You are here

Leeds General Infirmary Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 27 September 2016

Leeds Teaching Hospitals NHS Trust is one of the largest trusts in the United Kingdom and serves a population of around 780,000 in Leeds and up to 5.4 million in surrounding areas, treating around 2 million patients a year. In total the trust employs around 15,000 staff and provides 1785 inpatient beds across Leeds General Infirmary, St James’s University Hospital, Leeds Children’s Hospital and Chapel Allerton Hospital. Day surgery and outpatient services are provided at Wharfedale Hospital and outpatients services are also provided at Seacroft Hospital. The Leeds Dental Institute, although part of the trust, was not inspected at this inspection.

We carried out a follow up inspection of the trust from 10 to 13 May 2016 in response to the previous inspection as part of our comprehensive inspection programme in March 2014. We also undertook an unannounced inspection on 23 May 2016 to follow up on concerns identified during the announced visit.

Focussed inspections do not look across a whole service; they focus on the areas defined by information that triggers the need for an inspection. Therefore, we did not inspect all the five domains: safe, effective, caring, responsive and well led for each core service at each hospital site. We inspected core services where they were rated requires improvement. We also checked progress against requirement notices set at the previous inspection due to identified breaches in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. As a result of the March 2014 inspection, we issued a number of notices, which required the trust to develop an action plan on how they would become compliant with regulations. We reviewed the trust’s progress against the action plan as part of the inspection.

We inspected the following locations:

At Leeds General Infirmary (LGI), we inspected the following domains:

  • Urgent and emergency care (A&E) - safe and effective
  • Medicine - safe, effective, responsive and well-led
  • Surgery - safe, responsive and well-led
  • Critical care - safe, responsive and well-led
  • Maternity and gynaecology - safe
  • End of life care - safe

We inspected the following domains for children’s and young people’s services at the Children’s Hospital, which is reported in the LGI location report – safe, responsive and well-led.

At St James’s University Hospital (SJUH), we inspected the following domains:

  • Urgent and emergency care (A&E) – effective
  • Medicine – safe, responsive and well-led
  • Surgery - safe, responsive and well-led
  • Critical care - safe, responsive and well-led
  • Maternity and gynaecology - safe
  • End of life care - safe

At Chapel Allerton and Wharfedale Hospitals, we inspected the safety domain within surgery.

We did not inspect the Leeds Dental Institute and we did not inspect the outpatients’ services across the trust as these had previously been rated as good.

We did not inspect the caring domain across the trust as this was rated as good across all trust services at the previous inspection.

Overall, we rated the trust as good. We rated safe as requires improvement, effective, responsive and well-led as good. We rated Leeds General Infirmary and St James’s University Hospital as requires improvement, Chapel Allerton Hospital as good and Wharfedale Hospital as good.

Our key findings were as follows:

