingly delivered in community settings, and by bringing together commissioning responsibility across the whole health economy. The model cut across organisational boundaries and included enhanced access to community nursing services, fully coordinated discharge and shared IT that supported better care in a number of health settings as well as patients homes.
  • In September 2015 the trust was announced as only one of three NHS organisations across the country to lead on work to develop new ways of working known as “multihospital chains”. By creating the Northumbria Foundation Group the trust aims to provide support and services to other organisations to help them improve.
  • The pit stop handover for all admissions to the critical care unit was developed with human factors training, to facilitate a structured handover and improve patient safety. Staff had presented the service’s work on human factors at the trust’s nurse conference.
  • The immediate response team (IRT) provided urgent support for people in a time of crisis. The IRT team joint worked across adult social care between Northumbria Healthcare NHS Foundation Trust and the local authority. The partnership working had developed a range of integrated services to support care closer to home for patients and avoid unnecessary hospital admissions. The fully integrated team of community health and social care staff aim to make contact with the person in need within two hours of the first call for assistance, and could provide equipment to help people move around their house, and arrange emergency short term care support to enable them to remain at home, and help people to regain their confidence and independence.
  • Community Adult Services ran a free of charge ‘Inspired Carer Masterclass’ for staff from local residential care and nursing homes to improve care for patients receiving care in care homes. This was a one day course for care home managers and staff. The training covered dementia care, falls prevention, infection prevention and control, swallowing assessment, depression, skin integrity, and supporting families. The training was delivered by a variety of CAS staff including community matrons, SALT, and physiotherapists.
  • Community Adult Services had specialist community research nurses that were funded by the trust’s research and development team. For example, the Tissue Viability Service (TVS) research nurse was involved with a university in a clinical trials study into pressure ulcer mattresses. The TVS service had also conducted research for a large corporate company who specialised in providing products for advanced wound management.
  • The trust has undertaken extensive public consultation over recent years to review the scope and scale of Healthcare Service provision. The proposed redevelopment project of Berwick Infirmary reflected the trusts emphasis on strengthening and building upon an integrated partnership with Primary and Intermediate care, Secondary care and Social Services to enable high quality services provided locally. The intention is to: maximise the availability of services closer to patients homes; strengthen the service reputation in the context of choice;deliver locally based assessment services for patients who may require admission; and to relieve pressure on the general hospital sites and, where possible, to reduce waiting times overall.
  • WOW – well organised ward based upon the productive ward improvement methodology was being rolled out across all of the clinical areas
Checks on specific services

Community mental health services with learning disabilities or autism

Outstanding

Updated 2 August 2017

  • There was a proactive approach to anticipating and managing risks to people who use the services. This was embedded and recognised as being the responsibility of all staff. People who use and those close to them were actively involved in managing their own risks.

  • There was a holistic approach to assessing, planning, and delivering care and treatment to people who use services. The use of innovative approaches to care was actively encouraged. New evidence based techniques and technologies were used to support the delivery of the service.

  • There was continued development of staff skills, competence, and knowledge. Staff were proactively supported to acquire new skills and share best practice.

  • The service was committed to working collaboratively and had developed innovative and efficient ways to deliver more joined-up care to people who use the service.

  • There was a holistic approach to planning people’s discharge, transfer, or transition to other services. Arrangements fully reflected patient needs.

  • There was participation in relevant local and national audits, including clinical audits and other monitoring activities such as reviews of services, benchmarking, peer review and service accreditation.

  • There was a strong, visible person-centred culture. Staff were highly motivated and inspired to offer care that is kind and promotes people’s dignity. Relationships between people who use the service, those close to them and staff were strong, caring, and supportive. These relationships were highly valued by staff and promoted by leaders

  • People’s individual needs and preferences were central to the planning and delivery of services. The services were flexible, provided choice, and ensured continuity of care.

