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Royal Victoria Infirmary

Provider The Newcastle upon Tyne Hospitals NHS Foundation Trust Type NHS Healthcare Organisation Region North East

Overall rating: Not Yet Rated  View full CQC report

Domain ratings

Five CQC key questions
Safe
Not Yet Rated
Effective
Not Yet Rated
Caring
Not Yet Rated
Responsive
Not Yet Rated
Well-led
Not Yet Rated

Earlier inspection findings

pre-2024 framework · 107 must-do 27 should-do

Must-do actions (107)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 107
Must do
Well-led
The trust must ensure its supports all staff, including those with particular equality characteristics, to feel respected and valued and support an environment where staff are encouraged to speak up and raise concerns without fear of blame or reprisal.
Regulation: Regulation 18(2)(a).
⚠ Although staff were focused on the needs of patients receiving care, they did not always feel respected, supported, and valued. Some staff told us they did not feel they could raise concerns without fear of blame or reprisal.
Must-do action 2 of 107
Must do
Well-led
The trust must demonstrate its supports its staff by challenging unacceptable behaviours and language. This includes but is not limited to discrimination.
Regulation: Regulation 18(2)(a).
⚠ Comments spoke to a culture of favoritism and bullying, where problematic behaviour went unchallenged, and concerns went unheard.
Must-do action 3 of 107
Must do
Well-led
The trust must ensure that feedback from staff is used to drive improvements to the quality and safety of services, and once improvements are identified they are made without delay.
Regulation: Regulation 17(2)(e).
⚠ Respondents felt information was cascaded down from management, rather than in dialogue with them. They did not always feel there were many opportunities for feedback.
Must-do action 4 of 107
Must do
Safe
The trust must ensure that staff are able to report service user safety concerns without fear of reprisal, retribution or detriment using internal routes and in line with policies and procedures.
Regulation: Regulation 17(2)(e).
⚠ Some staff told us they did not feel they could raise concerns without fear of blame or reprisal.
Must-do action 5 of 107
Must do
Safe
The trust must ensure it encourages the identification, reporting and investigation of incidents and risks in a timely fashion and shares learning to improve safety and quality of the service.
Regulation: (Regulation 17(2)(b).
⚠ The trust was in the lowest 25% of reporters nationally based on the number of incidents reported per 1,000 bed days... not all staff reported incidents in a consistent and standardised way. Staff did not always receive feedback or learning from incidents.
Must-do action 6 of 107
Must do
Well-led
The trust must ensure that risks recorded at corporate level and in the board assurance framework are current and have clear actions for mitigation which can be monitored and measured.
Regulation: Regulation 17(2)(b).
⚠ The BAF did not provide detail to effectively describe actions take and responsibility for those actions. Many of the actions didn't have timescales.
Must-do action 7 of 107
Must do
Well-led
The trust must ensure that high level risks are fully assessed and mitigated to the lowest level of risk.
Regulation: Regulation 17(2)(b).
⚠ The executive oversight risk register was not reflective of service level risk and did not identify all of the issues regarding patient safety we found on inspection.
Must-do action 8 of 107
Must do
Well-led
The service must ensure robust governance processes are in place to lead, manage, risk assess and sustain effective services.
Regulation: Regulation 17.
⚠ Whilst governance processes were in place, they did not always operate effectively across the organisation to ensure risk and performance issues were identified, escalated appropriately, managed, and addressed promptly.
Must-do action 9 of 107
Must do
Well-led
The trust must ensure there is full clinical engagement to support operational performance and that challenges are resolved with a focus upon patient safety across the organisation.
Regulation: Regulation 17(2)(a).
⚠ Engagement with clinicians was not always addressed by executive directors, which could impact upon overall confidence and performance of the trust.
Must-do action 10 of 107
Must do
Safe
The trust must ensure all staff are aware of and consistently follow the trust policy, systems and processes to safely prescribe, administer, record and store and dispose of medicines.
Regulation: Regulation 12(1)(2)(g).
⚠ Services we inspected did not follow their own systems and processes to ensure that medicines were stored, administered, and recorded safely, this included the safe storage and oversight of prescribing documentation.
Must-do action 11 of 107
Must do
Safe
The trust must maintain securely an accurate, complete, and contemporaneous record including a record of the care and treatment provided to patients and of decisions taken in relation to the care and treatment provided.
Regulation: Regulation 17(1)(2)(c).
⚠ Care plans which were not in place for fundamental aspects of care and for key clinical devices such as catheters and peripheral lines. Records were not personalised as the system was not being used to its potential.
Must-do action 12 of 107
Must do
Safe
The trust must ensure that all premises and equipment are clean, secure, suitable for the purpose for which they are being used, properly used and properly maintained. This includes but is not limited to daily checks of emergency equipment and COSHH chemicals.
Regulation: Regulation 15(1)(a)(b)(c)(d)(e).
⚠ We found rooms unlocked that had potential for patient harm... COSHH chemical were not always stored safely... Oxygencylinders were not always stored securely.
Must-do action 13 of 107
Must do
Well-led
The service must ensure systems and processes are established and operated effectively to assess, monitor and improve the quality and safety of the services provided in delivery of regulated activities, in line with national guidance and frameworks.
Regulation: Regulation 17(2)(a).
⚠ We saw examples within the service where there were no processes in place to ensure effective governance. We found significant omissions within medicines management, infection prevention and control and within environment and equipment.
Must-do action 14 of 107
Must do
Safe
