North Tyneside General Hospital

Updated 16 October 2019

North Tyneside General Hospital is situated in North Shields, east of the city of Newcastle upon Tyne. The hospital provides a full range of diagnostic testing, medical and surgical services, outpatient clinics covering a range of specialties, as well as facilities for care of the elderly. The hospital has over 21,000 inpatient and 186,000 outpatient attendances annually.

Services had been reconfigured in June 2015 when the Northumbria Specialist Emergency Care Hospital (NSECH) opened. This had resulted in a new model of care and different patient pathways in emergency, medical and surgical care and maternity services.

During this inspection we inspected medicine services.

Our inspection was unannounced (staff did not know we were coming) to enable us to observe routine activity.

Before this inspection we reviewed information about the service and after the inspection we requested further information from the trust.

Updated 16 October 2019

At that inspection in 2015 we rated the core services of outpatients and diagnostic imaging, medical care, surgery and end of life care all as outstanding. Urgent and emergency care services and maternity and gynaecology services were rated as good.

On this inspection, we inspected medical care only at this hospital and rated it as requires improvement. The overall deterioration was due to issues we found in the oversight of clinical governance and assurance.

See below for further information about our inspection of medical care.

Updated 16 October 2019

• We found a number of issues surrounding patient safety, risk of re-admission, access and flow, and the governance, oversight and quality monitoring of the medical care service.
• The service did not monitor nurse staffing levels for patients receiving acute non-invasive ventilation and could not assure us that patients were nursed according to British Thoracic Society guidelines surrounding one nurse to two patients.
• The policy surrounding non-invasive ventilation (NIV) did not adequately describe the process for initiation of NIV on base sites.
• Patients were not continuously monitored when patients were moved between clinical areas while receiving non-invasive ventilation. We escalated this to the business unit management team. As a result, they assured us a business case would be submitted to purchase additional monitoring equipment.
• Although the electronic track and trigger system indicated when patients should be observed, we found that patient observations were not consistently monitored according to the flag alert on the system. In the four weeks prior to inspection, out of 77,350 observations recorded only 44,610 had been completed within 15 minutes of need.
• Although patient records contained comprehensive information, patient identifiers were not consistently used, entries were not always signed and dated, alterations to records were not appropriately made with a single line, countersigned, timed or dated, and fluid balance charts were not always totalled.
• We lacked assurance surrounding clinical governance dissemination in some instances due to the use of wipe clean boards for weekly ward meetings. There was no record of staff attendance at these meetings.
• The risk register did not evidence a robust process surrounding review dates or target dates.
• The model of care separated emergencies from planned care at base sites, however access and flow were impacted due to bed pressures at Northumbria Specialist Emergency Care Hospital and ward closures at base sites.
• The service had a higher than expected risk of readmission for elective admissions in gastroenterology and respiratory medicine and a higher than expected risk of readmission for non-elective admissions in general and respiratory medicine compared to the England average.
• Two specialties were below the England average for admitted referral to treatment times within gastroenterology and rheumatology.
• The service used systems and processes to prescribe, administer, record and store medicines. However, patient group directions had not been reviewed in line with the review date set by the trust and oxygen was not prescribed or recorded in line with national guidance on all wards that we inspected. Medicines had been administered to patients in an emergency without a clear or retrospective record.
• Overall mandatory training compliance, including safeguarding training, Mental Capacity and Deprivation of Liberty Safeguards training did not meet the trust target. Staff were not given protected time to complete mandatory and safeguard training.
• Although senior leadership were aware of training non-compliance surrounding mandatory, safeguarding and Mental Capacity Act & Deprivation of Liberty Safeguards. We lacked assurance of how the service would improve upon this.
• Not all staff received appraisals to assess their work performance and promote their professional development. Appraisal compliance did not meet the trust target.

