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Leicester Royal Infirmary Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 26 January 2017

University Hospitals of Leicester NHS Trust is a teaching trust that was formed in April 2000 following the merger of Leicester General Hospital, the Glenfield Hospital and Leicester General Hospital. The trust has 1,959 general and acute beds. 147 of these beds are maternity beds and 49 are critical care beds. 975 inpatient beds and 66 day-case beds are located at Leicester Royal Infirmary.

University Hospitals of Leicester NHS Trust provide specialist and acute services to a population of one million residents throughout Leicester, Leicestershire and Rutland. The trust’s nationally and internationally-renowned specialist treatment and services in cardio-respiratory diseases, cancer and renal disorders reach a further two to three million patients from the rest of the country. The trust provides services from four hospital sites, Leicester Royal Infirmary, Leicester General Hospital,Glenfield Hospital and St Mary's maternity hospital.

Leicester Royal Infirmary is close to Leicester city centre and provides Leicestershire’s only emergency department. The hospital has approximately 975 inpatient beds and 66 day-case beds. There were 86,943 inpatient admissions, 511,864 outpatient attendances and 135,111 emergency department attendances between April 2015 and March 2016.

We inspected Leicester Royal Infirmary in January 2014 under our new inspection methodology and rated it as requiring improvement. We also undertook an unannounced focused inspection of the emergency department at Leicester Royal Infirmary on the evening of 30 November 2015 because we were concerned about potential risks to patient safety in the emergency department. Following this inspection, we undertook urgent enforcement action to protect patients from the risk of harm.

During this inspection we followed up on the identified areas that required improvement from the 2014 inspection. We looked at a wide range of data, including patient and staff surveys, hospital performance information and the views of local partner organisations. The announced part of the inspection took place between the 20 and 23 June 2016, but the critical care service was inspected between the 25 and 27 July 2016. We also carried out unannounced inspections to Leicester Royal Infirmary, the Glenfield Hospital and Leicester General Hospital on 27 June, 1 July and 7 July 2016.

Overall we found the Leicester Royal Infirmary was performing at a level which led to the judgement of requires improvement. We inspected all eight core services at this hospital; two were rated as good and six were rated as requires improvement.

Our key findings were as follows:

  • There was a good incident reporting culture in the trust and systems were in place to enable staff to report incidents. Staff were aware of their responsibilities in relation to reporting incidents, managers undertook incident analyses and investigations to determine any areas of improvement and staff were provided with feedback.
  • Staff had a varied understanding about the duty of candour regulation and we saw examples where duty of candour had been applied appropriately.
  • Recognised staffing assessment tools were used to assess the required numbers and skill mix of staff.
  • Like many trust's in England, there were staff shortages in some areas for doctors, nurses and allied health professionals. Some areas had higher vacancy levels than others. The trust had recruited a number of registered nurses from overseas. The trust also used bank and agency staff to meet the needs of patients.
  • There were effective safeguarding procedures in place for both adults and children. However, staff were not always sure of the level of safeguarding children training they had received.
  • Emergency equipment was checked on a daily basis. We found that relevant checks had been undertaken and documented.
  • We were concerned about the trust’s management of deteriorating patients and those who presented with sepsis. This is a severe infection which spreads in the bloodstream and if left untreated can lead to death. Where patients had met the trust’s criteria for sepsis screening, they were not all screened in accordance with national guidance. This put patients at risk of not receiving the correct treatment in a timely manner.
  • Medicines in the emergency department were not always securely stored.
  • Staff mostly followed infection prevention and control policies and cleansed their hands between tasks and contact with patients.
  • It was not always clear to see whether equipment was cleaned following use as it was not always labelled appropriately to indicate it had been cleaned. In some areas effective cleaning would not be possible due to aging and damaged furniture.
  • Until May 2016, cleaning services had been contracted out to a private provider. There had been problems with cleanliness prior to our inspection which were identified through the trusts own audits. During our inspection, we found that environmental cleanliness had not always been given sufficient priority, especially in public areas such as toilets.
  • In most of the services, patients’ needs were assessed and care and treatment was delivered in line with legislation, evidence based practice.
  • Staff on all the wards were mostly observed to be polite and courteous to patients and saw a number of examples of good care.