  • Since the last inspection, the trust had invested time, effort and finances into developing a culture that was open, transparent and supported the involvement of staff, and reflected the needs of the people who used the services.
  • Changes such as the development of clinical service units and governance arrangements that were in their infancy at the last inspection had been further embedded and embraced by staff in the organisation.
  • Each clinical service unit had clear direction and goals with steps identified in order to achieve them.
  • The leadership team had remained stable. Staff across the organisation were positive about the access and visibility of executives and non-executives, particularly the Chief Executive. There had been improvements to services since the last inspection.
  • The leadership team were aware of and addressing challenges faced with providing services within an environment that had increasing demand, issues over patient flow into, through and particularly out of the organisation, including the impact this had on service provision; and the recruitment of appropriately skilled and experienced staff.
  • The trust values of, ‘The Leeds Way’ were embedded amongst staff and each clinical service unit had a clear clinical business strategy, which was designed to align with the trust’s ‘Leeds Way’ vision, values and goals. This framework encouraged ownership from individual CSU’s.
  • We saw strong leadership of services and wards from clinicians and ward managers. Staff spoke positively about the culture within the organisation.
  • Staff reported across the trust that they were proud to work for the organisation and felt that they worked well as a team across the different sites.
  • The trust invited all 15,000 staff to participate in the national staff survey, with a response rate of over 8,000 staff across the organisation. The survey showed that there was continuous improvement. The response rate for the NHS Staff Survey 2015 was 50%, this was better than the England average of 41%.
  • At service level there were governance processes and systems in place to ensure performance, quality and risk was monitored. Each CSU met weekly and used the ward health check to audit a range of quality indicators including the number of falls, complaints, pressure ulcers, staffing vacancies and staff sickness. This information was then escalated to senior staff and through the trust’s governance structure.
  • There was a positive culture around safety and learning from incidents with appropriate incident reporting and shared learning processes in place. However, learning from Never Events was not consistent amongst all staff within theatres. All steps of the World Health Organisation (WHO) safety checklist were not consistently taking place: audit data and our observations supported this. The audit data provided by the trust did not assure us that national early warning score (NEWS) and escalation was always done correctly.
  • There were occasions when nurse and care support worker staffing levels were below the planned number. Despite having a clear escalation process, non- qualified staffing levels did not always mitigate for the reduction in qualified nursing levels. Nursing, midwifery and medical staffing levels did not meet national guidelines in some areas, particularly surgery, theatres, critical care, maternity and children and young peoples’ services. The trust was actively recruiting to posts and supporting a range of role development programmes to diversify the staff group, including supporting advance roles and role specific training for non-qualified staff.
  • Arrangements and systems in place were not sufficiently robust to assure staff that the maintenance of equipment complied with national guidance and legislation.
  • There were arrangements in place for assessing the suitability of patients who were appropriate to wait on trolleys on the assessment ward. However, these were not consistently applied, or risk assessments undertaken. There was a lack of robust assurance over the oversight of patients waiting on trolleys.
  • Adherence to General Medical Council (GMC) guidance and the trust consent policy was not consistently demonstrated in patient records. In accordance with trust policy, a two stage consent process including two patient signatures was not consistently evidenced in patient records. However, we were assured that patients were well informed about their surgical procedure and had time to reflect on information presented to them at the pre-assessment clinic.
  • There was a much improved mandatory training programme. However, there were still low completion levels in some training, particularly resuscitation and role relevant safeguarding.
  • The Summary Hospital-level Mortality Indicator (SHMI) and the Hospital Standardised Mortality Ratio (HSMR) indicated there was no evidence of risk compared to the England average.
  • There were suitable arrangements in place for the prevention and control of infections, including policies, procedures and a dedicated infection prevention control team. Areas visited were clean and staff generally adhered to good infection control practices.
  • The trust responded to complaints and concerns in a timely manner. Improvements were made to the quality of care as a result of complaints and concerns.
  • The trust took into consideration the needs of different people when planning its services and made reasonable adjustments for vulnerable patient groups.
  • There was clear guidance for staff to follow within the care of the dying person’s individual care plan when prescribing medicines at the end of their life. Patients’ individual needs and wishes at the end of their life were represented clearly in the documentation.
  • Policies and guidelines were based on the latest national and international guidelines such as from the National Institute for Health and Care Excellence (NICE) and Royal College of Emergency Medicine.
  • On the whole, patients received pain relief in a timely manner and were able to access food and drinks as required.
  • Arrangements were in place to alert staff when patients were in receipt of treatment or admitted with special needs or were vulnerable, including living with dementia and learning disabilities. Staff had received training on how to support patients and individualise care to meet specific needs.
  • Staff understood their responsibilities in relation to the Mental Capacity Act (2005), restraint of patients and the treatment of detained patients, although there was some inconsistent practice over care of patients receiving rapid tranquilisation treatment.

We saw several areas of outstanding practice including:

  • There were outstanding examples of record keeping in the care of the dying person care plan. We saw that staff recorded sensitive issues in a clear comprehensive way to enable safe care to be given.
  • The development of Leeds Children’s Hospital TV allowed families to explore the wards and meet the teams.
  • Organ transplantation which included a live liver donation and transplant programme had been undertaken, which was the largest in the UK. Other aspects of the transplantation programme included Neonatal organ retrieval and transplantation, Life Port Trial, Kidney Transplantation, QUOD Trial, Quality in Organ Donation National Tissue Bank, Revive Trial, Organ Care System and Normothermic perfusion, Support for Hand Transplantation.
  • Procedures such as minimally invasive oesophagectomies were being performed. The colorectal team were using sacral nerve stimulation for faecal incontinence.
  • There is a consultant led virtual fracture clinic. This allows patients to be assessed without attending the hospital and then have the most appropriate follow up. This reduces unnecessary hospital attendances.
  • Revolutionary hand transplant surgery had taken place within plastic surgery.
  • Nurse-led wards for patients who were medically fit for discharge had been introduced to allow the service to adapt their staffing model to meet the needs of patients.
  • In response to patient carer feedback the acute medicine Clinical Service Unit had introduced John's campaign. This allowed carers to stay in hospital with patients with dementia.

