Northumbria Specialist Emergency Care Hospital (NSECH) is one of the acute hospitals providing care as part of Northumbria Healthcare NHS Foundation Trust. NSECH opened on 16 June 2015, providing specialist emergency care for seriously ill and injured patients from across Northumberland and North Tyneside. It is England’s first purpose-built specialist emergency care hospital, with emergency consultants on site 24 hours a day, seven days a week, as well as consultants in a range of specialties working seven days a week. NSECH provides emergency care, critical care, medical and surgical services, a neonatal unit, children and young people’s services, maternity services and a full range of outpatient and diagnostic imaging services. The opening of this hospital had resulted in new models of care and different patient pathways in all of its services, with some services, departments and staff teams coming together from different hospitals within the trust.

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. Northumbria Specialist Emergency Care Hospital has 337 beds.

We inspected Northumbria Specialist Emergency Care Hospital as part of the comprehensive inspection of Northumbria Healthcare NHS Foundation Trust, which included this hospital, North Tyneside General Hospital, Wansbeck General Hospital, Hexham General Hospital, and community services. We inspected Northumbria Specialist Emergency Care Hospital between 9 and 13 November 2015 and 2 December 2015.

Overall, we rated Northumbria Specialist Emergency Care Hospital as outstanding. We rated it outstanding for being effective, caring, responsive and well-led, and requires improvement for safe care.

We rated surgical services, critical care, children and young people's services, end of life and outpatient and diagnostic imaging services as outstanding. Urgent and emergency services and medical care we rated as good. Maternity and gynaecology was rated as requires improvement.

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.

• Access and flow within the hospital was improving. The new model of care was becoming embedded after only a short time. This was due to the positivity and commitment of staff at all levels embracing the new way of working.

• 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 October 2015 there had been no cases of methicillin resistant staphylococcus aureus (MRSA) at this hospital and six cases of c-difficile (five of which dated from October 2015 or earlier).

• The hospital had implemented a ‘Safer Nursing Care Tool’ (SNCT) to assess the staffing requirements across wards. Nurse staffing was maintained at safe levels in most areas.

• 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.

• There was representation from the specialist palliative care team at regular mortality review meetings. Their remit was to review and comment on the end of life care journey of patients and provide constructive feedback and advice in relation to ongoing learning and improving patient care.

• 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 critical care services:

• Over 300 days without an avoidable pressure ulcer and the overall safety thermometer results.

• Patient outcomes and the access and flow data were adjusted internally to monitor the standardised mortality ratio following the trust’s change to the model of delivery of care.

• A member of staff had been nominated for multiple awards for their compassionate care: The NHS FAB stuff awards; patient champion of the year: North East, and the team came second in the patient experience national awards.

• The culture of everyone was valued and had a voice seemed embedded in the daily multidisciplinary safety huddle.

• The pit stop handover for all admissions to the unit had been developed with human factors training using formula one pit-stop models, to facilitate a structured handover and improve patient safety.

• Staff considered patients individual preferences and evidently went out of their way to exceed expectations to meet their wishes particularly in end of life care.

• Staff had adapted the “This is me” booklet and used it for long term patients where they included information from relatives and visitors about patients personal preferences.

• The rehabilitation after critical illness service.

• Leadership of the service was excellent particularly in relation to the planning, preparation and the move to NSECH. Time was taken to engage staff in cross-site working prior to the move and work undertaken to standardise guidelines, procedures and equipment.

In children and young people's services:

• Planning for the new model of care and facilities in the hospital was excellent. Managers had fully engaged staff in planning which resulted in a smooth transition into the new build and services being quickly up and running. Following a training needs analysis, staff had received additional training to ensure they had the correct skills to deliver the new model of care. There was ongoing work to further support staff in adjusting to the new services especially in the Children’s Unit.

• The volume of information collected from service users was outstanding. The trust had innovative ways of engaging with patients and used a number of different methods for collecting information. This was shared with managers and clinical staff in order to improve services for children and young people.

