The Newcastle upon Tyne Hospitals NHS Foundation Trust

Updated 24 January 2024

This report describes our judgement of the quality of care provided by this trust. We base it on a combination of what we found when we inspected and other information available to us. It includes information given to us from staff at the trust, people who use the service, the public and other organisations.

We rated well-led (leadership) from our inspection of trust management, taking into account what we found about leadership in individual services. We rated other key questions by combining the service ratings and using our professional judgement.

We carried out this unannounced inspection of six acute services provided by this trust as part of our continual checks on the safety and quality of healthcare services. These were urgent and emergency care, medicine, surgery, maternity, children and young people, and NECTAR, the trust’s ambulance service.

We carried out an unannounced focused responsive inspection of the maternity service in response to six whistleblowing concerns about patient safety and the culture in the service. We reviewed some of the safe, effective, responsive, and well led key lines of enquiry.

We also inspected the well-led key question for the trust overall.

We carried out a further targeted inspection into surgical cardiothoracic services on 28 September 2023 in response to increased concerns raised by whistleblowers following the core services inspection. The details of this are reported in a separate report dated the same.

We did not inspect critical care, diagnostic and imaging, outpatients, end of life and community.

Overall summary

The Newcastle upon Tyne Hospitals NHS Trust received NHS Foundation Trust status in June 2006. The trust provided a full range of acute and specialist hospital and community services.

The Trust serves the City of Newcastle upon Tyne for secondary health services, and also provides specialist tertiary and quaternary services to the region and nationally. 14% of the population of Newcastle upon Tyne are aged 65 and over, compared to 18% nationally. The Local Authority (LA) had a similar breakdown by ethnicity to the national average, with 13% of the population being BAME (Black, Asian, and Minority Ethnic) residents.

Newcastle upon Tyne performed significantly below the England average for most of the indicators in the Local Health Profile, particularly on the mortality indicators. The health of people in Newcastle upon Tyne was generally worse than the England average.

Newcastle upon Tyne was one of the 20% most deprived districts/unitary authorities in England and about 25% (12,000) of children live in low income families. Life expectancy was 12.9 years lower for men and 10.4 years lower for women in the most deprived areas of Newcastle upon Tyne than in the least deprived areas.

The trust had approximately 1729 beds and employed 14710 members of staff. Activity at the trust was in the highest 20% of trusts nationally for inpatient admissions, outpatients and UEC (Urgent and Emergency Care) attendances. In the second highest quintile for deliveries (Mar 21 to Feb 22).

It is one of the largest teaching hospitals in England providing academically led acute, specialist and community services for adults and children to a large and diverse population across the North East and Cumbria as well as nationally and internationally.

The trust operated from six registered locations.

• The Royal Victoria Infirmary (which includes the Great North Children’s Hospital)

• The Freeman Hospital which includes the Northern Centre for Cancer Care and Institute of Transplantation

• Campus for Ageing and Vitality

• The Dental Hospital

• The Centre for Life

• The Regional Drug and Therapeutics Centre

• Various community sites

The CQC had carried out a number of inspections of the trust; the last comprehensive inspection of the acute services was in January 2016. We rated effective, caring, responsive and well led as outstanding safe was rated as good.

Following that inspection, we inspected Emergency Care, End of Life and Diagnostic and Imaging services in May 2019. We rated effective, caring, responsive and well led as outstanding. Safe was rated as good.

In November 2022 we carried out an unannounced focused inspection which looked specifically at the quality and safety of care provided to patients with a mental health need, a learning disability or autism. We carried out inspection activity in five of the acute services provided by this trust because we had concerns about the quality of services provided to people with a mental health need, a learning disability or autism.

