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Provider: Northumbria Healthcare NHS Foundation Trust Outstanding

Reports


Inspection carried out on 9th - 13th November 2015

During a routine inspection

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


CQC inspections of services

Service reports published 2 August 2017
Inspection carried out on 24-26 April 2017 During an inspection of Community mental health services with learning disabilities or autism Download report PDF | 306.71 KB (opens in a new tab)
Service reports published 17 February 2017
Inspection carried out on 22-23 September 2016 During an inspection of Specialist community mental health services for children and young people Download report PDF | 297.74 KB (opens in a new tab)
Service reports published 5 May 2016
Inspection carried out on 9-13 November 2015 During an inspection of Community health services for adults Download report PDF | 396.61 KB (opens in a new tab)
Inspection carried out on 9 – 13 November 2015 During an inspection of End of life care Download report PDF | 326.88 KB (opens in a new tab)
Inspection carried out on 9 - 13 November 2015 During an inspection of Community health inpatient services Download report PDF | 325.32 KB (opens in a new tab)
Inspection carried out on 9 - 13 November During an inspection of Community dental services Download report PDF | 307.16 KB (opens in a new tab)
Inspection carried out on 9 – 13 November 2015 During an inspection of Urgent care services Download report PDF | 323.23 KB (opens in a new tab)
Inspection carried out on 10-13 November 2015 During an inspection of Wards for older people with mental health problems Download report PDF | 304.24 KB (opens in a new tab)
Inspection carried out on 9-13 November 2015 During an inspection of Community health services for children, young people and families Download report PDF | 381.39 KB (opens in a new tab)
See more service reports published 5 May 2016

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