The Care Quality Commission (CQC) carried out an unannounced inspection at the Gateshead Health NHS Foundation Trust on 26 September 2018 following two serious patient safety incidents within the short stay unit within 18 months.

Gateshead Health NHS Foundation Trust was subject to a comprehensive inspection in Septemeber 2015. We did not gather sufficient evidence to impact upon trust ratings from that inspection. During this inspection we visited the emergency department and the short stay unit (ward 2) in the Queen Elizabeth Hospital.

This focussed inspection confirmed that lessons had been learnt following the incidents and in addition, processes and risk assessments had been put in place to reduce the risk of further serious patient safety incidents.

We will continue to monitor the trust’s action plan through our routine engagement with the trust.

Professor Edward Baker

Chief Inspector of Hospitals

People told us what it was like to be a patient in the Queen Elizabeth Hospital. They described how they were treated by staff and their involvement in making choices about their care. They also told us about the quality and choice of food and drink available. This was because this inspection was part of a themed inspection programme to assess whether older people in hospitals were treated with dignity and respect and whether their nutritional needs were met.

The inspection team was led by Care Quality Commission (CQC) inspectors, joined by a practising professional and an Expert by Experience, who has personal experience of using or caring for someone who uses this type of service.

We met with patients and staff on a short stay unit and on two wards that provided care and treatment to older people. Patients told us that their views were respected and expressed no concerns about how they were treated. Their comments included, “The staff listen to me. They know what I want and are doing everything possible to get me back home”, and, “They (staff) are kind and look after us properly”.

Patients said they were given choices of meals and drinks and told us they liked the food. Their comments included, “There’s always something on the menu I can have”; “They give us plenty of drinks and snacks”; and, “I look forward to the cooked breakfasts”. We saw that patients were well supported with eating and drinking and that staff recognised the importance of making the mealtime a relaxed and enjoyable experience.

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

During the visit we spoke with patients on Wards 1, 2, 21 and the Medical Admission Unit about their experiences of the Queen Elizabeth hospital. They were without exception positive and were very complementary about the staff and the way that they were being supported.

They said “They tell me about my care and what is going to happen” and “The staff are good and keep me informed,” and that staff were always patient and sought their permission before providing them with care. Relatives told us that staff keep them informed about care, treatment and support. They said when asked about the staff that they "couldn’t be better,” and when patients were asked about how they were treated and one said that they were "Very good, the staff couldn’t be nicer, there are no twisty ones and nothing seems to be a bother to them" another said we "couldn’t ask for anything better, the food is very good.”

We asked patients how well staff passed on information to them and to each other about the care. In response one told us "They keep me informed all of the time, and tell me about the drugs I take, and when I said that I did not want to take one of the medicines they brought me because I didn’t recognise it they took time to explain what it was for. The doctor came and explained it to me.” Another said "two nurses helped me to make sure that my daughter was told about coming to hospital.” One said "the staff tell me what is going on, I don’t know when I am going home but my son has spoken to the nurse and they make sure I understand what is going on.”

We asked the patients how they felt they were being looked after one said “a 100%, the Doctors and the nurses, couldn’t fault them for anything, they are all nice” and another said “they are very polite, they introduce themselves and they laugh and joke with me, they’re great people.” Only one expressed any concern and that was about the way that some patients are moved to another ward just prior to discharge “boarding out” as this can be distressing for them.

We observed that people using the service were provided with care, treatment and support appropriate to their needs. The people we spoke with said about their care and staff “could not have been better” and “couldn’t fault them.”

Patients spoken to said that they felt safe and that the staff listened to them if they were worried about anything. One said “if I was worried I would speak to one of the nurses, they are always asking if there is anything they can do.”

Queen Elizabeth Hospital is the acute hospital forming part of Gateshead Health NHS Foundation Trust. It provides a range of services including medical, surgical, maternity and gynaecology and services for children and young people, end of life and critical care. It has approximately 580 beds. The hospital also provides emergency and urgent care, outpatients and diagnostic imaging.

We inspected Queen Elizabeth Hospital as part of the comprehensive inspection of the Foundation Trust from 29 September to 2 October 2015 and undertook an unannounced inspection on 23 October 2015.

Overall, we rated Queen Elizabeth Hospital as good. We rated it good for being safe, effective, responsive and well-led and outstanding for caring.

Our key findings were as follows:

• The majority of areas inspected were clean; however, we did identify some infection control issues in the critical care unit and the waste disposal unit.

• Rates of infection were within an expected range for the size of the trust.