Following our inspection of the trust’s services in December 2022, we formally wrote to the trust to share our concerns about our inspection findings. The trust provided details of the immediate steps taken to ensure patient safety. In response to our findings, we served the trust with a Warning Notice under Section 29A of the Health and Social Care Act 2008. The Warning Notice told the trust that they needed to make significant improvements in the quality and safety of healthcare provided in relation to patients with a mental health need, a learning disability or autism. We asked the trust to take action to improve the quality and safety of services.

In January 2023, we inspected maternity services as part of the CQC national programme. The service was rated requires improvement for safe and good for well led. This inspection report was published in May 2023.

After this inspection we have used our enforcement powers to impose conditions on the trust's registration. The conditions require the trust to make specific improvements within a specified timescale, and to submit monthly reports to CQC showing progress with actions taken to improve quality and safety. The conditions required the trust to:

Implement an effective governance system. This must assess, monitor, and drive improvement in the quality and safety of the services provided, including the quality of the experience for service users in line with the regulations.

Our rating of services went down. We rated them as requires improvement because:

• We rated well led as inadequate, safe, effective, and responsive as requires improvement, and caring as good.

• We rated 5 of the trust’s 9 services as requires improvement and 1 as inadequate. In rating the trust, we took into account the current ratings of the 8 services not inspected this time.

• Some of the services did not always have enough staff to care for patients and keep them safe. However, we saw evidence of staffing escalation frameworks to maintain patient safety. Staff did not always assess monitor or manage risks to patients, act on them or keep good care records. They did not always store and manage medicines safely. Not all staff reported incidents in a consistent and standardised way. Services did not always define the correct levels of harm according to the NRLS (National Reporting and Learning System) definition. Staff we spoke to did not always receive feedback or learning from incidents. However, the CQC noted the results of the national staff survey which showed that the trust was above sector average in scores relating to reporting of errors, incidents and near misses.

• Care and treatment was not always delivered in accordance with national guidance or evidence-based practice. Managers did not always monitor the effectiveness of the service or always work well together for the benefit of patients.

• People could not always access the services when they needed it to receive the right care promptly. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were not always in line with national standards.

• Senior staff were not always visible and approachable in the services for patients and staff. They did not always use systems to manage performance effectively or make decisions and improvements. They did not have clear oversight of the key risks and had not always mitigated immediate risks. Staff did not always feel respected, valued, and supported. The trust did not have a culture where staff could raise concerns without fear as they were not always managed appropriately. Although the NHS Staff Survey showed that in 2022 74% of staff felt secure about raising concerns about unsafe clinical practice. This is the same as the regional average for acute Trusts and higher than the national statistic of 71%. However, CQC staff survey indicated that the trust did not have a culture where staff could raise concerns without fear.

• It should be noted that the NHS staff survey was completed in 2022, a different time period to the CQC staff survey completed as part of this inspection.

However:

• Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families, and carers.

• Staff had training in key skills and understood how to protect patients from abuse.

• There were ongoing examples of innovation and research.

How we carried out the inspection

The team that carried out the core services and well led inspection included two deputy directors of operations, an operations manager, 10 hospital inspectors, three mental health inspectors, two pharmacy inspectors and an inspection planner. In addition, there were 10 specialist advisors with clinical expertise in the core services areas. There was an executive reviewer plus four specialist advisors experienced in executive leadership of NHS trusts. The inspection team was overseen by Sarah Dronsfield, Deputy Director of Operations.

During the inspection we spoke with a variety of staff including consultants, doctors, therapists, nurses, healthcare support workers, pharmacy staff, domestic staff and administrators. We held staff focus groups attended by representatives of all grades of staff across nursing, midwifery, allied health professions and medical staff networks. We also carried out a confidential staff survey. This was to enable staff to share their views with the inspection team.

Updated 29 May 2019

Updated 29 May 2019

Updated 6 June 2016

Overall, we rated this service as good because:

• Staff knew how to report incidents and most received feedback when requested. Lessons learnt from incidents were found to be shared by distribution of team meeting minutes. Pressure ulcers were the most commonly reported incident.