However:

• The service-controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection.
• Nurse staffing was managed using recognised tools and professional judgment. To maintain safe staffing levels, the service monitored staffing levels and reviewed these daily using nationally recognised tools alongside clinical judgment.
• The service had enough nursing staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment.
• Staff identified patients at risk of nutritional and dehydration risk or requiring extra assistance at pre-assessment stage. Patients were offered support when required.
• Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. We observed positive, kind and caring interactions on the day units and between staff and patients.
• The service had stable management structures in place, with clear lines of responsibility and accountability. We saw evidence of learning, continuous improvement and innovation within medical services at the location.
• Patients we spoke to felt involved in their care and had been provided with information to allow them to make informed decisions.
• The trust had systems and processes in place to ensure that the needs of local people were considered when planning the service delivery.
• Managers at all levels in the trust had the right skills and abilities to run a service providing high-quality sustainable care.
• The trust had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff, patients, and key groups representing the local community.

Updated 5 May 2016

We rated end of life care as outstanding because:

We found that the trust was providing high quality end of life care services using an innovative model of working and effective partnership working. There had been significant investment in palliative and end of life care services and the trust was responsive to addressing issues as they arose with flexibility in relation to staffing and resources. There was a clear vision, strategy and leadership at all levels of the organisation with a focus on good quality end of life care. The structure of the hospital liaison service that had been developed in partnership with Marie Curie provided additional flexibility to enable specialist palliative care staff to provide support to patients at the end of life irrespective of the complexities of their condition. This was sometimes in the form of supporting a rapid discharge to the patients preferred place of care in the community and as such involved a very hands on approach to ensuring as straightforward a transition as possible with hospital staff accompanying the patient in order to handover to community staff.

We saw evidence of the use of national guidance and appropriate anticipatory prescribing of medicines at the end of life. Multidisciplinary working was apparent across services within the hospital and the community. The use of a dedicated palliative care unit and hospital liaison meant that there was a culture of understanding of palliative and end of life care that was integrated across disciplines and with other services. Patients and their families were involved in that care and we saw a number of initiatives in use to record patient wishes including advance care plans, emergency healthcare plans and treatment escalation plans.

Feedback from patients and their relatives was positive about the way staff treated them with one person telling us that staff really care and go above and beyond what they would expect. There was a strong person-centred culture within the hospital and staff consistently appeared to be committed to providing compassionate care and promoting people’s dignity. The trust performed in the top ten NHS trusts in England in the 2014 National Cancer Patient Experience Programme national survey, with 95% of respondents rating the care as being excellent or very good. Spiritual care was seen to be important with initiatives having been developed in supporting staff in the assessment of spiritual needs through training and the use of an internally designed assessment tool. Chaplaincy support saw multi-denominational ministers and faith leaders available for patients, relatives and staff.

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. There was a clear proactive approach to seeking out and embedding new and more sustainable models of care. Staff we spoke with consistently told us they felt that end of life care was a priority for the trust.

Updated 5 May 2016

We rated obstetrics and gynaecology services as good overall with the well-led domain rated as requires improvement because:

There were systems for reporting, investigating and acting on adverse events. The service routinely collected and reviewed standards and safety and shared it with staff. Medicines were stored correctly and checks on emergency equipment were in line with trust policy and were complete. Staff followed safety guidance for infection prevention and control. We found clear safeguarding processes in place; staff knew their responsibilities in reporting and monitoring safeguarding concerns. There were plans in place to ensure staff attended mandatory training. There was no medical staff present on the pregnancy assessment unit, however, support was provided from the antenatal clinic and staff had open access to the medical team based at NSECH.

We found the service used evidence-based guidelines to determine the care and treatment they provided. We reviewed the annual audit plan.Staff were involved in regular local audit. We found staff had the correct skills, knowledge and experience to do their role, however, we found that training had not been provided to support staff on ward 7when gynaecology was relocated. Training ensured medical and midwifery staff could carry out their roles effectively. Competencies and professional development were maintained through supervision.

We found patients were respected and valued. Feedback from patients was positive about the care they experienced and were fully informed about what to expect. We observed patient care in the pregnancy assessment unit and antenatal clinic staff were supportive and compassionate.

The service had gone through a significant reconfiguration to a new model of care. Services were maintained at North Tyneside to support the local population. We found there were robust policies in place to ensure that patients were seen at the right place at the right time. We were informed of occasions where women experiencing miscarriage and termination of pregnancy were next to each other. The fertility control pathway provided an efficient and effective service to women in response to their respective needs, and was provided with choice in how they would like to dispose of pregnancy remains. Women using the service could raise a concern and be confident that concerns and complaints would be investigated and responded to.