The service must ensure that all staff complete required mandatory training.
Regulation: Regulation 12(1)(2)(c).
⚠ All staff initially received mandatory training but did not keep up to date with their mandatory training.
Must-do action 15 of 107
Must do
Well-led
The service must assess, monitor, and improve the quality and safety of the services provided in the carrying on of the regulated activity.
Regulation: Regulation 17(1)(2)(a).
⚠ We saw no evidence of regular governance meetings held for the service.
Must-do action 16 of 107
Must do
Well-led
The service must use performance data to identify and drive improvements.
Regulation: Regulation 17(1)(2)(a).
⚠ We did not see any examples of data being analysed to improve performance, make decisions, or make improvements.
Must-do action 17 of 107
Must do
Well-led
The service must ensure there are clearly defined assurance processes, including audits, and that all staff are aware of the required frequency and recording of these.
Regulation: Regulation 17(1)(2)(b).
⚠ We saw no processes in place to monitor staff compliance with infection prevention and control (IPC) measures. Audits of environment cleanliness, equipment cleanliness and adherence to hand hygiene and the principles of bare below elbow (BBE) were not undertaken.
Must-do action 18 of 107
Must do
Well-led
The service must ensure ways to improve access to management, the staff experience, and methods to improve staff morale.
Regulation: Regulation 18(1)(2)(a).
⚠ Not all staff reported that senior leaders were a visible presence within the department due to flexible working patterns nor that they were always approachable. We were given examples of staff not feeling confident to escalate issues to all senior leaders for fear of negative reactions.
Must-do action 19 of 107
Must do
Safe
The service must ensure that mandatory training compliance meets the trust target.
Regulation: Regulation 12(1)(2)(c).
⚠ Mandatory training completed was 75.5% for nursing staff which did not meet the 95% trust target compliance. Mandatory training completed was 85.4% for medical roles which did not meet the 95% trust target compliance.
Must-do action 20 of 107
Must do
Effective
The service must ensure that all staff receive training in how to interact appropriately with people with a learning disability and autistic people, at a level appropriate to their role.
Regulation: Regulation 12(2)(c).
⚠ Staff told us they had not received training specifically in learning disability or autism awareness, but that there was a e-learning disability and mental health awareness course.
Must-do action 21 of 107
Must do
Safe
The service must ensure that patient records include plans for managing risks.
Regulation: Regulation 12(2)(b).
⚠ Staff did not complete plans of care for all patients as the record system didn’t generate these.
Must-do action 22 of 107
Must do
Safe
The service must ensure they are doing all that is reasonably practicable to mitigate risks including following best practice guidance.
Regulation: Regulation 12(2)(b).
⚠ We saw an incident that occurred during an inpatient stay for sepsis. Staff had taken patient observations triggering two amber PEWS scores 2 hours apart with no further review until the next morning resulting in the patient’s deterioration.
Must-do action 23 of 107
Must do
Safe
The service must ensure equipment used by staff to provide care and treatment is properly maintained.
Regulation: Regulation 12(2)(e).
⚠ We observed that across the wards/units that electrical equipment portable appliance testing (PAT) dates were overdue. We requested the service’s register for the servicing of equipment. This showed 77 items of equipment that required servicing between 1 and 2 years ago.
Must-do action 24 of 107
Must do
Safe
The service must ensure that persons providing care or treatment to children and young people have the qualifications, competence, skills, and experience to do so safely.
Regulation: Regulation 12(2)(c).
⚠ There were a number of newly qualified nursing staff in post who were developing their skills and knowledge, with support from the Trust. However, this meant at times there was not always enough staff with experience, to meet the needs of children, young people, and their families.
Must-do action 25 of 107
Must do
Well-led
The service must monitor progress against plans to improve the quality and safety of services and take appropriate action without delay where progress is not achieved as expected.
Regulation: Regulation 17(1)(2)(a).
⚠ Managers did not consistently use information from audits to improve care and treatment. Processes were not embedded to share audit findings to staff despite this being provided regularly to ward managers, sisters, and matrons.
Must-do action 26 of 107
Must do
Safe
The service must implement an effective system to ensure incidents are appropriately reported to external systems within appropriate timescales.
Regulation: Regulation 17(1)(2)(a)(b).
⚠ Data provided showed that DOC was not always provided in full for all incidents graded moderate or severe in line with their statutory duty.
Must-do action 27 of 107
Must do
Caring
The service must ensure that Duty of Candour is given in full to patients when incidents occur.
Regulation: Regulation 20(3).
⚠ Data provided showed that DOC was not always provided in full for all incidents graded moderate or severe in line with their statutory duty.
Must-do action 28 of 107
Must do
Effective
The service must ensure that all staff receive training at a level appropriate to their role in how to respond appropriately to the needs of autistic people.
Regulation: Regulation 12(1)(2)(c).
⚠ We were not provided with any clarity that the training specifically included autism awareness. Staff we spoke to were not able to clearly articulate what autism specific training they had received.
Must-do action 29 of 107
Must do
Safe
The service must ensure arrangements are in place and adhered to in order to ensure prevention and control of the spread of infections.
Regulation: Regulation 12(1)(2)(h).
⚠ We saw some missed opportunities for hand hygiene.
Must-do action 30 of 107
Must do
Safe
The service must ensure that all gas cylinders are stored securely.
Regulation: Regulation 15(1)(b).
⚠ Oxygen cylinders were not always stored securely by chain or in cages. For example, on one ward we entered an unlocked room containing multiple gas cylinders that were not stored securely by chain or in a cage.