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

Importantly, the trust must:

  • The trust must ensure at all times there are sufficient numbers of suitably skilled, qualified and experienced staff in line with best practice and national guidance taking into account patients’ dependency levels.
  • The trust must ensure all staff have completed mandatory training and role specific training.
  • The trust must ensure staff have undertaken safeguarding training at the appropriate levels for their role.
  • The trust must review the admission of critical care patients to theatre recovery areas when critical care beds are not available to ensure staff are suitably skilled, qualified and experienced.
  • The trust must review how learning from Never Events is embedded within theatre practice.
  • The trust must review the appropriateness of out of hours’ operations taking place and take the necessary steps to ensure these are in compliance with national guidance.
  • The trust must review the storage arrangements for substances hazardous to health, including cleaning products and sharps disposal bins to ensure safety in line with current procedures.
  • The trust must review and address the implementation of the WHO Five Steps to Safer Surgery within theatres.
  • The trust must ensure that physiological observations and NEWS are calculated, monitored and that all patients at risk of deterioration are escalated in line with trust guidance.
  • The trust must ensure that all equipment used across core services is properly maintained and serviced.
  • The trust must ensure that staff maintain patient confidentiality at all times, including making sure that patient identifiable information is not left unattended.
  • The trust must ensure that infection prevention and control protocols are adhered to in theatres.

In addition the trust should:

  • The trust should review and improve the consent process to ensure trust policies and best practice is consistently followed.
  • The trust should review the availability of referral processes for formal patient psychological and emotional support following a critical illness.
  • The trust should review the provision of post-discharge rehabilitation support to patients discharged from critical care.
  • The trust should ensure that appropriate staff have access to safeguarding supervision in line with best practice guidance.
  • The trust should continue to monitor the safe and correct identification of deceased patients before they are taken to the mortuary and take necessary action to ensure this is embedded in practice.
  • The trust should continue to work towards improving the assessment to treatment times within the ED department. The trust should also continue to work towards improving ambulance handover times and reduce the number of handovers that take more than 30 minutes.
  • The trust should ensure that systems and processes are in place and followed for the safe storage, security, recording and administration of medicines including controlled drugs.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 27 September 2016

Effective

Good

Updated 27 September 2016

Caring

Good

Updated 7 January 2014

Staff were caring, compassionate and ensured that the patients’ privacy and dignity were respected when attending to individuals’ personal needs.

Patients told us they had been involved in decisions about their care and treatment. Nurses introduced themselves to their patients at all times. Doctors explained to patients their diagnosis and made them aware of what was happening with their care.

Analysis of patient feedback information showed that generally patients were positive about their experience, particularly in the cardiac, children’s and accident and emergency services. For example, - the A&E Friends and Family test results were above the national average for recommending the A&E to friends and family for the four months from September to December 2013.

Responsive

Requires improvement

Updated 27 September 2016

Well-led

Good

Updated 27 September 2016

Checks on specific services

Maternity and gynaecology

Good

Updated 27 September 2016

We rated maternity and gynaecology services as good because:

  • Staff were encouraged to report incidents and systems were in place following investigation to disseminate learning to staff.
  • Records relating to women’s care were of a good standard and were kept secure in line with the data protection procedures.
  • There was a ‘Safe Staffing Levels and Escalation Protocol’ for staff to follow.
  • Women’s privacy, dignity and independence was maintained wherever possible. For example, in antenatal clinic staff asked for chaperones in line with the trust’s policy when carrying out intimate procedures.
  • Staff within the directorate spoke positively about the service they provided for patients. Quality and patient experience was seen as a priority and everyone’s responsibility.