We saw several areas of outstanding practice including:

  • Staff in the paediatric emergency department told us about the development of ‘greatix’, this was to enable staff to celebrate good things in the department. Staff likened it to ‘datix’, which enabled staff to raise concerns. Staff used greatix to ensure relevant people received positive feedback relating to something they had done. Many staff throughout the emergency department told us of times when they had received feedback though greatix and told us how this made them feel proud and valued.
  • On Ward 42, we attended a ‘posh tea round’. This took place monthly on the ward and provided an opportunity for staff and patients to engage in a social activity whilst enjoying a variety of cakes not provided during set meal times.
  • During our visit to Ward 23, a patient was refusing to eat. The meaningful activities facilitator sat and had their dinner with the patient. They told us by making it a social event they hoped the patient would eat.
  • Within oncology and chemotherapy, a 24-hour telephone service was available for direct patient advice and admission in addition to a follow up telephone service to patients following their chemotherapy at 48 hours, one week and two weeks post treatment.

  • The trust had introduced a non-religious carer to provide pastoral support in times of crisis to those patients who do not hold a particular religious affiliation .Also to provide non-religious pastoral and spiritual care to family and staff.

  • Midwifery staff used an innovative paper based maternity inpatient risk assessment booklet which included an early warning assessment tool known as the modified early obstetric warning score (MEOWS) to assess the health and wellbeing of all inpatients. This assessment tool enabled staff to identify and respond with additional medical support if required. The maternity inpatient risk assessment booklet also included a situation, background, assessment, recommendation (SBAR) tool, a sepsis screening tool, a venous thromboembolism (VTE) assessment tool which also had a body mass index chart, a peripheral intravenous cannula care bundle, a urinary catheter care pathway and assessment tools for nutrition, manual handling and a pressure ulcer risk score. This meant that all assessment records were available together.
  • The pain management service won the national Grünenthal award for pain relief in children in 2016. The Grünenthal awards recognised excellence in the field of pain management and those who were striving to improve patient care through programmes, which could include the commissioning of a successful pain management programme.

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

Importantly, the trust must:

Urgent & emergency services

  • The trust must take action to ensure nursing staff adhere to the trust’s guidelines for screening for sepsis in the ward areas and in the emergency department. This also applies to medical areas.

  • The trust must take action to ensure standards of cleanliness and hygiene are maintained at all times to prevent and protect people from a healthcare-associated infection. This also applies to medical areas and outpatient and diagnostic areas.

  • The trust must ensure that patients in the emergency department have venous thromboembolism (VTE) risk assessments completed.
  • The trust must ensure the privacy and dignity of patients within the majors area and the assessment area of the emergency department.

Medicine

  • The trust must ensure patient side rooms with balconies have been risk assessed in order to protect vulnerable patients from avoidable harm.

Critical Care

  • The trust must ensure 50% of nursing staff within critical care have completed the post registration critical care module. This is a minimum requirement as stated within the Core Standards for Intensive Care Units.

Surgery

  • The trust must ensure DNACPR decisions are documented fully in accordance with the legal framework of the Mental Capacity Act 2005.

Maternity

and gynaecology

  • The trust must ensure there are sufficient numbers of suitably qualified, competent, skilled and experienced persons to meet the requirements of the maternity and gynaecology service.
  • The trust must ensure that midwives have the necessary training in the care of the critically ill woman and anaesthetic recovery in line with current recommendations.

Services for children and young people

  • The trust must ensure at least one nurse per shift in each clinical area is trained in APLS or EPLS as identified by the RCN (2013) staffing guidance.
  • The trust must ensure Neonatal staffing at the Leicester Royal Infirmary (LRI) neonatal unit is compliant with the British Association of Perinatal Medicine Guidelines (BAPM) (2011).
  • The trust must ensure children under the age of 18 years are not admitted to ward areas with patients who are 18 years and above unsupervised.
  • The trust must ensure nursing staff have the appropriate competence and skills to provide the required care and treatment for children who require high dependency care.

