Archived: South Tyneside NHS Foundation Trust

We inspected South Tyneside NHS Foundation Trust from 5 – 8 May 2015 and undertook an unannounced inspection on 3 June 2015. We carried out this comprehensive inspection as part of the Care Quality Commission (CQC) comprehensive inspection programme.

The trust had a well-established executive team with the Chief Executive being in post since 1997 and the Chairman since 2006. The Chief Executive planned to retire in September 2015 and at the time of the inspection the trust was in the process of appointing a new Chief Executive.

We inspected the following core services:

• South Tyneside District Hospital; urgent and emergency care; medical care; surgical care; critical care; maternity services; children’s and young people’s services; end of life care; outpatient services and diagnostic imaging.
• Community services: community adult and long term conditions; end of life care; community health services for children, young people and families and dental services

Overall the trust was rated as ‘Requires Improvement’ however the community services for this trust were rated as ‘Good’.

Our key findings were as follows:

• Across both the acute hospital and community services, arrangements were in place to manage and monitor the prevention and control of infection. There was a dedicated infection control team to support staff and ensure policies and procedures were implemented and adhered to. We found that the areas we visited were clean. Infection rates for Methicillin Resistant Staphylococcus Aureus (MRSA) and Clostridium Difficile (C. Difficile) were within an acceptable range for this size of trust.
• Patients were able to access suitable nutrition and hydration, including special diets and they reported that, on the whole, they were content with the quality and quantity of food.
• There were staffing shortages in some areas across both nursing and medical professions with some wards unable to meet the safer staffing requirements. The trust used agency nurses and locum doctors to address the staffing requirements.
• There were processes for implementing and monitoring the use of evidence based guidelines and standards to meet the needs of differing patient groups across both the hospital and community services.
• There were processes in place from ward and department level through to Board level for the reporting of incidents.
• There were long waits in the Emergency Department through the winter period with patients being cared for in the department; it was noted that patients were placed on a bed after being in the department for six hours.
• There were six instances in a six month period when a lack of critical care capacity resulted in patients being cared for in theatre recovery unit rather than in the intensive care unit.
• Equipment was well maintained both in hospital and community services.
• Governance processes were not fully developed or embedded across the divisions.
• The staff engagement is set out in the overarching trust strategy and we saw examples of staff engagement such as team brief and the Chief Executive ‘cheer up Friday’ email message.
• There was a clear strategic development plan which included both community and hospital services.
• There were concerns regarding leadership of some services.

We saw several areas of outstanding practice including:

• 100% of patients at St Benedict’s hospice died at their preferred place and for the out of hours team at the hospice, 399 out of 404 (99%) patients died at home. For patients cared for by the Gateshead out of hours team, 246 (98%) patients in the Gateshead area died in their preferred place of care.
• The trust came top of the league for best performing hospital in England in 'The Cancer Patient Experience Survey: Insight Report and League Table' (2014) and was in the top three in the same survey in 2013. Areas of excellent performance in the survey included emotional support from nursing and medical staff, clear explanations of what was wrong and what to expect, involvement of family members and easy contact with the cancer specialist nurse.
• An outstanding level of care and compassion for patients and their relatives using community end of life care services. Patients and relatives were truly respected and valued as individuals and were empowered as partners in their care.
• The Trust was one of the 40 hospitals to receive the CHKS Top Hospitals Award in May 2015 through the CHKS national assessment and award programme. The evaluation considers safety, clinical effectiveness, health outcomes and patient experience and quality.
• There was a bereavement ward specialist nurse who held bereavement meetings and the chaplain was also a trained psychotherapist who would also provide support to the patient and their family.
• The trust’s electronic referral and caseload scheduling for community nursing system, Hydra, won the ‘embracing technology’ category at the lean healthcare awards in 2014. The awards recognised excellent service improvements and enhanced efficiencies carried out by healthcare organisations. Hydra was also a runner-up in the national patient experience (PEN) awards.
• The community dental service had developed a DVD for Learning Disability patients. This video was used to help prepare Learning Disability patients for visits to the dentist. The staff reported positive feedback from the Learning Disability Team about this innovation.
• The development of an intra-nasal sedation service within community dental services. This approach tried to ensure that patients did not receive an unnecessary general anaesthetic because there are inherent risks associated with this procedure.
• The Trust’s services to support older people won the value in healthcare ward in the Health Service Journal national awards. The service works closely with older people in South Tyneside to support people who are malnourished to ensure they were receiving the right, high quality care regarding their diet. A training programme was also set up in local care homes, resulting in more than 1,000 carers being trained to ensure residents receive a high energy, high protein diet.
• The children’s diabetic team used a computer system that allowed uploading of information from glucose meters, insulin pumps, and mobile apps. The system consolidated and presented the information in reports which allowed the clinicians to see a more accurate picture of the patient’s health over a period of time.
• The staff from the Endoscopy Unit won the 2015 ‘Study Team of the Year’ category awarded by the National Institute for Health Research North East and North Cumbria Clinical Research Network.
• The Endoscopy Unit had participated in an international programme ‘Endo-live’ where live investigations were carried out and transmitted via satellite to conferences. The event in 2014 was opened by a professor from the endoscopy unit at South Tyneside District Hospital.
• Ward 19 had received a quality mark in 2014 from the Royal College of Psychiatrists as a result of positive work in the delivery of good quality, essential care for older people.
• The IT department was working collaboratively with the community IT team to ensure both the acute and community electronic patient systems will be compatible.
• Maternity services used a telehealth system (the delivery of health information using telecommunications technology). This system enabled women to monitor their blood glucose levels and blood pressure in their own homes, avoiding unnecessary visits to the clinic.
• A new form of renal replacement therapy which improved outcomes for patients with renal failure and meant that they could be stabilised prior to transfer to a hospital with a renal service (South Tyneside does not have a renal service).

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

Importantly, the trust must:

• Review compliance with mandatory training and in particular training in safeguarding, medical device management, medicines management and Mental Capacity Act and Deprivation of Liberty Safeguards.
• Ensure that medical staff receive mandatory training including fire prevention and child and adult safeguarding.
• Ensure all necessary patient risk assessments, for example, venous thromboembolism (VTE) and early warning scores for deteriorating patients are completed and recorded appropriately.
• Ensure assurance processes are in place to confirm the 'five steps to safer surgery' (part of the WHO surgical safety checklist) is being consistently completed.
• Review the policy, processes, procedures, training, and support arrangements for the safe care and treatment of medical ‘boarders’ within surgical wards and the impact on services.
• Review the arrangements for the provision of a care pathway and formal medical rota for the management of patients with gastrointestinal bleeds.
• Review how the flow of patients is managed through the emergency department (ED) and ensure that there is a documented escalation plan that is implemented when required to deal with patients waiting for more than four hours for transfer to a ward. This should include action to avoid patients staying in ED longer than 12 hours.
• Review the quality of record keeping in the emergency department to ensure that records accurately reflect the standard of care provided including risk assessments, nutrition and hydration and provision of nursing care.
• Improve the quality of documentation for the decision to admit time and discharge time if the primary record is the ED documentation.
• Ensure that when patients complain about their care, there is an effective process in place for staff to receive feedback and learning.
• Conduct a full environmental risk assessment for the Intensive Therapy / High Dependency Unit (ITU) and take action to mitigate the risks posed by lack of storage space.
• Implement an escalation plan approved by operating theatre and critical care nursing and clinical leads that ensures that appropriate support systems are available on a timely basis if critical care patients are nursed in the recovery room.
• Ensure that all theatre staff caring for Level 2 and Level 3 ITU patients have received the appropriate training and that training records are retained.
• Implement dedicated pharmacy support for ITU.
• Ensure appropriate staffing on all children’s inpatient areas particularly the special care baby unit.
• Ensure that all medical devices receive service testing as required.
• Ensure that COSHH risk assessments are completed for all areas storing substances hazardous to health to ensure that these are stored securely.
• Ensure that effective control measures are in place to monitor exposure levels of nitrous oxide and the checking of ventilation and scavenging systems on the delivery suite.
• Ensure resuscitation equipment checks are carried out regularly and consistently across all areas of the department.
• Ensure that all employees receive an annual appraisal.
• Ensure that there is a formal strategy for maternity and gynaecology services which sets out how the service is to achieve its priorities and that staff understand their role in achieving service objectives.