However:

  • Medical staffing levels did not meet national guidelines.
  • Not all staff were up to date with mandatory training.
  • Due to insufficient dedicated theatre staff to ‘scrub’ and recover patients, midwives were taken away from their duties when a second theatre team was needed; this occurred an average of twice a week.

Medical care (including older people’s care)

Good

Updated 27 September 2016

We rated medical care as good because:

  • Staff understood their responsibilities to raise concerns and report incidents and near misses. Nursing staff received feedback about incidents through team meetings, ‘safety matters’ bulletins and in safety huddles.
  • Safety thermometer data showed the service performed well. The service had introduced initiatives to reduce falls and pressure ulcers.
  • Staff were compliant with infection prevention and control measures and the service demonstrated good compliance with hand hygiene and cleaning audits.
  • Systems and processes for safeguarding were reliable and appropriate to keep patients safe.

However:

  • Registered nurse and care support workers staffing levels were below the planned levels in some areas. The service had a clear escalation process for when staffing levels fell below the planned levels.

Urgent and emergency services (A&E)

Good

Updated 27 September 2016

We rated the emergency department as good because:

  • There were sufficient medical and nursing staff employed by the department and staffing levels were acceptable. Staff followed safeguarding processes to protect vulnerable adults and children from abuse and referred suspected cases of abuse to the proper authority in a timely way. Staff were up to date with annual appraisals.
  • The department had evidence-based policies and procedures relating to care and treatment, which were easily accessible to staff and were audited to ensure that staff were following relevant clinical pathways. Information about patients (such as test results) was readily accessible. There was evidence of different staff groups working well together throughout the department. The department offered services round the clock every day. Staff understood their responsibilities in relation to patients giving consent to treatment and the principles of the Mental Capacity Act 2005 that applied where a patient’s capacity to consent was in doubt.

Surgery

Requires improvement

Updated 27 September 2016

We rated surgical services as requires improvement because:

  • Two Never Events related to a wrong site anaesthetic block and guidance on this had not been fully adhered to.
  • Within Jubilee theatres we found some infection prevention and control practice issues.
  • Supporting documentation for Mental Capacity Assessments could not be provided.
  • Adherence to General Medical Council (GMC) guidance and the trust consent policy was not consistently demonstrated in patient records. However, we were assured that patients were well informed about their surgical procedure and had time to reflect on information presented to them at the pre-assessment clinic.
  • We found from audit data and our observations that not all aspects of the World Health Organisation (WHO) safety checklist took place.
  • The audit data provided by the trust did not assure us that national early warning score (NEWS) and escalation was always done correctly.
  • Readmission rates for elective and non-elective admissions were higher than the England average. In vascular surgery this was 1.2 times the England average.
  • Only two specialities were performing above 90% for the 18 week national indicators.

However:

  • We saw evidence of the individual needs of patients being met. This included patients with a learning difficulty or living with dementia.
  • Service planning was patient focused and collaborative working was in place with other organisations and trusts.
  • Projects such as the productive operating theatre were in place to provide data on performance and improve teamwork.
  • The trust had a strategy which was patient focused and there was evidence of innovative work to develop services.
  • We saw positive leadership at all levels with staff feeling able to escalate concerns and describing a positive change in culture.
  • A range of information was collated monthly into dashboards which fed into good governance arrangements.

Intensive/critical care

Good

Updated 27 September 2016

We rated critical care as good because:

  • The leadership change at Leeds Teaching Hospitals NHS Trust has promoted management team visibility, accessibility and engagement with staff. To address the ‘us and them’ culture between the two main hospital sites an external facilitator was employed to help staff build useful relationship between the two hospital units.
  • There was a good safety culture. Staff demonstrated an open and honest culture when responding and reporting incidents. When mistakes were made practices were reviewed, training and support was offered to staff so they learnt from mistakes.
  • Safety huddles were taken up by staff and they were confident to speak up about problems.
  • Environments were clean and there were effective infection, prevention and control practices embedded across the units.
  • There were good handover processes in place amongst medical, nursing and multidisciplinary staff.
  • Staff took into account the circumstances of each patient, their personal preferences and their coexisting conditions when planning and delivering care. The complaint policy and the procedures were well advertised and people told us they knew what to do if they were dissatisfied with the service.