Must-do action 31 of 107
Must do
Safe
The service must ensure that all nutritional supplements are stored according to guidelines.
Regulation: Regulation 12(2)(g).
⚠ We found cartons of Total Parenteral Nutrition (TPN) stored in an unlocked fridge in a room marked staff only with the door wedged open. TPN is prescription only and was not stored safely or securely.
Must-do action 32 of 107
Must do
Safe
The service must ensure risk assessments have been carried out to minimise ligature risks and ensure that the premises and equipment used by the service users are done so in a safe way.
Regulation: Regulation 12(1)(2)(e)(f).
⚠ We observed call bells with cords that were not plastic coated, were long and on occasion to the floor... We were not provided with any evidence of ligature risk assessment or risk reduction for the ward.
Must-do action 33 of 107
Must do
Safe
The service must ensure that all staff complete safeguarding training appropriate to their role.
Regulation: Regulation 13(1).
⚠ We found no data to confirm that allied health professionals (AHP’s) had completed level three safeguarding adults training. There was a safeguarding policy in place, but this did not specify the level of training each staff group required.
Must-do action 34 of 107
Must do
Safe
The service must have robust procedures in place for the identification, review and management of clinical risk when providing care and treatment.
Regulation: Regulation 12(1)(2)(a)(b).
⚠ We found two of the three had NEWS charts completed, one did not. There was no automatic alert on recording physiological observations to trigger a change to NEWS scores.
Must-do action 35 of 107
Must do
Caring
The service must ensure that people who use the service receive person centred care and treatment that is appropriate, meets their needs and reflect their personal preferences.
Regulation: Regulation 9(1)(2).
⚠ In the absence of effective care planning there was a risk that patients would have received incomplete care and treatment and the effectiveness of any care provided could not be measured accurately.
Must-do action 36 of 107
Must do
Safe
The service must ensure that there is timely review of dementia friendly environments, ensuring that premises used by the service provider are safe to use for their intended purpose.
Regulation: Regulation 12(1)(2)(d).
⚠ We found rooms unlocked that had potential for patient harm. On one ward we were able to access an unlocked door into the electrical switch room.
Must-do action 37 of 107
Must do
Effective
The service must ensure that staff complete mental capacity and best interest decisions, when obtaining consent and that they clearly document the assessment and decision making process.
Regulation: Regulation 13.
⚠ When a patient’s capacity to consent was queried, staff did not always undertake appropriate assessments of their mental capacity to determine the need for best interest decisions to be made.
Must-do action 38 of 107
Must do
Well-led
The service must ensure there are clear processes and timescales for carrying out audit and re-audit of activities including the use of hospital passports in order to improve practice.
Regulation: Regulation 17(1)(2)(f).
⚠ We found that whilst five of six wards scored 100% for patients with a confirmed learning disability having a passport in place and evidence of this being discussed one ward scored 17% for overall compliance.
Must-do action 39 of 107
Must do
Safe
The service must ensure robust oversight and management of incidents and ensure incidents are shared across the health group.
Regulation: Regulation 12.
⚠ We found no evidence managers shared learning with their staff about never events that happened elsewhere.
Must-do action 40 of 107
Must do
Caring
The service must ensure that people who use the service receive person centred care and treatment that is appropriate, meets their needs and reflect their personal preferencesRegulation9(1)(2).
Regulation: Regulation 9(1)(2).
⚠ In the absence of effective care planning there posed a risk that patients would receive incomplete care and treatment and the success of any care provided could not be measured accurately.
Must-do action 41 of 107
Must do
Safe
The service must ensure that mandatory and core competency training compliance meets the trust target.
Regulation: Regulation 12(1)(2)(c).
⚠ Overall mandatory training compliance was slightly below the trust target at 90% for June 2023.
Must-do action 42 of 107
Must do
Effective
The service must ensure that all staff receive training in how to interact appropriately with people with a learning disability and autistic people, at a level appropriate to their role.
Regulation: Regulation 12(2)(c).
⚠ The trust told us they had introduced the regional ICS endorsed Learning Disabilities Diamond Standards mandatory training for all clinical and patient facing staff in March 2023. This training includes some aspects of autism training but has been enhanced with additional autism awareness education sessions from April 2023.
Must-do action 43 of 107
Must do
Safe
The service must ensure arrangements are in place and adhered to in order to ensure prevention and control of the spread of infections.
Regulation: Regulation 12(2)(h).
⚠ Staff did not dispose of clinical waste safely. We also saw across both hospital sites that clinical waste storage areas were not always secure.
Must-do action 44 of 107
Must do
Safe
The service must ensure care and treatment is provided in a safe way. This includes assessing the health and safety risks for service users receiving the care or treatment and doing all that is reasonably practicable to mitigate any such risks. This includes but is not limited to the use of bedsides.
Regulation: Regulation 12(1)(a)(b).
⚠ We requested risk assessments for these but were told by all staff there were no risk assessments completed. Therefore, we were not assured that risk and safety management processes were robust and did not always protect patients from possible harm.
Must-do action 45 of 107
Must do
Safe
The service must ensure all staff are engaged with and participate in all steps of the World Health Organisation (WHO) surgical safety checklist, the checklist is fully completed, and observational and record audits are undertaken to monitor compliance.
Regulation: Regulation 12(1)(2)(a)(b).