In addition the trust should:

• Review the continuing concerns raised by staff of bullying and harassment and the difficult working environment within theatres.
• Review the concerns raised by medical staff from the trauma and orthopaedics department about individual bullying and harassment leading to concerns about patient care.
• Develop a strategy to support dedicated educational support for critical care staff.
• Develop a formal process for safeguarding supervision in maternity services.
• Develop processes to ensure that there is an audit trail for submission of HSA4 (abortion notification) forms to the Department of Health.
• Consider improving facilities for children waiting within the main outpatients department.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Overall, we rated community health services for children, young people and families as good.

Services were safe and people were protected from harm. The staff knew how to manage and report incidents, we saw there had been learning following a serious case review. Risks were actively monitored and acted upon. We found that there were good safeguarding processes in place. We found that there was enough staff with the right qualifications to meet families needs. In addition, we saw that the clinics and health centres we visited were clean.

Services were effective. We found good evidence that the service reviewed and implemented national good practice guidelines. The trust had also successfully implemented evidence based programmes, such as the family nurse partnership programme. We also saw that patient outcomes and performance were monitored regularly, and that all staff received regular training, supervision and an annual appraisal. There was good evidence of multidisciplinary and multi-agency working across the services.

Services were caring. Children, young people and parents told us that they received compassionate care with good emotional support.

Services were responsive. We found the service planned and delivered services to meet the need of local families. In addition parents, children and young people were able to quickly access care at home or in a location that was appropriate to them.

Services were well led. Staff we spoke with told us the patient was at the centre of what they do, they were positive and proud about working for the organisation. There was an open culture in the service, and staff were engaged in the process of service improvement. Staff reported being supported by their line managers and teams within the organisation. Staff participated in a successful flu vaccination pilot, which has been widened and commissioned for a further three years. Staff were proud of this work and the positive evaluation.

Overall rating for this core service Good l

Overall community health services for adults were good, with caring rated as outstanding. Incidents were reported across teams and learning from incidents was identified. The safeguarding policy was understood by staff and used as part of their practice. Equipment was used safely. The service had infection prevention and control policies in place. Staffing levels were sufficient in most areas to meet current demand. The service had a lone working policy in place and implemented procedures to reduce the risks to staff working alone. The service had plans in place to respond to major incidents.

The service undertook a range of audits to improve performance and ensure patient safety. Clinical governance meetings were held regularly. The service had introduced the Friends and Family Test (FFT) patient satisfaction survey in January 2015. The service was in the process of introducing integrated care an innovative multi-disciplinary practice model.

Staff understood their individual roles and responsibilities. Recognised assessment tools were used for the assessment, planning, and review of patient care and treatment. There was good multi-disciplinary working and effective handover and multi-disciplinary team meetings. Staff consistently told us they had good links, and access to, a wide range of other services. Staff felt the executive team were approachable; but the community teams were attached to different divisions. Managers and team leaders demonstrated a clear understanding of their role and position in the trust. Local team leadership was effective.

Patients and their relatives were truly respected and valued as individuals and were empowered as partners in their care. Feedback from patients and their families was consistently positive about the way staff treated them. Patients thought staff went the extra mile in providing care, treatment, and support.There was a strong person-centred culture. Staff were considerate and empathetic towards patients and their relatives. Staff respected patient confidentiality in written records and other communications. The approach staff used in the home setting demonstrated compassion and consideration for the patient.

Patients could access community health services promptly. Discharge liaison arrangements between the acute hospital and community settings were in place. Arrangements were in place for the training of clinical staff in caring for patients living with dementia. Staff were aware of complaints patients had made, and what was done to resolve complaints. Following the investigation of complaints actions were identified. This was discussed with patients and actions were monitored to completion.

