Freeman Hospital

We inspected the trust from 19 to 22 January 2016 and undertook an unannounced inspection on 5 February 2016. We carried out this inspection as part of Care Quality Commission's (CQC) comprehensive inspection programme.

We included the following locations as part of the inspection:

• Freeman Hospital incorporating The Northern Centre for Cancer Care
• Centre for Ageing and Vitality

We inspected the following core services:

• Medical Care
• Surgery
• Critical Care
• Services for Children and Young People
• End of Life Care
• Outpatients & Diagnostic Imaging

Overall, we rated the Freeman Hospital as outstanding.

Our key findings were as follows:

• The trust had infection prevention and control policies, which were accessible, and used by staff. Patients received care in a clean, hygienic and suitably maintained environment.

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

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

• Patient outcome measures showed the trust performed mostly within or better than national averages when compared with other hospitals. Stroke pathways and long-term cancer outcomes were particularly effective. Death rates were within expected levels.

• There were clearly defined and embedded systems and processes to ensure staffing levels were safe. The trust had challenges due to national shortages however; it was actively addressing this through a range of initiatives including the development of new and enhanced roles, and overseas recruitment. There were particular challenges in the provision of consultant to patient ratios and pharmacy cover in critical care.

• The trust was meeting its waiting time targets for urgent and routine appointments.

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

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

• Information written in clinical notes about the care patients received in the Emergency Department and on some wards was minimal.

• Feedback from patients, those close to them and stakeholders was consistently positive about the way staff treated people. There were many examples of exceptional care where staff at all levels went the extra mile to meet patient needs.

• The trust used innovative and pioneering approaches to deliver care and treatment. This included new evidence-based techniques and technologies. Staff were actively encouraged to participate in benchmarking, peer review, accreditation and research.

• The trust worked hard to ensure it met the needs of local people and considered their opinions when trying to make improvements or develop services. It was clear that the opinion of patients and relatives was a top priority and highly valued.

• There was a proactive approach to understanding the needs of different patients. This included patients who were in vulnerable circumstances and those who had complex needs.

• There were strong governance structures and a systematic approach to considering risk and quality management. Senior and local site management was visible to staff. Staff were proud to work in the organisation and spoke highly of the quality of care provided.

• There were consistently high levels of constructive engagement with patients and staff, including all equality groups.

We saw several areas of outstanding practice including:

• There was an integrated model of care between the Specialist Palliative Care Team and the Cardiothoracic Transplant Team. The teams worked alongside patients with advanced disease including those waiting for transplant and those with ventricular assist devices.

• A sleep checklist was developed for patients in critical care to optimise sleep. This included measures such as environmental factors, noise, temperature and light in patient areas.

• Hydrotherapy rehabilitation after critical illness had been developed for patients who were ventilated which enabled them to move their limbs supported by water. This gave psychological support to patients and helped them engage with their rehabilitation programme.

• Radiology facilities were adapted to meet the needs of patients with dementia or learning difficulties. This included distraction aids and mood lighting to help patients relax.

• The trust Falls and Syncope Service was the largest of its kind in Europe and undertook research and treatment for patients presenting with a range of problems such as balance disorders, dizziness, low blood pressure, balance problems or unspecified lack of co-ordination and falls.

• The Northern Centre for Cancer Care (NCCC) in partnership with Macmillan was providing chemotherapy in three community health centres enabling access for non-complex treatments closer to home. Chemotherapy nurses from the NCCC ran this service.

• The perioperative care team at the Freeman were national leaders in pre-operative assessment, cardiopulmonary exercise testing after major intra-abdominal surgery (including shared decision making in the pre-operative counselling process).

• The pancreatic service had developed a remote care service to assist clinicians in outlying hospitals to manage their patients. This was to avoid transferring ill patients to Newcastle when they could be managed at their base hospital. This service was coordinated by a nurse specialist and saved patients being unnecessarily transferred to Newcastle. It also ensured that those patients who may require specialist care were transferred at the correct time.

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

Importantly, the trust MUST:

• Ensure that care documentation in the Emergency Care Department and on some wards are fully completed to reflect accurately the treatment, care and support given to patients, and is subject to clinical audit.

In addition the trust SHOULD:

• Ensure processes are in place to meet national best practice guidelines for diagnostic imaging reporting turnaround times for inpatients and patients attending the Emergency Care Department.
• Ensure that all groups of staff complete mandatory training in line with trust policy particularly safeguarding and resuscitation training. Ensure that all staff are up to date with their annual appraisals.
• Ensure that the departmental risk register in End of Life Care accurately reflects the current clinical and non-clinical risks faced by the service.
• Ensure that all housekeeping staff who undertake mattress contamination audits are aware of the trust policy relating to mattress cleanliness and the criteria for when to condemn a mattress.
• Ensure staff follow the systems and processes for the safe storage of medicine and the recording and checking of resuscitation equipment.
• Ensure that the storage of patient records is safe to avoid potential breaches of confidentiality.
• Ensure that arrangements are robust to enable patients to transfer safely with continuity of syringe drivers in place from hospital to the community to avoid the risk of breakthrough pain being encountered.
• Ensure that the Care for the Dying Patient documentation is fully implemented and embedded across acute hospital sites.
• Ensure that processes are developed to identify if patients achieved their wish for their preferred place of death.

Professor Sir Mike Richards

Chief Inspector of Hospitals