  • Leaders had an inspiring shared purpose, and motivated staff to succeed. Comprehensive and successful leadership strategies were in place to ensure delivery and to develop the desired culture.

  • There were high levels of staff satisfaction across the service. Staff were proud of the organisation as a place to work and spoke highly of the management and culture. Staff at all levels were actively encouraged to raise concerns.

Community dental services

Outstanding

Updated 5 May 2016

Overall rating for this core service Outstanding 

We rated the dental services at this trust as outstanding because:

Services were effective, evidence based and focused on patients’ needs. We saw examples of excellent collaborative team working. We also saw examples of innovative working including an orthodontic service that catered primarily for the needs of vulnerable children such as those with disabilities and complex medical conditions. The service had also co-developed with colleagues in the North East Oral Health Promotion Group, a comprehensive resource pack to support the maintenance of oral health of elderly residents in care homes. The service had implemented an award scheme in care homes across Northumberland with the aim of assuring improved oral health in a care home setting. The continuing development of staff was seen as integral to providing high quality care and all staff received professional development appropriate to their role and learning needs. Staff, registered with the General Dental Council had frequent continuing professional development and met their professional registration requirements.

The service was extremely responsive to patients’ needs; people could access services in a timely way that suited them. Service waiting times for each clinic and the waiting times for general anaesthesia at each hospital showed that waiting times for the first available appointment were within one to three weeks dependant on the clinic. The waiting times for special needs adults under general anaesthesia were 6 weeks or less. However, patients requiring urgent care could be seen earlier. Effective multidisciplinary team working and links between clinics ensured patients received appropriate care at the right times and without avoidable delays. Patients from all communities could access treatment if they met the service’s criteria. The dental service had been recognised for pioneering work involving looked after children across North Tyneside and had received a national award by the Patient Experience Network for this work. The service had a proactive approach to understanding the needs of different groups of people. We found that the oral health promotion team had developed a patient information booklet explaining the patient journey for dentistry through the eyes of a patient with learning disabilities. Learning disability patients had taken a joint lead role in developing the booklet

The service was very well-led with organisational, governance and risk management structures in place.

These governance arrangements were proactively reviewed and reflected best practice. There was strong leadership of the service, with an emphasis on driving continuous improvement. The local management team were visible and the culture was seen as open and transparent. There was strong collaboration and support across all of the service with a strong emphasis on improving the quality of care.

Staff were aware of the way forward and vision for the organisation and said that they felt well supported and could raise any concerns with their line manager. Staff at all levels were actively encouraged to raise concerns. There were high levels of staff satisfaction across all staff groups. Team meetings and staff surveys demonstrated that the service engaged all staff.

Staff protected patients from abuse and avoidable harm. Systems for identifying, investigating and learning from patient safety incidents were in place. Infection control procedures were in place. The environment and equipment were clean and well maintained.

Patients, relatives and carers said they had positive experiences of care within the service. We saw good examples of staff providing compassionate and effective care. We also saw effective interactions taking place between individual staff members. We found staff to be hard working, caring and committed to the care and treatment they provided. Staff spoke with passion about their work and conveyed their dedication to what they did.

Community health inpatient services

Good

Updated 5 May 2016

We rated community inpatient services as good because:

The service prioritised patient protection from avoidable harm and abuse. There were clearly defined and embedded systems, processes and standard operating procedures to keep people safe and safeguarded from abuse. We saw evidence of an open and transparent culture in relation to incident reporting. Opportunities were available to learn from investigations and the service was aware of areas in which it needed to improve, such as falls. The department was clean and there was an active infection control and prevention audits, which showed high scoring outcomes. Risks to people who used services were assessed, monitored and managed on a day-to-day basis. Escalation and deterioration plans were in place for patients when staff had concerns regarding a patients condition and wellbeing. All wards had good staffing levels and frontline staff told us their managers supported them if they needed to increase their staffing numbers when patient dependency increased.

