Queen Elizabeth Hospital

Queen Elizabeth Hospital is the acute hospital forming part of Gateshead Health NHS Foundation Trust. It provides a range of services including medical, surgical, maternity and gynaecology and services for children and young people, end of life and critical care. It has approximately 580 beds. The hospital also provides emergency and urgent care, outpatients and diagnostic imaging.

We inspected Queen Elizabeth Hospital as part of the comprehensive inspection of the Foundation Trust from 29 September to 2 October 2015 and undertook an unannounced inspection on 23 October 2015.

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

Our key findings were as follows:

• The majority of areas inspected were clean; however, we did identify some infection control issues in the critical care unit and the waste disposal unit.

• Rates of infection were within an expected range for the size of the trust.

• Patients were able to access suitable nutrition and hydration, including special diets, and they reported that, overall, they were content with the quality and quantity of food.

• There were processes for using and monitoring evidence-based guidelines and standards to meet patients’ care needs. Although policies and care pathways held electronically on the trust systems were in-date some paper copies held in ECC and SCBU were out of date or had no review date.

• The trust promoted a positive incident reporting culture. Processes were in place for being open and honest when things went wrong and patients given an apology and explanation when incidents occurred.

• The trust was not meeting all its waiting time targets; the national target for two week cancer waiting times had not been met for a number of tumour sites for four consecutive quarters. This was identified by the trust as a governance concern.

• Systems and processes on some wards for the storage of medicine and the checking of resuscitation equipment did not comply with trust policy and guidance.

• Nurse staffing was maintained at safe levels in most areas. However, there were occasions where staff had asked for additional support to provide ‘special’ nursing care (individual attention) to meet the physical and mental health needs of patients and shifts had not been covered. The trust had a business case to increase staffing levels in certain areas and had escalation processes when staffing fell below recommended levels.

• The trust had gaps in medical staffing because of national shortages in certain specialties however; the trust was actively recruiting to these including international recruitment. This risk was further reduced by the use of advance nurse practitioners to support doctors.

• Safeguarding procedures were in place and staff could demonstrate an understanding of their role and what action to take if they were concerned about a person.

• Feedback from patients and their relatives was very positive about the care they received and there were examples of some outstanding caring practice.

• Patient outcome measures showed the trust performed mostly within or better than national averages when compared against other hospitals. Death rates were within expected levels.

• Following an external review of governance processes, the trust was reviewing its service strategies to ensure that they remained achievable and relevant. The Board had the experience, capacity and capability to ensure that the strategy was delivered.

We saw several areas of outstanding practice including:

• The Rehabilitation after Critical Illness Team (RaCI) led by nurses, health care assistants and physiotherapists had developed new pathways to help patients recover from critical illness. The team provide rehabilitation while a patient was in the critical care unit, throughout their stay and following discharge.

• Therapy staff were part of the frailty model and worked in the emergency care centre to support elderly patients with mobility aids and discharge plans avoiding unnecessary admissions to hospital.

• A combined referral pathway and documentation was being used by GP practices to refer into the trust’s diabetes-integrated service. It included advice and guidance for GPs, a specialist nursing helpline and multi-disciplinary clinical assessment. Clear protocols were in place to identify when a patient could be managed within primary and/or secondary care and when care transfer was appropriate and/or possible.

• Pathology services had achieved the national external quality assurance scheme (NEQAS) accreditation for cellular pathology and was recognised as a national centre for excellence.

• Ward 23 was a 24 bedded acute ward providing specialist care to older people with physical and mental health illness (predominantly dementia care) in a dementia friendly therapeutic environment, respecting patient’s dignity whilst also promoting their independence in preparation for discharge from hospital. A team of specialists who had both physical and mental health skills and knowledge cared for patients, their philosophy was to deliver holistic, timely care to patients and their carers.

• The design of the Emergency Care Centre was innovative and recognised by NHS England as a best practice model providing a single point of access for emergency care.

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

Importantly, the trust must:

• Ensure that a clean and appropriate environment is maintained throughout the critical care department and waste disposal unit for the prevention and control of infection; including the provision of appropriate personal protective clothing for staff working in the waste disposal unit.

In addition the trust should:

• Take action to meet the national 2-week cancer waiting time targets in all tumour sites.

• Ensure that staffing and skill mix is reviewed on ward 23 to take account of the dependency of patients and ensure that sufficient staff are in place, particularly where special one to one support is identified as being required.

• Ensure that processes are consistently followed in all areas for checking the storage of medicines particularly recording of fridge temperatures and signing and dating medication entries.

• Ensure that SCBU moves towards introducing a National Early Warning Score chart.

• Ensure that there is a strategy for optimising patient outcomes from medicines in line with best practice guidance from the Royal Pharmaceutical Society that has Board approval and reviewed regularly.

• Ensure processes are consistently followed particularly in SCBU and critical care for the checking of resuscitation equipment.

• Ensure where required, staff are up to date with Paediatric Immediate Life Support (PILS) and Advanced Paediatric Life Support (APLS) training.

• Review processes to reduce the number of clinic appointments cancelled.

• Continue to implement and strengthen governance processes in response to recommendations following an external independent review including strengthening the board assurance framework, clinical engagement and management of performance and risk.

• Review version control arrangements for the updating of paper copies of polices and care pathways held in clinical areas to ensure staff are using policies which are in date and reflect the latest best practice guidelines.

• Ensure cause for concern-safeguarding forms identify if a child is, or is not, subject to a child protection plan to enable swift and appropriate action.

Professor Sir Mike Richards

Chief Inspector of Hospitals