• We found that staff had a good understanding of safeguarding and how to report concerns.

• Medicines were managed appropriately and equipment was checked and serviced. Waste management and disposal information and guidance was in place.

• Records viewed were accurate and complete. There was some duplication of work in community services due to paper records being used alongside the electronic patient system.

• Recruitment to community staffing was highlighted as a concern and managers were using different strategies to address this. Staffing was on the risk register. Staff we spoke to felt caseloads were manageable. Therapy staffing had few vacancies and the actual staffing levels versus planned was good. Community nursing staffing data showed the whole time equivalent against the planned staffing levels to be similar.

• Staff base buildings were highlighted on the risk register and staff told us of the challenges of being based in such buildings. Lack of access to IT was found to be an issue in some areas of community services. This was highlighted as a risk and managers were actively seeking a mobile solution to allow access to the required systems.

• There was good evidence based care and treatment using national and local guidance. We saw person centred care and the use of risk-based tools through the electronic patient system. Patient outcome data was collected and community services participated in a number of audits.

• Staff had received the appropriate training and development. Learning needs were identified during annual appraisals, staff told us they had access to further training, and development was good.

• Patients received compassionate care and their dignity and privacy was respected. Staff interacted with patients and provided the emotional support required. We found staff had a strong sense of patient understanding and staff involved patients, families and carers where appropriate.

• Feedback from patients and carers was consistently positive. Community services sought feedback from patients and carers and the walk in centres actively engaged with the public.

• The culture in the community teams was one of teamwork and supporting each other. Management were found to be visible and supportive. There was a clear strategy in place for community services for adults. The strategy had yet to be implemented fully. Governance arrangements were in place and a clinical governance data pack included a clinical assessment tool, care summary data and patient outcome data.

Updated 6 June 2016

We rated this service as good overall because:

• Staff were aware of their responsibility to report incidents, they knew how to report incidents, near misses and accidents and were encouraged to do so. Learning from incidents was shared between teams and across the organisation.
• There were safeguarding systems in place to protect children from harm, although some staff in the health visiting and school nursing teams were not receiving recommended amounts of safeguarding supervision. There was a dedicated safeguarding team in place.
• Staff received mandatory training, although it was not clear whether all staff were up to date due to differences between recorded data held by the trust and individual practitioner’s records.
• Staff received regular supervision and appraisals, although it was not clear whether some staff were up to date with their appraisal as figures provided by the trust indicated that they were not meeting the target for appraisals.
• The service had sufficient numbers of staff and had appropriate sized caseloads in line with national guidance.
• Care and treatment was evidence based with policies, procedures and pathways available to staff. There was good evidence of multi-disciplinary working and good transition arrangements were in place. Staff were aware of their responsibilities with regards to obtaining consent.
• We observed staff treating people with compassion, kindness, dignity and respect. Feedback from children, young people and their families was positive.
• Services were planned to meet people’s needs and the needs of different people were taken in to account. There were systems in place to make sure that children, young people and their families could access care at the right time and services were flexible enough to fit in with individuals needs. There were examples of innovative practice that aimed to make the services more accessible to people such as those with a learning disability. Feeback from service users was taken in to consideration when developing services.
• Leaders were approachable, supportive and encouraged staff engagement. Staff knew the trust vision and values. Governance systems were in place to ensure delivery of good quality care.
• While most of the services had their own strategy, the community directorate strategy did not incorporate children’s services within it.