The trust’s contribution to local and national audit was in line with the national average, and evidence of changes made by specialities in response to their outcomes was available and had been actioned. Accurate and up-to-date information was shared with staff and used to improve care and treatment and people’s outcomes. People’s care and treatment was planned and delivered in line with current evidence-based guidance, standards, best practice and legislation. People had good assessments of their needs, which included consideration of clinical needs, mental health, physical health and wellbeing, and nutrition and hydration needs. Staff were qualified and had the skills they needed to carry out their roles effectively and in line with best practice. Staff were supported to maintain and further develop their professional skills and experience. We saw strong and respectful multidisciplinary team working during our inspection and feedback from all disciplines emphasised this. They worked closely with the local authority when planning discharge of complex patients and when raising safeguarding alerts.

We observed the treatment of patients to be compassionate, dignified, and respectful throughout our inspection. Feedback from numerous patients across all five of the community locations was exceptional. We heard that staff went

the extra mile to be supportiv

e, to assist patients over and above routine tasks and ensure that patients were fully included in all decision making regarding their health and wellbeing. Relatives said they felt involved in their care and had the opportunity to speak with the doctor looking after their family member. Staff spoke with passion about their work and were proud of what they did. Complaints and concerns were taken seriously and responded to in a timely way. Improvements were made to the quality of care as a result of complaints and concerns.

There was a clear vision and strategy for the service, which was well developed and well understood throughout the department. The behaviours and actions of staff working in the division mirrored the trust values of ‘patient’s first, safe and high quality care, and responsibility and accountability’ of which we saw multiple examples of during our inspection. There was evidence of ownership of services and patient centred care was clearly a priority. Risks and potential risks discussions were ongoing and there was a governance structure for formal escalation where appropriate. Many of the wards were piloting a scheme called ‘Board to Ward’, which encouraged staff to develop safety and quality priorities specific to them and lead on improvements. It provided an opportunity to focus on the issues that matter at ward level, with staff having ownership in deciding what priorities should be, and how to meet these goals.

Community health services for adults

Outstanding

Updated 5 May 2016

Overall rating for this core service Outstanding

We rated community adult services as outstanding because:

National guidance, the National Institute of Health and Care Excellence (NICE) and professional bodies were complied with and that staff showed awareness of relevant guidance in their work. Staff were actively engaged in activities to monitor and improve quality and outcomes. For example, the tissue viability service (TVS) used the SSKIN bundle, this was a five step model to reduce incidents of pressure ulcers and endorsed by NHS England. The service had gone further in pioneering their own pressure ulcer and skin integrity ‘aide memoire’ for staff to assist in identifying patients at risk of developing pressure ulcers. This had resulted in the trust moving from being a national outlier for pressure ulcer care to consistently performing better than the national average. Quality of care was monitored through audits, which informed the development of local guidance and practice. We found that patients could access all professionals relevant to their care through a system of truly integrated multi-disciplinary teams; and that patients’ care was co-ordinated and managed. There were systems to gain people’s consent prior to care and treatment. Where patients lacked the capacity to give consent, there were arrangements to ensure that staff acted in accordance with their legal obligations. There were robust systems to ensure professional staff remained registered with the relevant professional body.

Patients and carers we spoke with were overwhelmingly positive about their experience of care and treatment, and feedback gathered by the organisation showed high levels of satisfaction. Words and phrases such as “tremendous,” “cheerful and considerate,” “extremely happy with the care,” were used extensively in their feedback. We viewed the Community Services Business Unit (CSBU) Friends and Family Test (FFT) results November 2015; 99% of patients said they were treated with dignity and respect. We reviewed results from the FFT for the period July – September 2015 for 24 Community Adult Services Teams. The average score for people who responded that they would be likely to recommend community services was 99%. We observed all staff responding to people with kindness and compassion. Patients told us they were treated with dignity and respect, and that they were involved in the planning and delivery of their care to the extent they wished to be. Staff were prepared to and did go the ‘extra mile’ for patients.