The service had governance and risk processes in place. The service actively maintained a risk register and responded to identified risks; long-term staff sickness was not identified on the register. The service planned for seasonal fluctuations in demand. Managers and staff told us they felt integrated care provided a clear vision for community services. The service had a strategy of improvement and changes to service delivery.

Overall rating for this core service GOOD l

Overall, we rated community end of life care services as good, with caring rated as outstanding. Incident reporting was effective and embedded across the service. Staff were aware of their reporting responsibilities and there was evidence of learning from incidents. When things went wrong incidents were investigated, and lessons learned were shared. Risks to patients were assessed and managed to ensure safe delivery of care. Staff responded appropriately to safeguarding concerns. There were systems and processes for the monitoring of medication and infection control and they were regularly reviewed and improvements made. Staffing levels were monitored and reviewed to keep patients safe and meet their needs at all times of the day and night. Documentation and care records were completed appropriately. Do not attempt cardio-pulmonary resuscitation (DNACPR) forms were completed consistently. Equipment was available for patients and appropriate safety checks were in place.

Care and treatment followed evidence based guidance and legislation. Patient care was based on the best available evidence. Patients needs were assessed appropriately and care and treatment was planned and delivered in line with current legislation. Staff were appropriately qualified and competent to carry out their roles. There was a multi-disciplinary collaborative approach to care and treatment. Staff worked effectively in partnership with the mental health trust to promote the best outcomes for patients who were subject to the Mental Health Act.

Patients and their families were respected and valued and were empowered as partners in their care. Feedback from patients and their families was continually positive about the way staff treated them. There was a strong person centred culture. Staff always took patients personal, cultural, social and religious needs into account when delivering care. Patients emotional and social needs were valued by staff and was an important part of their care and treatment. Any complaints were dealt with appropriately and any lessons learnt were cascaded to staff.

Patients needs and preferences were important in the planning and delivery of services. The involvement of other organisations and the local community was important to how services were planned to ensure patients needs were met. Patients could access services in a way that suited them.

The leadership, governance and culture were used to drive and improve the delivery of high quality patient centred care. Staff were actively involved in the development of the service. Staff worked in collaboration with other services to provide high quality care. There were systems in place to monitor and audit the quality of care. Patients and their families were approached for their views and feedback was shared and acted upon.

Overall we rated dental services at this trust as good, with well led as outstanding. The service was very well-led with organisational, governance and risk management structures in place. These governance arrangements were proactively reviewed and reflected best practice. There was strong leadership of the service, with an emphasis on driving continuous improvement. The local management team were visible and the culture was seen as open and transparent. There was strong collaboration and support across all of the service with a strong emphasis on improving the quality of care. Staff were aware of the way forward and vision for the organisation and said that they felt well supported and could raise any concerns with their line manager. Staff at all levels were actively encouraged to raise concerns. There was high levels of staff satisfaction across all staff groups. Team meetings and staff surveys demonstrated that the service engaged all staff.

Patients’ were protected from abuse and avoidable harm. Systems for identifying, investigating and learning from patient safety incidents were in place. Infection control procedures were in place. The environment and equipment were clean and well maintained.

Dental services were effective and focussed on the needs of patients and their oral health care. We observed good examples of effective collaborative working practises within the service. The service is able to meet the needs of the patients who visited the clinics for care and treatment because of the flexible attitude of all members of the service.

The patients we spoke with, their relatives or carers, said they had positive experiences of their care. We saw good examples of care being provided with compassion and of effective interactions between staff and patients. We found staff to be hard working, caring and committed to the care and treatment they provided. Staff spoke with passion about their work and conveyed how dedicated they were in what they did.

At each of the clinics we visited the staff responded to patient’s' needs. We found the service had begun actively seeking the views of patients using a variety of means using the new Friends and Family Test. People from all communities, who fit the referral criteria, could access the service. Effective multidisciplinary team working ensured patients were provided with care that met their needs and at the right time. Through effective management of resources, delays to treatment were kept to reasonable limits.