⚠ We reviewed four surgical safety checklists on ward 25 at The Freeman hospital and saw that none of them had been signed off to show all aspects of the pause and check processes were carried out.
Must-do action 46 of 107
Must do
Effective
The service must ensure that staff complete mental capacity and best interest decisions, where appropriate, when obtaining consent and that they clearly document the assessment and decision-making process.
Regulation: Regulation 13(4)(d).
⚠ Staff did not always gain consent from patients for their care and treatment in line with legislation and guidance. Staff did not always clearly record consent in the patient records.
Must-do action 47 of 107
Must do
Safe
All premises and equipment used by the service provider must be secure and suitable for the purpose for which they are being used, properly used, properly maintained, and appropriately located for the purpose for which they are being used. This includes but is not limited to the storage of medical gases.
Regulation: Regulation 15(1)(b)(c).
⚠ We found no medical gas signs on the storeroom doors of all wards we visited. These rooms stored some entonox and oxygen inappropriately on the floor behind the door. Storeroom doors were all unlocked which meant medical gases were accessible to anyone on the ward.
Must-do action 48 of 107
Must do
Effective
The service must ensure clinical care and treatment are delivered and monitored in accordance with national guidance and best practice.
Regulation: Regulation 17.
⚠ In the absence of effective care planning there posed a risk that patients would receive incomplete care and treatment and the success of any care provided could not be measured accurately.
Must-do action 49 of 107
Must do
Safe
The service must ensure learning from never events is shared with all staff.
Regulation: Regulation 17.
⚠ We also spoke with theatre staff in regard to lessons learnt following these never events but none of the staff we spoke with, were aware of the incidents.
Must-do action 50 of 107
Must do
Safe
The service must improve its monitoring and auditing of surgical safety checklists and ensure the finding of these audits are shared with staff.
Regulation: Regulation 17.
⚠ We reviewed four surgical safety checklists on ward 25 at The Freeman hospital and saw that none of them had been signed off to show all aspects of the pause and check processes were carried out.
Must-do action 51 of 107
Must do
Safe
The service must ensure that serious incidents are reported and investigated in a timely manner in line with national guidance.
Regulation: Regulation 17(1).
⚠ We saw insufficient pace when sharing the learning, resulting in potential subsequent harm to patients.
Must-do action 52 of 107
Must do
Well-led
The service must ensure a robust audit plan is in place and key audits are conducted, which include record keeping, medicines management and infection prevention and control audits. The service must ensure relevant actions identified by local audits are acted on.
Regulation: Regulation 17(1)(2)(a)(b).
⚠ We saw gaps in audits undertaken which were not flagged or actioned for further improvement.
Must-do action 53 of 107
Must do
Well-led
The service must operate effective systems and processes to make sure they assess and monitor their service. This should include the auditing of surgical safety checklists, documentation, infection prevention and control.
Regulation: Regulation 17(1).
⚠ We saw gaps in audits undertaken which were not flagged or actioned for further improvement.
Must-do action 54 of 107
Must do
Well-led
The service must monitor progress against plans to improve the quality and safety of services and take appropriate action without delay, where progress is not achieved as expected.
Regulation: Regulation 17(2)(a).
⚠ It was not clear what actions were undertaken when the register was reviewed as there were no dates shown against each action or point of review.
Must-do action 55 of 107
Must do
Well-led
Senior managers must ensure robust systems and processes are in place to identify, manage, mitigate and if appropriate escalate risks. This must ensure senior managers and the board members have clear oversight of service risks.
Regulation: Regulation 17(1)(2)(a)(b).
⚠ It was not clear how risks were identified and escalated to the risk register with the latter two risks being added during 2022 and the earlier two being added in 2012 and 2013.
Must-do action 56 of 107
Must do
Safe
The service must ensure that there are sufficient numbers of suitably competent, skilled, medical staff to meet minimum staffing levels and meet the care and treatment needs of service users.
Regulation: Regulation 18.
⚠ Both junior and middle career doctors at both hospital sites, told us that they felt the workload was unmanageable at times and expressed concerns as to how ‘stretched’ they felt.
Must-do action 57 of 107
Must do
Safe
The service must ensure that mandatory training compliance meets the trust target.
Regulation: Regulation 12(1)(2)(c).
⚠ Paediatric staff were 78.7%% compliant with level 2 safeguarding training and 62.6% compliant with level 3 safeguarding training which was below the trust’s target of 95%.
Must-do action 58 of 107
Must do
Effective
The service must ensure that all staff receive training in how to interact appropriately with people with a learning disability and autistic people, at a level appropriate to their role.
Regulation: Regulation 12(2)(c).
⚠ Staff told us they had not received training specifically in learning disability or autism awareness, but that there was a e-learning disability and mental health awareness course.
Must-do action 59 of 107
Must do
Safe
The service must ensure that timely care planning takes place where responsibility for care and treatment is shared with, or transferred to others services.
Regulation: Regulation 12(2)(i).
⚠ Staff did not complete plans of care for all patients as the record system didn’t generate these.
Must-do action 60 of 107
Must do
Safe
The service must ensure equipment used by staff to provide care and treatment is properly maintained.
Regulation: Regulation 12(2)(e).
⚠ We observed that across the wards/units that electrical equipment portable appliance testing (PAT) dates were overdue. We requested the service’s register for the servicing of equipment. This showed 77 items of equipment that required servicing between 1 and 2 years ago.
Must-do action 61 of 107
Must do
Safe