The involvement of other organisations and the local community was integral to how services were planned and ensured that services meet people’s needs. We found that community adult services had a model of integrated community teams across health and social care to ensure people received truly joined up working that was responsive to patients’ individual needs. There was a focus of providing services close to where people lived and at times that were convenient to them. There was provision to ensure that essential services were available out-of-hours, and there were no major issues with waiting lists.

There was a clear vision and values that were shared by staff and demonstrated in their work. There was a clear articulation of the strategic direction for the service and staff felt engaged with the strategy. Consideration was given to ensure that developments were sustainable. We found evidence of innovative practice and research including partnership working with industry. The leadership drove continuous improvement and staff were accountable for delivering change. There was a clear proactive approach to seeking out and embedding new and more sustainable models of care. There were systems to ensure good governance and monitoring of standards and performance. There was an effective escalation and cascading of information from the board to front-line workers, and vice-versa. We found that there was a positive culture, with staff and managers feeling proud of their work and achievements and speaking well of their colleagues and the organisation.

We found that community adult services (CAS) achieved a good standard of safety. This was because there were robust methods of reporting, investigating and learning from incidents and near misses that were well understood by staff and embedded in their daily work. There were plans to deal with major incident or events that would disrupt the delivery of care. We saw evidence that CAS staff were making appropriate adult safeguarding referrals. There were processes and systems that protected patients from the risk of infection, and the risks associated with equipment used in their care and treatment. There were safe systems of medicines management. Records were accurate, comprehensive and current, and supported the delivery of safe care. We saw that between 85% and 100% of mandatory training had been completed across CAS against a trust target of 85%. Staffing numbers were reviewed, an active recruitment programme was in progress and arrangements to ensure any staffing shortfalls were managed on an on-going basis to minimise the impact on patients.

Community health services for children, young people and families

Outstanding

Updated 5 May 2016

Overall, we rated community health services for children, young people and families as outstanding because:

Managers and staff created a strong, visible, person-centred culture and were highly motivated and inspired to offer the best possible care to children and young people, including meeting their emotional needs. Staff were very passionate about their role and, in some cases, went beyond the call of duty to provide care and support to families. There was respect for the different personal, cultural, social and religious needs of the children and young people they cared for, and care and treatment was focussed on the individual person rather than the condition or service.

Families were very positive about the service they received. They described staff as being very caring, compassionate, understanding and supportive. Children and young people were able to see a healthcare professional when they needed to and received the right care at the right time. Services were flexible, provided choice and ensured continuity of care. The care and treatment of children and young people achieved good outcomes and promoted a good quality of life. Staff proactively collected and monitored this data and used the information to improve the care they delivered.

The culture was open and transparent with a clear focus on putting children and young people at the centre of their care. Services had good strategies and plans, each with service-specific objectives and goals to meet the needs of children and young people and deliver a high quality service. These plans directly linked with the overarching trust vision and goals.

Staff protected children and young people from avoidable harm and abuse. Managers and staff discussed incidents regularly at monthly meetings and took appropriate action to prevent them from happening again. Staff regularly received safeguarding supervision from managers and the trust safeguarding children team, who also kept services updated on outcomes and learning from serious case reviews. The clinics, health centres, children’s centres and school premises we visited were clean and staff followed national guidance in relation to hand hygiene and infection prevention and control. Staff managed medicines safely and the quality of healthcare records was good. Clinical leads and service managers audited records annually and outcomes shared with individuals and the wider team.

Managers and staff managed caseloads well, and there were effective handovers between health visitors and school nurses to keep children safe at all times. On a day-to-day basis, staff assessed, monitored and managed risks to children and young people and this included risks to children who were subject to a child protection plan or who had complex health needs.

Staff were very positive about working for the trust and leadership was excellent across all services. There was a clear management structure and managers were visible and involved in the day-to-day running of services. Staff could contact them whenever they needed to and received regular supervision from line managers and clinical leads. The trust provided opportunities for training and development and staff were well trained and highly motivated to offer the best possible care to children and young people.