• 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.

• There were processes for using and monitoring evidence-based guidelines and standards to meet patients’ care needs. Although policies and care pathways held electronically on the trust systems were in-date some paper copies held in ECC and SCBU were out of date or had no review date.

• 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.

• The trust was not meeting all its waiting time targets; the national target for two week cancer waiting times had not been met for a number of tumour sites for four consecutive quarters. This was identified by the trust as a governance concern.

• 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.

• Nurse staffing was maintained at safe levels in most areas. However, there were occasions where staff had asked for additional support to provide ‘special’ nursing care (individual attention) to meet the physical and mental health needs of patients and shifts had not been covered. The trust had a business case to increase staffing levels in certain areas and had escalation processes when staffing fell below recommended levels.

• The trust had gaps in medical staffing because of national shortages in certain specialties however; the trust was actively recruiting to these including international recruitment. This risk was further reduced by the use of advance nurse practitioners to support doctors.

• Safeguarding procedures were in place and staff could demonstrate an understanding of their role and what action to take if they were concerned about a person.

• Feedback from patients and their relatives was very positive about the care they received and there were examples of some outstanding caring practice.

• Patient outcome measures showed the trust performed mostly within or better than national averages when compared against other hospitals. Death rates were within expected levels.

• Following an external review of governance processes, the trust was reviewing its service strategies to ensure that they remained achievable and relevant. The Board had the experience, capacity and capability to ensure that the strategy was delivered.

We saw several areas of outstanding practice including:

• The Rehabilitation after Critical Illness Team (RaCI) led by nurses, health care assistants and physiotherapists had developed new pathways to help patients recover from critical illness. The team provide rehabilitation while a patient was in the critical care unit, throughout their stay and following discharge.

• Therapy staff were part of the frailty model and worked in the emergency care centre to support elderly patients with mobility aids and discharge plans avoiding unnecessary admissions to hospital.

• A combined referral pathway and documentation was being used by GP practices to refer into the trust’s diabetes-integrated service. It included advice and guidance for GPs, a specialist nursing helpline and multi-disciplinary clinical assessment. Clear protocols were in place to identify when a patient could be managed within primary and/or secondary care and when care transfer was appropriate and/or possible.

• Pathology services had achieved the national external quality assurance scheme (NEQAS) accreditation for cellular pathology and was recognised as a national centre for excellence.

• Ward 23 was a 24 bedded acute ward providing specialist care to older people with physical and mental health illness (predominantly dementia care) in a dementia friendly therapeutic environment, respecting patient’s dignity whilst also promoting their independence in preparation for discharge from hospital. A team of specialists who had both physical and mental health skills and knowledge cared for patients, their philosophy was to deliver holistic, timely care to patients and their carers.

• The design of the Emergency Care Centre was innovative and recognised by NHS England as a best practice model providing a single point of access for emergency care.

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

Importantly, the trust must:

• Ensure that a clean and appropriate environment is maintained throughout the critical care department and waste disposal unit for the prevention and control of infection; including the provision of appropriate personal protective clothing for staff working in the waste disposal unit.

In addition the trust should:

• Take action to meet the national 2-week cancer waiting time targets in all tumour sites.

• Ensure that staffing and skill mix is reviewed on ward 23 to take account of the dependency of patients and ensure that sufficient staff are in place, particularly where special one to one support is identified as being required.

• Ensure that processes are consistently followed in all areas for checking the storage of medicines particularly recording of fridge temperatures and signing and dating medication entries.

• Ensure that SCBU moves towards introducing a National Early Warning Score chart.

• Ensure that there is a strategy for optimising patient outcomes from medicines in line with best practice guidance from the Royal Pharmaceutical Society that has Board approval and reviewed regularly.

• Ensure processes are consistently followed particularly in SCBU and critical care for the checking of resuscitation equipment.

• Ensure where required, staff are up to date with Paediatric Immediate Life Support (PILS) and Advanced Paediatric Life Support (APLS) training.

• Review processes to reduce the number of clinic appointments cancelled.

• Continue to implement and strengthen governance processes in response to recommendations following an external independent review including strengthening the board assurance framework, clinical engagement and management of performance and risk.

• Review version control arrangements for the updating of paper copies of polices and care pathways held in clinical areas to ensure staff are using policies which are in date and reflect the latest best practice guidelines.

• Ensure cause for concern-safeguarding forms identify if a child is, or is not, subject to a child protection plan to enable swift and appropriate action.

Professor Sir Mike Richards

Chief Inspector of Hospitals