The service must ensure that persons providing care or treatment to children and young people have the competence, skills, and experience to do so safely.
Regulation: Regulation 12(2)(c).
⚠ There were a number of newly qualified nursing staff in post who were developing their skills and knowledge, with support from the Trust. However, this meant at times there was not always enough staff with experience, to meet the needs of children, young people, and their families.
Must-do action 62 of 107
Must do
Well-led
The service must monitor progress against plans to improve the quality and safety of services and take appropriate action without delay where progress is not achieved as expected.
Regulation: Regulation 17(1)(2)(a).
⚠ Managers did not consistently use information from audits to improve care and treatment. Processes were not embedded to share audit findings to staff despite this being provided regularly to ward managers, sisters, and matrons.
Must-do action 63 of 107
Must do
Well-led
The service must ensure they have an up to date and robust risk register in place, and there is appropriate oversight and management of this.
Regulation: Regulation 17(1)(2)(a)(b).
⚠ However, there were 2 risks within the register that scored 15 but had not been escalated onto the corporate risk register in line with policy, this meant there was a risk senior leadership could not take action to mitigate risk.
Must-do action 64 of 107
Must do
Safe
The service must implement an effective system to ensure incidents are appropriately reported to external systems within appropriate timescales.
Regulation: Regulation 17(1)(2)(a)(b).
⚠ Data provided showed that DOC was not always provided in full for all incidents graded moderate or severe in line with their statutory duty.
Must-do action 65 of 107
Must do
Caring
The service must ensure that Duty of Candour is given in full to patients when incidents occur.
Regulation: Regulation 20(3).
⚠ Data provided showed that DOC was not always provided in full for all incidents graded moderate or severe in line with their statutory duty.
Must-do action 66 of 107
Must do
Effective
The service must ensure that all staff receive training at a level appropriate to their role in how to respond appropriately to the needs of autistic people.
Regulation: Regulation 12(1)(2)(c).
⚠ We were not provided with any clarity that the training specifically included autism awareness. Staff we spoke to were not able to clearly articulate what autism specific training they had received.
Must-do action 67 of 107
Must do
Safe
The service must ensure arrangements are in place and adhered to in order to ensure prevention and control of the spread of infections.
Regulation: Regulation 12(1)(2)(h).
⚠ We saw one area that was visibly dirty. We observed dust on the resuscitation trolley and specifically on the defibrillator pads packaging.
Must-do action 68 of 107
Must do
Safe
The service must ensure that all gas cylinders are stored securely.
Regulation: Regulation 15(1)(b).
⚠ Oxygen cylinders were not always stored securely by chain or in cages. For example, on one ward we entered an unlocked room containing multiple gas cylinders that were not stored securely by chain or in a cage.
Must-do action 69 of 107
Must do
Safe
The service must ensure risk assessments have been carried out to minimise ligature risks and ensure that the premises and equipment used by the service users are done so in a safe way.
Regulation: Regulation 12(1)(2)(e)(f).
⚠ We observed call bells on cords in private bays and in private toilet areas. These were a ligature risk. For example, on one ward we identified ligature risk throughout the ward.
Must-do action 70 of 107
Must do
Safe
The service must ensure that all staff complete safeguarding training appropriate to their role.
Regulation: Regulation 13(1).
⚠ We found no data to confirm that allied health professionals (AHP’s) had completed level three safeguarding adults training. There was a safeguarding policy in place, but this did not specify the level of training each staff group required.
Must-do action 71 of 107
Must do
Safe
The service must have robust procedures in place for the identification, review and management of clinical risk when providing care and treatment.
Regulation: Regulation 12(1)(2)(a)(b).
⚠ We saw examples of two patients who had not had their NEWS scores repeated within appropriate timescales. There was no automatic alert on recording physiological observations to trigger a change to NEWS scores.
Must-do action 72 of 107
Must do
Caring
The service must ensure that people who use the service receive person centred care and treatment that is appropriate, meets their needs and reflect their personal preferencesRegulation9(1)(2).
Regulation: Regulation 9(1)(2).
⚠ In the absence of effective care planning there was a risk that patients would have received incomplete care and treatment and the effectiveness of any care provided could not be measured accurately.
Must-do action 73 of 107
Must do
Safe
The service must ensure that there is timely review of dementia friendly environments, ensuring that premises used by the service provider are safe to use for their intended purpose.
Regulation: Regulation 12(1)(2)(d).
⚠ We opened some doors marked bathroom and found unused equipment stored within the rooms. For example, there were large amounts of moving and handling equipment found in a room marked bathroom on a main corridor in ward 13.
Must-do action 74 of 107
Must do
Effective
The service must ensure that staff complete mental capacity and best interest decisions, when obtaining consent and that they clearly document the assessment and decision making process.
Regulation: Regulation 13.
⚠ When a patient’s capacity to consent was queried, staff did not always undertake appropriate assessments of their mental capacity to determine the need for best interest decisions to be made.
Must-do action 75 of 107
Must do
Well-led
The service must ensure that guidance in policies is up to date and systems and processes are embedded and operated effectively to ensure compliance with the Mental Capacity Act.
Regulation: Regulation 17(1)(2)(a).
⚠ There was a Mental Capacity Act policy in place, however this was not updated to reflect the training requirements and responsibilities of staff in completion of mental capacity assessments.
Must-do action 76 of 107
Must do
Well-led
The service must ensure there are clear processes and timescales for carrying out audit and re-audit of activities including the use of hospital passports in order to improve practice.