Although the senior management team were aware of the challenges to the service and had a vision for the future, 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. The risk register did not reflect the current concerns of the senior management team. We found there were risk and governance processes in place; however, we were concerned with the levels of scrutiny provided by the directorate with regard to the clinical dashboard. Risks were reported and monitored and action taken to improve quality.

Updated 5 May 2016

We rated North Tyneside General Hospital outpatients and diagnostic imaging services as outstanding because:

Staff and managers had a clear vision for the future of the service. They knew the risks and challenges the service faced. Staff we spoke with at all levels felt supported by their line managers, who encouraged them to develop and improve their practice. Staff embraced change and there was a real focus on patient experience and leaders and managers drove this. There were well embedded systems and processes for gathering and responding to patient experiences and the results were well publicised throughout the departments. There were effective and comprehensive governance processes to identify, understand, monitor, and address current and future risks. These were proactively reviewed. There was an open, honest and supportive culture where staff discussed incidents and complaints, lessons learned and practice changed. All staff were encouraged to raise concerns. The departments supported staff who wanted to work more efficiently, be innovative, and try new services and treatments and ways of engaging with the public.

Waiting times and cancellations were minimal and managed appropriately. Diagnostic image reporting times for urgent and non-urgent procedures consistently met or were better than national and trust targets for all scans and x-rays for emergency patients, inpatients, and outpatients. A radiographer discharge programme facilitated the discharge of patients having soft tissue injuries directly from radiology by suitably trained radiographers. Prior to emergency services moving to NSECH in June 2015, the radiology department had developed trauma image reporting, which was swift with an emphasis on “results within minutes” for emergency patients. This was the process that had been adopted at the new NSECH hospital and enabled medical teams to complete assessments and manage risks quickly. The department teams recorded concerns and complaints and used patient feedback proactively to prevent recurrence that might affect others. They reviewed and acted on problems quickly and demonstrated an open and transparent outlook with the aim to learn from them and improve patient experience.

The hospital had good systems and processes in place to protect patients and maintain their safety. The departments were clean and hygiene standards were good. Medical records were stored and transported securely.

Patients were happy with the care they received and found it to be caring and compassionate. Staff worked within nationally agreed guidance to ensure that patients received the most appropriate care and treatment. Trust policies protected patients from the risk of harm by making sure they met any individual support needs. Staff demonstrated understanding of these policies and followed them.

Updated 5 May 2016

We rated surgery services as outstanding because:

There were consistently high levels of staff satisfaction and staff spoke strongly about the supportive and open culture at the trust; staff were proud to work for the service.

There was a clear vision for the service and the new model of care being delivered, with a clear focus on improving the quality of care and people’s experiences. The change to the provision of emergency and high risk surgical services centred at NSECH ensured patients received the right care and treatment, support services, nursing and clinical staff at the appropriate time and location. The strategy clearly identified the new model of emergency and high-risk surgery provided at NSECH and the relationship between NSECH and the base hospitals. The new model was under constant review to determine the most effective site to undertake different procedures depending upon risk and safety.

Local communities had been engaged in the consultation and development of the strategy for the new model of care. This had a positive effect upon the feedback received from patients and relatives received during the inspection at NSECH and also at the base hospitals.

Senior leaders welcomed innovation and there was a continuing history of innovation being embraced and promoted amongst staff. Strong and robust governance structures were in place across the directorate and there was a systematic approach to considering risk and quality management. Senior and site level leadership was visible and accessible to staff. Staff spoke very positively about their immediate line managers and senior leaders. Comprehensive leadership strategies were in place to promote and ensure delivery of the desired culture. This included pilot initiatives such as the ‘shared purpose’ wards and value based recruitment. The surgical services at this hospital used various innovative ways to gather feedback from patients. There was evidence of innovative practice to improve patient outcomes.