Updated 6 June 2016

Overall rating for this core service Good

We rated the community dental services at this trust as good because:

• We considered the service was staffed by people who were trained and regularly appraised and who were willing to learn and improve from any incidents and who showed a real commitment to safeguarding their patients.
• The community dental service had an effective referral based service for the local community, including managing an emergency ‘out of hours’ service and an oral health promotion team which worked with local schools and other agencies.
• We observed care from caring and committed staff who had chosen to work in a community setting to provide consistently patient focussed and compassionate care.
• The community dental service was responsive to the needs of its patients who often had complex needs, for example those with a learning disability. Staff spoken with saw complaints as a way to improve and shape the service given to patients and could describe how changes had been made to their practice to deliver better care.
• The community dental service was led by a consultant in special care dentistry. The service had robust governance arrangements in place which were evidenced in minutes of meetings seen and reported to the Board through the medical director. Staff were engaged and motivated and spoke proudly about the innovations they had achieved, particularly with regard to the dental student programme which ran throughout the year to provide training for future dentists.

Updated 29 May 2019

• Staff knew how to report an incident using the trust’s electronic system and were aware of the importance of doing this. There were clear routes for feedback and learning from incidents to be shared and these were being used effectively.
• Staff understood how to protect patients from abuse. Safeguarding was well understood with comprehensive training delivered to staff.
• There was evidence of well worked out systems for multidisciplinary working between different staff groups, between different parts of the trust, and with external agencies; such as hospices and the ambulance service.
• There was good input from general practitioners and pharmacies. Systems for the provision of out-of-hours and anticipatory medicines were in place.
• Staff assessed risks to patients during their visits and advice from a consultant was always available.
• The service worked towards a standard based on the principles of the national palliative care ‘Gold Standards’ framework.
• Evidence from surveys, statements by relatives, and our conversations with patients, and staff, showed the highest degree of compassion, emotional support, understanding and involvement of patients and those close to them.
• The service linked into a general practitioner risk register used to identify patients who were in need of end of life care input.
• Consent was informed and discussed with patients. ‘Do not attempt cardiopulmonary resuscitation’ (DNACPR) forms we reviewed were signed and dated
• We observed compassionate care that met patients’ emotional needs. We saw the team engaging with patients, and understanding their needs, and involving them and those closest to them.
• There was evidence of a high level of responsiveness in the way the service linked with patients from different backgrounds and facilitated the inclusion of hard to reach groups. The latter being seen clearly in the work done, in collaboration with a local charity, to reach homeless people.
• The service fully supported patients in helping them choose their final place of care. This included the compassionate way in which they supported a patient who was considering using the Dignitas service.
• There was an effective referral system from the in-patient hospital team to ensure new patients accessed the community team quickly and effectively. There was a system of triage to ensure patients got the care and support at the right time.
• There were explanatory leaflets for patients and those close to them that was written in an empathetic and jargon free style. These were also available in different languages.
• There was a culture of everybody working together in a non-hierarchical manner for a common goal.

However:

• The trust had a mandatory training target of 95%. In the case of qualified nursing staff ten out of fourteen training modules exceeded the target with a compliance rate of 100%. Although the target was not achieved in the training modules of; anti-bribery and corruption, fire safety, health and safety, and Prevent (Prevent is part of the UK's Counter Terrorism Strategy that works to stop individuals from getting involved or supporting terrorism or extremist activity). These latter areas had a compliance rate of 89%.
• Staff were aware of the principles of cleanliness and infection control. However, because of the nature of the work being undertaken in patients’ homes we could not observe staff providing clinical care to patients that required a clean or aseptic environment. Staff did not always keep detailed records of patients’ care and treatment. A review showed that not all paper records had signatures and that conversations with patients were not always recorded.
• Although we saw evidence that consent was being sought it was not recorded in all the records that there had been a full discussion with the patient and their family.
• We saw one record where the use of bed sides was not recognised as a possible use of restraint.
• There was a lack of provision of end-of-life care provision for children although this was a commissioning issue outside of the responsibilities of the service. It was noted that one of the consultants worked pro-bono in their own time to help the service meet patients’ needs.
• There was no operational manager post within the team, that was jointly consultant and nurse led. The team recognised that this role would further strengthen their leadership, and conversations had taken place at an executive level with a view to implementing this.

Updated 24 January 2024