Regulation: Regulation 17(1)(2)(f).
⚠ We found that whilst five of six wards scored 100% for patients with a confirmed learning disability having a passport in place and evidence of this being discussed one ward scored 17% for overall compliance.
Must-do action 77 of 107
Must do
Safe
The service must ensure all staff are aware of and consistently follow the service policy to safely prescribe, administer, record and store and dispose of medicines.
Regulation: Regulation 12(1)(2)(g).
⚠ On our first inspection we found medicines were not always stored securely or safely. Fridgetemperature records were not recorded consistently and when out of range no actions were taken.
Must-do action 78 of 107
Must do
Safe
The service must ensure robust oversight and management of incidents and ensure incidents are shared across the health group.
Regulation: Regulation 12.
⚠ We found no evidence managers shared learning with their staff about never events that happened elsewhere.
Must-do action 79 of 107
Must do
Caring
The service must ensure that people who use the service receive person centred care and treatment that is appropriate, meets their needs and reflect their personal preferences.
Regulation: Regulation 9(1)(2).
⚠ In the absence of effective care planning there posed a risk that patients would receive incomplete care and treatment and the success of any care provided could not be measured accurately.
Must-do action 80 of 107
Must do
Safe
The service must ensure that mandatory and core competency training compliance meets the trust target.
Regulation: Regulation 12(1)(2)(c).
⚠ Overall mandatory training compliance was slightly below the trust target at 90% for June 2023.
Must-do action 81 of 107
Must do
Effective
The service must ensure that all staff receive training in how to interact appropriately with people with a learning disability and autistic people, at a level appropriate to their role.
Regulation: Regulation 12(2)(c).
⚠ The trust told us they had introduced the regional ICS endorsed Learning Disabilities Diamond Standards mandatory training for all clinical and patient facing staff in March 2023. This training includes some aspects of autism training but has been enhanced with additional autism awareness education sessions from April 2023.
Must-do action 82 of 107
Must do
Safe
The service must ensure arrangements are in place and adhered to in order to ensure prevention and control of the spread of infections.
Regulation: Regulation 12(2)(h).
⚠ Staff did not dispose of clinical waste safely. We also saw across both hospital sites that clinical waste storage areas were not always secure.
Must-do action 83 of 107
Must do
Safe
The service must ensure care and treatment is provided in a safe way. This includes assessing the health and safety risks for service users receiving the care or treatment and doing all that is reasonably practicable to mitigate any such risks. This includes but is not limited to the use of bedsides.
Regulation: Regulation 12(1)(a)(b).
⚠ We requested risk assessments for these but were told by all staff there were no risk assessments completed. Therefore, we were not assured that risk and safety management processes were robust and did not always protect patients from possible harm.
Must-do action 84 of 107
Must do
Effective
The service must ensure that staff complete mental capacity and best interest decisions, where appropriate, when obtaining consent and that they clearly document the assessment and decision-making process.
Regulation: Regulation 13(4)(d).
⚠ Staff did not always gain consent from patients for their care and treatment in line with legislation and guidance. Staff did not always clearly record consent in the patient records.
Must-do action 85 of 107
Must do
Safe
All premises and equipment used by the service provider must be secure and suitable for the purpose for which they are being used, properly used, properly maintained, and appropriately located for the purpose for which they are being used. This includes but is not limited to the storage of medical gases.
Regulation: Regulation 15(1)(b)(c).
⚠ We found no medical gas signs on the storeroom doors of all wards we visited. These rooms stored some entonox and oxygen inappropriately on the floor behind the door. Storeroom doors were all unlocked which meant medical gases were accessible to anyone on the ward.
Must-do action 86 of 107
Must do
Effective
The service must ensure clinical care and treatment are delivered and monitored in accordance with national guidance and best practice.
Regulation: Regulation 17.
⚠ In the absence of effective care planning there posed a risk that patients would receive incomplete care and treatment and the success of any care provided could not be measured accurately.
Must-do action 87 of 107
Must do
Safe
The service must ensure learning from never events is shared with all staff.
Regulation: Regulation 17.
⚠ We also spoke with theatre staff in regard to lessons learnt following these never events but none of the staff we spoke with, were aware of the incidents.
Must-do action 88 of 107
Must do
Safe
The service must ensure that serious incidents are reported and investigated in a timely manner in line with national guidance.
Regulation: Regulation 17(1).
⚠ We saw insufficient pace when sharing the learning, resulting in potential subsequent harm to patients.
Must-do action 89 of 107
Must do
Well-led
The service must ensure a robust audit plan is in place and key audits are conducted, which include record keeping, medicines management and infection prevention and control audits. The service must ensure relevant actions identified by local audits are acted on.
Regulation: Regulation 17(1)(2)(a)(b).
⚠ We saw gaps in audits undertaken which were not flagged or actioned for further improvement.
Must-do action 90 of 107
Must do
Well-led
The service must operate effective systems and processes to make sure they assess and monitor their service. This should include the auditing of surgical safety checklists, documentation, infection prevention and control.
Regulation: Regulation 17(1).
⚠ We saw gaps in audits undertaken which were not flagged or actioned for further improvement.
Must-do action 91 of 107
Must do
Well-led
The service must monitor progress against plans to improve the quality and safety of services and take appropriate action without delay, where progress is not achieved as expected.