Surgery services at NTGH were planned and delivered to meet the needs of local people in a timely way. The service was part of the wider hospital network and incorporated the NSECH emergency care model. This allowed patients access to elective care at North Tyneside Hospital and emergency support when needed. The service reported waiting times better than NHS averages and had been responsive in analysing, assessing and considering patient risk when identifying where best to care for high risk patients. Staff understood the different needs of individual patients and were able to take a tailored approach to meet their needs. This included dementia pain training, access to bariatric equipment, and an understanding of the support needed for some patients with learning disabilities. This included individual experiences for patients with learning disabilities to ensure a positive patient experience. Low levels of complaints had been received. When a complaint was made they were actively reviewed and taken seriously.Action was taken as a result with improvements to the service.

The surgical services in this North Tyneside General Hospital received consistently positive feedback scores and comments through the NHS Friends and Family test. There were a number of approaches taken at the trust to gather feedback from people, the local ‘2 minutes of your time’ survey, a real-time feedback process and a social media feedback approach managed by the Trust Communications and PALS team. All patients we spoke with in wards 7 and 8 and reported staff were friendly, professional and caring. Staff offered patients positive encouragement and challenge when mobilising following surgery. Patients told us this support and encouragement struck the right balance between encouraging them while respecting their limitations. We observed examples of staff compassion with patients and caring communication amongst staff and patients. Comments were consistently positive without exception during our discussions with patients in both surgical wards.

Performance over time showed a good track record with regard to patient safety. Staff were confident in the reporting of incidents and felt supported in doing so. In order to improve services, we saw governance processes were in place to ensure incidents were discussed, and lessons learned and communicated to staff. Staffing levels were appropriate for the service being delivered and recruitment was underway to fill additional posts. Planning for staffing had taken into account the strategic changes in services and the new model of care in Northumbria NHS Foundation Trust. There was a comprehensive understanding of patient risk and staff monitored, recorded and assessed this appropriately. The hospital environment was clean. Medicines were stored and administered safely. Records were appropriate, well completed and stored appropriately. Compliance with wider mandatory training was good and was on target to be completed by the trust’s year end.

Staff used evidence based guidance to inform their practice and were encouraged to seek out new evidence-based techniques and technologies to support the delivery of high quality care. Appraisals were in place with rates above the trust target levels. Patients pain and nutritional needs were appropriately monitored and met by staff. Staff also had up to date training and sound knowledge of consent and mental capacity issues.

Updated 5 May 2016

We rated the emergency care centre as good because:

We observed that staff followed policies and procedures. Safeguarding processes, to protect vulnerable adults and children, were in place and referrals were made in a timely manner when necessary. There were sufficient medical and nursing staff employed by the department and staffing levels were acceptable. There were some areas where the department was not meeting the trust expected compliance rate for mandatory training. Staff were up to date with annual appraisals.

There were evidence based policies and procedures in place which were easily accessible to staff. These were audited to ensure staff were following relevant clinical pathways. Information about patients such as test results were readily accessible. There was evidence of multi-disciplinary working throughout the department and the department offered a seven-day service. Staff understood their responsibilities in relation to taking consent from patients and the principles of the Mental Capacity Act 2005.

The care given to patients by the department was very good. Privacy and dignity were maintained and people were dealt with in a kind and compassionate way. Staff ensured that patients received the care and support they needed. Patients and families were involved in decisions about their care and they had emotional support during difficult situations.

Patients who visited the department had their individual needs met. Interpreters were available and there were facilities available to assist patients with disabilities or specific needs. Pain relief and nutrition and hydration needs of patients were met. Most patients were discharged within three hours of admission and four hour waiting time targets were met. The trust was performing better than the England average for a number of other performance measures relating to the flow of patients. Patient complaints were managed in line with the trust’s policy and feedback was given to staff. Lessons were learned and where applicable, practice was changed to minimise the likelihood of recurrence.

Staff were fully engaged in the future development of the department and the vision and strategy of the trust were embedded in practice.

There were robust governance, risk management and quality measurement processes in place to enhance patient outcomes. Patient voice was seen as important and there were a number of initiatives within the trust designed to ensure that the opinions of patients influenced the delivery of services.

Staff felt that there was good leadership not only in the department but also within the trust. There was an inclusive, learning and supportive culture in the department and staff felt valued and appreciated. Staff were encouraged and supported to be innovative and we saw examples of innovative ways of working within the department.