• A mother told us that while she was in recovery following the birth of her baby, a member of staff from the special care baby unit brought her a picture of her baby. She was extremely happy with this, as she was upset that she had to be separated from her new born baby. We thought this was extremely caring and responsive to her needs.

• A parent passport was in place in the special care baby unit. This was held and completed by parents to increase their involvement in caring for their baby. The passport summarised the parents confidence and competence in carrying out this care. Following discharge, it provided a record for other healthcare professionals to understand the continuing needs of the parents in caring for their baby.

• The trust was supporting a Consultant Clinical Psychologist in a longitudinal study to address the question of how health services could contribute most effectively to facilitating successful transition of young people with complex health needs from childhood to adulthood. The study involved young people from the conception of the research idea and throughout the course of the programme. Information from the study was fed into the National Institute for Care Excellence (NICE) as part of a consultation on draft guidelines on transition. The trust had a robust trust policy, which included transition and transfer of young people with long-term conditions and disabilities, which was being rolled out across business units. We thought the work on transition was outstanding.

In end of life care:

• The model of end of life care services working alongside acute services at NSECH and out into the community was an innovative and pioneering approach to care.

• Specialist palliative care was aligned with emergency care to ensure patients received specialist palliative care at the earliest opportunity.

• The trust had responded to a higher than anticipated number of referrals to the specialist palliative care team by increasing the specialist palliative care resource within the hospital.

• 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.

• 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's understanding of spirituality and confidence around assessment.

• 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 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.

In outpatient and diagnostic imaging services:

• The hospital provided a seven day a week consultant led outpatient trauma service for people from across Northumberland and North Tyneside to access, as well as a teleconference clinic for patients who lived in Berwick, almost 60 miles away.

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.

• Ensure that the entry and exit to ward 16 in Maternity are as safe as possible to reduce the risk of infant abduction.

• Ensure that the storage of emergency drugs, within maternity services, are stored safely in line with the trust’s pharmacy risk assessment.

• Ensure risk assessments in relation to falls, pressure ulcers, VTE and nutrition are consistently completed for all patients within medical care services.

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 department:

• Ensure nursing care documentation is completed consistently throughout the department.

• Create a more dementia friendly environment (cubicle) to support patients with dementia.

In medical care services:

• Continue to review staffing levels on medical care wards.

In critical care services:

• Review the nurse staffing establishment to consider the inclusion of an additional supernumerary registered nurse over and above the clinical co-ordinator as recommended in Core Standards for Intensive Care Units (2013).

• Review the provision of the critical care outreach service following the change in model of delivering care and in relation to national critical care outreach standards.

• Consider the role of a clinical nurse educator on the unit as recommended in Core Standards for Intensive Care Units (2013).

In Maternity and gynaecology services:

• 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.

• Ensure all Patient Group Directions are signed by staff as appropriate.

• Consider sorting emergency drugs in tamper evident boxes if they are stored in an open ward area.

• Ensure that record keeping is consistent across all services.

• Consider reviewing midwifery staffing levels across the trust to ensure the midwife to birth ratio at NSECH is reduced from 1:36 to 1:28 as recommended.

• Consider the reconfiguration of pregnancy assessment unit to the Northumbria Specialist Emergency Care Hospital, to improve assess and flow of patients.

• Consider the provision of midwifery support for Teenage mothers in Northumbria in order to provide an equitable service throughout the Trust.

In children and young people's services:

• Fully embed the Duty of Candour with all staff.

• Ensure patients clinical records are always available for children attending for day surgery at the hospital.

• Address the issue of clerical support at weekends in the Children’s Unit, to ensure there is not a delay in sending out electronic discharge summaries to GPs.

• Ensure that non-qualified staff in the Children’s Unit have clearly defined job roles and have robust competencies in place.

Professor Sir Mike Richards

Chief Inspector of Hospitals