End of life

  • The trust must ensure 'do not attempt cardio-pulmonary resuscitation' (DNACPR) forms are completed appropriately in accordance with national guidance, best practice and in line with trust policy.
  • The trust must ensure there are sufficient numbers of suitable syringe drivers with accepted safety features available to ensure patients receive safe care and treatment.

Outpatients & Diagnostic Imaging

  • The trust must ensure the waiting environment for ophthalmic patients and eye casualty is fit for purpose.
  • The trust must ensure that all equipment, especially safety related equipment is regularly checked and maintained.
  • The trust must ensure it has oversight of planning, delivery and monitoring of all care and treatment so it can take timely action on treatment backlogs in the outpatient departments.

In addition the trust should:

  • The trust should ensure cleaning products are locked away and are not accessible to patients on Ward 23.
  • The trust should ensure patient side rooms with balconies have been risk assessed in order to protect vulnerable patients from avoidable harm.
  • The trust should ensure medical notes, for patients who have been discharged are locked away and are not accessible to patients or the public on Ward 23.
  • The trust should ensure patient’s individual care records are written and managed in a way that keeps patient’s safe. This includes ensuring patient records on ward 26 are up to date.
  • The trust should ensure assistance with mealtimes is carried out in a timely way and provision of food outside of mealtimes is sufficient and includes access to a hot meal.
  • The trust should ensure Deprivation of Liberty Safeguards (DoLS) are always applied appropriately.
  • The trust should ensure male and female patients are not occupying the same bed bay unless there is a clinical need to do so.
  • The trust should consider reviewing the numbers of patients being moved between wards out of hours.
  • The trust should consider reviewing the process of referral to the General Medicine Assessment Unit.
  • The trust should ensure that the actions initiated after the recent never event in the critical care unit and include re-enforcing the importance of the timely reporting of all incidents.
  • The trust should ensure that it works to improve the access and flow issues within critical care with focus on the high occupancy and its impact on the numbers of non-clinical transfers and cancelled elective surgical cases.
  • The trust should consider how it is going to meet the existing areas of non-compliance with the D16 National Service Specification for Adult Intensive care. More specifically, the shortfall in allied health professional support and NICE guidance compliance.
  • The trust should ensure that staff are aware of the level of safeguarding training they have received.
  • The trust should develop a transition pathway for children from children’s services to adult services.
  • The trust should identify a non-executive director lead for children’s services to represent the service at board level.
  • The trust should improve compliance of reviewing a child within four hours of being admitted.
  • The trust should improve compliance with the three non-compliant standards of the five standards of the neonatal audit programme (NNAP) 2014.
  • The trust should improve staff knowledge of the duty of candour processes throughout children’s services.
  • The trust should continue to work with outside agencies to reduce the backlog of 4565 letters for paediatric services and closely monitor the progress.
  • The trust should ensure medical records are kept securely throughout all services.
  • The trust should ensure that within children’s services, patient names are not visible for the public to see.
  • The trust should monitor did not attends in clinics and ensure staff are aware of the policy guidance.
  • The trust should audit data on the length of time children spend in the children’s assessment unit.
  • The trust should consider its procedures for retrieving syringe pumps from the community to ensure there are sufficient numbers for patients requiring them in the hospital.
  • The trust should review the leadership arrangements and focus on end of life care to ensure it is given sufficient priority at directorate and board level.
  • The trust should consider formulating an overall strategy for end of life care across the trust which is disseminated to all staff across all sites.
  • The trust should consider the redesign of services to match capacity to demand and reduce in-clinic waiting times.
  • The trust should ensure that needs for nutrition and pain relief are acted upon in cases of patients waiting in outpatients for a delayed appointment.
  • The trust should ensure governance arrangements enable services to take timely action to address delays and problems, and effectively identify risks.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 26 January 2017

Effective

Requires improvement

Updated 26 January 2017

Caring

Good

Updated 26 January 2017

Responsive

Requires improvement

Updated 26 January 2017

Well-led

Requires improvement

Updated 26 January 2017

Checks on specific services

Maternity and gynaecology

Requires improvement

Updated 26 January 2017

We rated maternity and gynaecology services as requires improvement overall.