However:

  • The trust provided specialist critical care service for a large geographical area therefore sometimes the demand for the service exceeded the resources they had causing problems with the access and flow to the critical care units particularly in relation to delayed discharges.
  • During our inspection we found equipment had service stickers to show that they had been checked however data supplied by the trust showed that they were not fully compliant and maintenance records indicated there was between 73% and 93% compliant on the units.
  • The critical care units could not demonstrate full compliance with GPICS ‘safe use of equipment’ standard which states that all staff must be appropriately trained, competent and familiar with the use of equipment. Staff we spoke with during the inspection told us they received training on equipment and were confident in using them. However information supplied by the trust on high risk equipment training showed low percentages of staff compliance with equipment training.
  • The outreach team did not work out of hours the current arrangements included medical and nursing support from the critical care units to the wards. However there were plans to introduce a 24/7 approach in October 2016 and staff had been recruited to this team.
  • Medical staffing did not achieve all of the requirements of the Guidelines for the Provision of Intensive Care Services GPICS (2015). Consultants were all experienced in critical care, however not all were trained as Faculty of Intensive Medicine (FICM).

Services for children & young people

Good

Updated 27 September 2016

We rated services for children and young people as good because:

  • Staff were encouraged to report incidents and learning was shared.
  • Staff were clear about their responsibilities if there were concerns about a child’s safety. Safeguarding procedures were understood and followed, and staff had completed the appropriate level of training in safeguarding. However, although the appropriate level training was given, the service was not meeting their target for safeguarding training for staff training and regular safeguarding supervision did not take place.
  • A paediatric early warning system was used for early detection of any deterioration in a child’s condition.
  • Plans were in place for the development of the children's hospital to centralise all children’s services. The youth forum provided input into how services were developed. Transition arrangements were good with a lead transition nurse appointed to ensure consistency.
  • The CAT unit improved patient access to the hospital and avoided unnecessary admissions; however, the wait in the CAT unit for admission to the ward could be long at times. Some specialities had long referral to treatment times.
  • Families knew how to make a complaint and appropriate information was available.
  • Children’s services had a clear vision and strategy. Staff were aware of the service and trust vision and values. There was an executive lead at board level for children’s services. Staff spoke highly of their leaders and were proud to work for the children’s hospital.

However:

  • Neonatal consultants were covering both St. James’s University Hospital and Leeds General Infirmary neonatal units out of hours on a weekend. There was not always sufficient nursing staff on every ward to meet the Royal College of Nursing (RCN) guidance and British Association of Perinatal Medicine (BAPM) guidelines. On five wards, the actual number of staff on duty did not meet the planned number on a regular basis. There were gaps in the junior doctors rotas, which were being filled with locum shifts or consultants were covering.

  • We were not assured that all equipment had been safety tested.
  • Staff were not meeting expected targets for safeguarding Level 2 and Level 3 training.

End of life care

Good

Updated 27 September 2016

We rated end of life care as good because:

  • Safety incidents were investigated when things went wrong and lessons learned were widely shared among staff to reduce the risk of re-occurrence. Staff were open and honest when they spoke with patients and families about incidents.
  • There was clear guidance for staff to follow within the care of the dying person individual care plan when prescribing medicines at end of life.
  • There was enough equipment including syringe pumps to support safe care of end of life patients.

Outpatients

Good

Updated 7 January 2014

Outpatient areas were appropriately maintained and fit for purpose. Staff at all levels told us they felt encouraged to raise concerns and problems. Incidents were investigated appropriately and actions were taken following incidents to ensure that lessons were learned and improvements were shared across the departments. The infection control procedures were adhered to in clinical areas, which appeared clean and reviewed regularly. Staffing levels were adequate to meet patients’ needs.

The trust completed audits and had implemented changes to improve the effectiveness and outcomes of care and treatment.

Patients told us they felt involved in their care and treatment and that staff supported them in making difficult decisions. The hospital provided interpretation services and patients told us that they felt their privacy and dignity were respected.

The outpatients were focused on patient care and this was reflected at all levels within the departments. Staff understood the vision and values of the organisation and felt encouraged to achieve continuous improvement.