Specialist community mental health services for children and young people

Good

Updated 17 February 2017

We rated specialist community mental health services for children and young people as good because:

  • The service had clear criteria for referrals into the service with timescales for assessment for urgent, priority and routine referrals.

  • Initial assessments were thorough and included a full assessment of risk and staff used a range of assessment and diagnostic tools for specific areas of need.

  • The service delivered a wide range of psychological interventions recommended by National Institute for Health and Care Excellence to meet the needs of children and young people who used the service.

  • Staff delivered care in a thoughtful and sensitive way that was adaptive to the needs of the young person. Interactions were at an appropriate level for young people which focussed on recovery and respected young people’s needs.

  • Feedback from people who use services and their carers was positive about the care they received.

  • Staff were passionate, enthusiastic and dedicated to their work with children and young people.

However:

  • Interview rooms were not fitted with alarms and staff did not have access to personal alarms. At the Albion Road clinic, the door from reception area to staff offices and rooms where staff saw patients was not secure.

  • Although risk was reviewed with young people and within multi-disciplinary teams, it was not easy to access this from the information in the care records.

  • The involvement of young people and parents was not well documented within care records.

  • There was insufficient hand washing and sanitising equipment at Albion Road and Baliol Centre.

Urgent care services

Good

Updated 5 May 2016

We rated urgent care as good because:

The service prioritised patient protection from avoidable harm and abuse. There was a genuinely open culture for both staff and patients to raise concerns and receive appropriate response, feedback and learning. We found ongoing progression towards safety goals including high standards of training, skill and experience. Medicine management and the recording of medical information was of a high standard and well maintained. Training and appraisal rates exceeded trust targets as a whole and we saw the staff were highly competent. Staff were openly encouraged to progress their training both internal and externally. We saw examples of staff being encouraged to undertake university degree courses and progress to Emergency Nurse Practitioner levels.

All staff were aware of their personal accountability in managing risk and took responsibility as a team to ensure that risk management plans were followed, maintained and changes discussed with senior staff. Specific areas of training identified by anticipating risk had been undertaken. We found that all staff were actively engaged in activities to monitor and improve quality outcomes. The trusts contribution to local and national audit was in line with the national average, and evidence of changes made by specialities in response to their outcomes was available and had been actioned.

There was a holistic approach to assessing, planning and delivering care and treatment. The telemedicine service, introduced by the trust in May 2013, used the latest digital technology to help treat fractures in Berwick and Alnwick. Specifically trained staff at each infirmary conducted a live video conferencing linkup to specialist doctors in Wansbeck General Hospital. This saved patients from travelling long distances for appointments and meant the rural population could receive treatment locally. This benefitted patients of all ages and increased multidisciplinary joined-up working with other hospital locations. We observed the telemedicine service provide real-time information across teams and services resulting in quicker treatment times and outcomes.

We found staff to be hard working, caring and committed to delivering a good quality service. They spoke with passion about their work and were proud of what they did. Staff clearly recognised the versatility of people’s needs and were skilled in dealing with vulnerable individuals with complex physical and mental health needs. There was a high emphasis on staff and public engagement. The trust encouraged members of the public to leave feedback, either formally or through social media. The patients we spoke to said they felt very confident about raising concerns or making suggestions.

There was a clear vision and strategy for the service, which was well developed and well understood throughout the department. The behaviours and actions of staff working in the service mirrored the trust values of ‘patients first’, safe high quality care, responsibility and accountability. We saw multiple examples of this during the inspection. There was clear ownership of services and patient-centred care was a priority.

