North Tyneside General Hospital

North Tyneside General Hospital is one of the acute hospitals providing care as part of Northumbria Healthcare NHS Foundation Trust. This hospital provides emergency care from an emergency care centre, medical and surgical services, midwifery led with no obstetric intervention maternity services, mental health care for older people, end of life care and a range of outpatient and diagnostic imaging services. North Tyneside General Hospital does not provide critical care and children and young people services. Services had been reconfigured in June 2015 when the Northumbria Specialist Emergency Care Hospital (NSECH) opened. The opening of NSECH had resulted in a new model of care and different patient pathways in emergency, medical and surgical care and maternity services.

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. North Tyneside General Hospital has 307 beds.

We inspected North Tyneside General Hospital as part of the comprehensive inspection of Northumbria Healthcare NHS Foundation Trust, which included this hospital, Hexham General Hospital, Wansbeck General Hospital, Northumbria Specialist Emergency Care Hospital, and community services. We inspected North Tyneside General Hospital between 9 and 13 November 2015.

Overall, we rated North Tyneside General Hospital as outstanding. We rated it outstanding for being caring, responsive and well-led, and good in providing safe and effective care.

We rated medical care, surgery, outpatient and diagnostic imaging services and end of life services as outstanding. Urgent and emergency services, maternity and gynaecology and the service for older people with mental health problems we rated as good.

Our key findings were as follows:

• The opening of NSECH 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.
• Staff felt fully informed about all the changes which had taken place and were proud of the hospital and the care it provided to the local community and beyond.
• Strong governance structures were in place across the hospital 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.
• Staff and patient engagement was seen as a priority with several systems in place to obtain feedback.
• The “Northumbria Way”, which incorporates the trust’s values, behaviours and culture, was evident when we spoke with managers and staff throughout the hospital.
• 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 processes to ensure patients were cared for in the right place at the right time. Patient flow was a priority, and the hospital proactively managed this.
• For all performance measures relating to the flow of patients the hospital was performing the same or better than the England average.
• The transfer of patients between NSECH and the ‘base’ hospitals was still being embedded at the time of inspection and staff were working flexibly to accommodate patient needs.
• The hospital 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.
• There was adequate personal protective equipment (PPE) such as aprons and masks available to staff. We routinely saw staff using this equipment during our inspection. Patients told us that staff washed their hands and used gloves and aprons.
• The hospital routinely monitored staff hand hygiene procedures and compliance, at the time of inspection, was high.
• Between April and September 2015 there had been no cases of methicillin resistant staphylococcus aureus (MRSA) at this trust and five cases of c-difficile. No cases were reported in surgery at this hospital.
• Nurse staffing was maintained at safe levels in most areas. The hospital 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 at this hospital.
• The hospital utilised advance nurse practitioners to support doctors.
• 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.
• Most wards 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.

In end of life care:

• The model of end of life care services saw that dedicated palliative care beds were operated alongside a specialist palliative in-reach service to general ward areas. This meant that specialist staff worked alongside general staff to deliver effective, coordinated care within a holistic approach.
• Services worked across both acute and community settings with a strong multi-disciplinary ethos.
• 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 trust was supporting increasing numbers of non-cancer patients.
• 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 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.
• The Palliative Care service had won the Quality Award for 2014 for their commitment to improvement and the excellent patient experience feedback received.
• 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.

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.
• Ensure that the maternity and gynaecology dashboard is fit for purpose, robust and open to scrutiny.

In addition the trust should:

• Ensure that levels of staff training continue to improve in the hospital so that the hospital meets the trust target by 31st March 2016.

In the Emergency Care Centre:

• Consider circulating guidance to staff about when to stop using the ‘see and treat’ model when the department is busy and revert to the triage model, to ensure patient safety and improve responsiveness.
• Consider training for reception staff to help identify patients who may need to be brought to the attention of clinical staff more quickly.
• Consider increasing the number of independent nurse prescribers to enable more flexibility in prescribing of medication in the ECC when there are no doctors available.

In maternity and gynaecology:

• Ensure that the clinical strategy for maternity and gynaecology services which is embedded within the Emergency Surgery and Elective Care Annual Plan, sets out the priorities for the service with full details about how the service is to achieve its priorities, so that staff understand their role in achieving those priorities.
• Consider the provision of separate accommodation for women undergoing pregnancy loss and termination of pregnancy.

In outpatient’s and diagnostic imaging:

• Ensure waiting time targets in ultrasound in diagnostic imaging continue to improve as more staff are appointed.

In wards for older people with mental health problems:

• The provider should ensure that all steps are taken to maintain the safety, privacy and dignity of patients on mixed sex wards until the wards move into new same sex accommodation.
• The provider should ensure that a programme of formal supervision is rolled out following completion of a pilot project.
• The provider should ensure that ligature risk assessments are comprehensive and consistent across sites.
• The provider should look to develop service specific key performance indicators to aid performance monitoring.

Professor Sir Mike Richards

Chief Inspector of Hospitals