Regulation: Regulation 17(2)(a).
⚠ It was not clear what actions were undertaken when the register was reviewed as there were no dates shown against each action or point of review.
Must-do action 92 of 107
Must do
Well-led
Senior managers must ensure robust systems and processes are in place to identify, manage, mitigate and if appropriate escalate risks. This must ensure senior managers and the board members have clear oversight of service risks.
Regulation: Regulation 17(1)(2)(a)(b).
⚠ It was not clear how risks were identified and escalated to the risk register with the latter two risks being added during 2022 and the earlier two being added in 2012 and 2013.
Must-do action 93 of 107
Must do
Safe
The service must ensure that there are sufficient numbers of suitably competent, skilled, medical staff to meet minimum staffing levels and meet the care and treatment needs of service users.
Regulation: Regulation 18.
⚠ Both junior and middle career doctors at both hospital sites, told us that they felt the workload was unmanageable at times and expressed concerns as to how ‘stretched’ they felt.
Must-do action 94 of 107
Must do
Safe
The service must ensure that mandatory and core competency training compliance meets the trust target.
Regulation: Regulation 12(1)(2)(c).
⚠ The maternity service was rated requires improvement for safe and good for well led.
Must-do action 95 of 107
Must do
Safe
The service must ensure premises are safe. This includes but is not limited to ensuring storeroom doors are not left open or unlocked.
Regulation: Regulation 12(1)(2)(d).
⚠ The maternity service was rated requires improvement for safe and good for well led.
Must-do action 96 of 107
Must do
Safe
The service must ensure there are sufficient quantities of cardiotocography (CTGs), central monitoring equipment and cleaning equipment to ensure the safety of women, birthing people, and babies.
Regulation: Regulation 12(1)(2)(f).
⚠ The maternity service was rated requires improvement for safe and good for well led.
Must-do action 97 of 107
Must do
Safe
The service must ensure they are delivering fundamental standards of care that meets the needs of women, birthing people, and babies. This includes assessing the health and safety risks and doing all that is reasonably practicable to mitigate any such risks. This includes but is not limited to staffing, risk assessments and security.
Regulation: Regulation 12(1)(2)(a)(b).
⚠ The maternity service was rated requires improvement for safe and good for well led.
Must-do action 98 of 107
Must do
Safe
The service must ensure that there are sufficient numbers of competent, skilled, and experienced midwifery and medical staff to meet minimum staffing levels and meet the care and treatment needs of women, birthing people, and babies. This includes but is not limited to ensure that the skill mix supports the acuity of patients.
Regulation: Regulation 18(1)(2)(a).
⚠ The maternity service was rated requires improvement for safe and good for well led.
Must-do action 99 of 107
Must do
Effective
The service must ensure newly qualified midwifery staff receive the appropriate support, training, professional development, and supervision as is necessary to enable them to carry out their duties.
Regulation: Regulation 18(1)(2)(a).
⚠ The maternity service was rated requires improvement for safe and good for well led.
Must-do action 100 of 107
Must do
Safe
The service must implement an effective system to identify and report incidents including the severity of harm. The system must ensure incidents are effectively reviewed, lessons and actions are identified and shared with staff.
Regulation: Regulation 17(1)(2)(a)(b).
⚠ The maternity service was rated requires improvement for safe and good for well led.
Must-do action 101 of 107
Must do
Well-led
The service must assess, monitor, and improve the quality and safety of the services and mitigate the risks relating to the health, safety and welfare of women, birthing people, and babies.
Regulation: Regulation 17(1)(2)(a)(b).
⚠ The maternity service was rated requires improvement for safe and good for well led.
Must-do action 102 of 107
Must do
Safe
The service must have robust procedures in place for the identification, review, and management of risk.
Regulation: Regulation 12.
⚠ The full waiting area in the emergency department was not visible from the reception and triage areas. We observed there was no formal arrangement for staff to observe this area or complete regular checks on patients to identify any deterioration in their condition.
Must-do action 103 of 107
Must do
Safe
The service must ensure that mandatory training compliance meets service and trust targets.
Regulation: Regulation 12(1)(2)(c).
⚠ Some of the services did not always have enough staff to care for patients and keep them safe.
Must-do action 104 of 107
Must do
Effective
The service must ensure that staff complete mental capacity and best interest decisions, when obtaining consent and that they clearly document the assessment and decisionmaking-making process.
Regulation: Regulation 13.
⚠ Some of the services did not always have enough staff to care for patients and keep them safe.
Must-do action 105 of 107
Must do
Well-led
The service must ensure a robust audit plan is in place and key audits are conducted, including recordkeeping, daily checks and medicines management audits. The service must ensure relevant actions identified by local audits are acted upon.
Regulation: Regulation 17(1)(2)(a)(b).
⚠ Some of the services did not always have enough staff to care for patients and keep them safe.
Must-do action 106 of 107
Must do
Well-led
The service must ensure it has an up to date and robust risk register in place with appropriate oversight, management, and implementation of identified actions.
Regulation: Regulation 17(1)(2)(a)(b).
⚠ Some of the services did not always have enough staff to care for patients and keep them safe.
Must-do action 107 of 107
Must do
Well-led
The service must ensure systems and processes are established, operated, and audited effectively to ensure compliance with the requirement to assess, monitor and improve the quality and safety of the services provided in the carrying on of the regulated activities.
Regulation: Regulation 17(1)(3).
⚠ Some of the services did not always have enough staff to care for patients and keep them safe.