Wards for older people with mental health problems

Good

Updated 5 May 2016

We rated wards for older people with mental health problems as good because:

  • assessments were comprehensive, carried out in a timely manner and regularly reviewed.
  • care and treatment was delivered in line with current evidence based guidance. A system of audit was in place to monitor compliance.
  • staff displayed a good understanding of their roles and responsibilities in relation to safeguarding. Safeguarding processes were robust.
  • ward shift establishment were developed using a staffing analysis tool. Actual staffing levels matched the identified need.
  • there were systems in place to ensure adherence with the Mental Health Act and Mental Capacity Act.
  • care plans were up to date and personalised.
  • patients and carers were involved in decisions about care and treatment.
  • feedback from patients, family members and carers was positive.
  • staff felt supported in their roles and worked effectively as a multidisciplinary team.
  • there was a good governance structure in place and an open and transparent culture evident on the wards.

However:

  • the two mixed sex wards were not compliant with same sex accommodation guidelines. However, the trust were aware of this issue and were due to move into new accommodation by March 2016. The new premises are compliant with same sex accommodation guidelines.
  • all staff received line management and caseload supervision.

End of life care

Outstanding

Updated 5 May 2016

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

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. We saw that staff were motivated to go the extra mile to meet patient’s needs and the care patients received exceeded their expectations. Results from the 2014 cancer patient experience survey showed Northumbria Healthcare NHS Foundation Trust was in the top ten best performance trusts. Families were very positive about staff and the service they received. The service demonstrated a high level of compassionate care to patients and their families. We saw that staff were motivated to go ‘the extra mile’ to meet patients’ needs. We observed a commitment to providing care that was of a consistently high standard and focused on meeting the emotional, spiritual and psychological needs of patients as well as their physical needs.

There was a clear vision and strategy that focused on the early identification of patients at the end of life, patients being cared for in their preferred place of care and the use of partnership working to develop services. The strategy clearly communicated the vision of integrated services across the community and acute sectors to support patients being cared for in their preferred place of care. There was end of life care representation/leadership at trust board level and we saw evidence of active engagement in end of life care at board level. There were innovative approaches being implemented to achieve the joined up service within acute and community end of life teams. There was comprehensive leadership within the palliative care service with clearly defined leadership roles. They were passionate about the service and encouraged staff to deliver high quality care. Local managers were proactive and came from a clinical background. They demonstrated an understanding of the current issues facing the service. There was a clear sense of pride and belonging amongst staff at all levels within the end of life care teams. Each person’s role was seen as being equally as important as the next. Staff appeared to have a genuine respect for each other within the team. Staff we spoke with demonstrated a commitment to the delivery of good quality end of life care. There was evidence that staff felt proud of the care they were able to give and there was positive feedback from nursing and care staff as to the level of support they received from the specialist palliative care team.

The trust was in the top ten and came 6th out of all trusts in England for the quality of care reported by the Cancer Patient Experience Survey 2014.

Staff understood their responsibilities to raise concerns and to record safety incidents. There was an open culture in reporting incidents and there were systems in place to learn from incidents and reduce the chances of them happening again. There was good identification of patients at risk of deterioration and we saw evidence of the use of emergency health care plans in ensuring that all patients had a plan in place should their condition deteriorate. There was appropriate equipment available in patients’ homes and use of anticipatory prescribing of medicines at the end of life. Mandatory training levels were good, with all community palliative care staff up to date across all localities.

The trust provided effective end of life care to patients. Patients in need of end of life care were identified at an early stage in their care, and staff were alerted to patients who were known to the community team or on a palliative care register. The trust had implemented the Care of the Dying Patient document which was being used as a guide to delivering high quality end of life care.

Policies and guidelines were all evidence based and we saw excellent examples of multi-disciplinary and multi-agency working and collaboration.

The partnership with Marie Curie provided additional flexibility to enable specialist palliative care staff to provide support to patients at the end of life. This was irrespective of the complexities of their condition. Also there were strong links between the hospital liaison service, Marie Curie and the specialist palliative care staff. There were integrated person-centred pathways that involved these different service providers. Services were flexible, provided choice and ensured continuity of care.