Should-do actions (27)

Recommended improvements to enhance service quality.

Should-do action 1 of 27
Should do
Well-led
The trust should consider ensuring all recording and timelines for grievances and disciplinary processes are a complete and contemporaneous record.
Should-do action 2 of 27
Should do
Well-led
The service should continue to act on concerns to improve culture within the Paediatric Intensive Care Unit.
Should-do action 3 of 27
Should do
Well-led
The service should consider how performance information is disseminated to staff at all levels.
Should-do action 4 of 27
Should do
Safe
The service should ensure that records are accessible to all people as necessary to deliver people’s care and treatment in a way that meets their needs and keeps them safe.
Should-do action 5 of 27
Should do
Safe
The service should ensure they continue to strive to achieve mandatory training compliance figures to achieve the trust target.
Should-do action 6 of 27
Should do
Well-led
The service should ensure regular completion of the clinical assurance tool and clear action plans are available for all staff.
Should-do action 7 of 27
Should do
Safe
The service should ensure that all clinical waste and sharps bins are marked and stored properly.
Should-do action 8 of 27
Should do
Safe
The service should ensure that all equipment that requires removal from ward areas is stored securely.
Should-do action 9 of 27
Should do
Safe
The service should ensure that service user records are stored securely.
Should-do action 10 of 27
Should do
Well-led
The service should ensure that there are effective communications systems and processes to seek and action feedback from staff on the services provided in the provision of the regulated activities. This includes visibility of the senior leadership teams.
Should-do action 11 of 27
Should do
Caring
The service should further improve the quality of food provided to all patients and seek regular patient feedback.
Should-do action 12 of 27
Should do
Responsive
The service should consider increasing the numbers of discharge co-ordinators across the speciality.
Should-do action 13 of 27
Should do
Caring
The service should consider the reintroduction of volunteers across the speciality
Should-do action 14 of 27
Should do
Safe
The service should consider a review of staffing on the Paediatric Intensive Care Unit to ensure that the skill mix supports the acuity of patients.
Should-do action 15 of 27
Should do
Well-led
The service should consider how performance information is disseminated to staff at all levels.
Should-do action 16 of 27
Should do
Safe
The service should ensure that records are accessible to all people as necessary to deliver people’s care and treatment in a way that meets their needs and keeps them safe.
Should-do action 17 of 27
Should do
Effective
The service should ensure the guidance within their PPH policy is clear about defining and grading maternal blood loss in accordance with national guidance.
Should-do action 18 of 27
Should do
Safe
The service should ensure that clinical sharps waste bins are dated and labelled in accordance with national guidance.
Should-do action 19 of 27
Should do
Caring
The service should further improve the quality of food provided to all patients and seek regular patient feedback.
Should-do action 20 of 27
Should do
Responsive
The service should consider increasing the numbers of discharge co-ordinators across the speciality.
Should-do action 21 of 27
Should do
Caring
The service should consider the reintroduction of volunteers across the speciality.
Should-do action 22 of 27
Should do
Well-led
The service should ensure regular completion of the clinical assurance tool and clear action plans are available for all staff.
Should-do action 23 of 27
Should do
Safe
The service should ensure they continue to strive to achieve mandatory training compliance figures to achieve the trust target.
Should-do action 24 of 27
Should do
Well-led
The service should ensure that there are effective communications systems and processes to seek and action feedback from staff on the services provided in the provision of the regulated activities. This includes visibility of the senior leadership teams.
Should-do action 25 of 27
Should do
Effective
The service should consider methods of recording pain relief that allows for review of care given.
Should-do action 26 of 27
Should do
Effective
The service should ensure that consent is recorded in all patient contact.
Should-do action 27 of 27
Should do
Responsive
The service should ensure that information for patients is available in languages other than English and in alternative formats.

Location details

CQC ID: RTD02
Local authority: Newcastle upon Tyne
Region: North East

Inspection report

Type: Location
Date: 24 January 2024
Rating: Requires improvement
Actions: 107 must-do 27 should-do
AI-extracted 3 Jun 2026

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