Midwifery staffing levels did not always meet minimum acceptable numbers for the unit and one-to-one care in labour was not always achieved. There was a lack of junior doctors to cover the service out of hours. Whilst the service mitigated these risks wherever possible, lack of staff, on occasion, posed a risk to patient safety.

Whilst most of the environment was visibly clean, there were some areas, which did not meet acceptable standards of infection control, and staff were not always compliant with hand hygiene standards.

Staff mostly planned and delivered care and treatment in line with current evidence-based guidance, standards, best practice and legislation; however, they did not always follow the trust’s policy on the disposal of fetal remains. Some midwifery staff did not have the competencies required when caring for women who were critically ill or following anaesthesia.

The majority of women, their partners and relatives were positive about the care they had received. Most of the women we spoke with told us staff were kind and caring and that they had been treated with dignity and respect and were happy with the emotional support they received. Staff involved patients in their care and treatment.

The trust provided an extensive range of specialist maternity and gynaecology services which included specialist midwives, ‘consultant direct’ and one-stop gynaecology clinics.

The service provided a cohesive and sensitive bereavement service for women experiencing pregnancy loss, including the employment of a specialist midwife, dedicated bereavement rooms and postnatal records; however, women experiencing pregnancy loss shared a ward entrance with antenatal patients, which could be distressing.

There was a clear vison and strategy for the service, which was shared by most staff, and most of the leadership team were visible and well respected.

There was a clear governance structure. Some outcomes on the quality dashboard were reported trust wide and others were not RAG (red, amber, green) rated. Most outcomes were reported at service level meaning site variance could not be identified. This meant we were not assured that service leads had good oversight of trends and outcomes for women at both sites. The outcomes for women against trust targets were mixed; the normal birth rate was above the national average and rates of instrumental birth were better than trust targets but the rates for caesarean section and postpartum bleeding were worse. We were also not assured that incidents were appropriately graded following discussions at clinical governance meetings. Clinical audits were undertaken but could be delayed because of staff availability to undertake them. We were not assured that results of audit were addressed in the action plans. The risk register was regularly reviewed however not all known risks were included.

Medical care (including older people’s care)

Updated 5 September 2017

Systems, processes and standard operating procedures were not always reliable to protect patients from avoidable harm as staff were not following these, for example medicines, infection prevention and control and the completion of patient records.

Compliance with resuscitation, fire safety and safeguarding adults and children training was low particularly amongst medical staff.

Staff did not always assess, monitor or manage the risk to patients. For example we saw fluid balance charts which were not up to date and patients did not always get their medicines when required. Care records were not always completed or updated appropriately.

Feedback from patient and relatives was mostly positive about the way staff treated them.

Staff mostly responded compassionately when patients needed help and support.

Staff helped patients and those close to them to cope emotionally.

Staff explained the treatment and care they were delivering to patients in a way patients could understand. We also heard staff talking to patients who required support with their personal hygiene, involving them in their care.

Urgent and emergency services (A&E)

Requires improvement

Updated 26 January 2017

We rated urgent and emergency care as requires improvement overall.

We rated the safety of urgent and emergency care as requires improvement. Where patients had met the trust’s criteria for sepsis screening, not all patients were screened in accordance with national guidance. This put patients at risk of not receiving the correct treatment in a timely manner. Care records were not always completed or updated appropriately to minimise risks to patients in the emergency department, for example in relation to pressure ulcers. Insufficient importance had been given to the prevention and control of infection, especially within the environment. Systems, processes and standard operating procedures were not always reliable or appropriate to keep people safe. Monitoring whether safety systems are implemented is not robust. There are some concerns about the consistency of understanding and the number of staff who are aware of them. Staff did not always sufficiently assess, monitor and manage risks to patients in the department, especially at times when the department was busy and overcrowded. However, where incidents were reported investigations took place and learning was shared. Staff had a good understanding of how to protect patients from abuse. Staff could describe what safeguarding was in addition to the processes to follow if they were concerned.

We rated the effectiveness of urgent and emergency services as requires improvement because patients were not always receiving effective care and treatment. Patients were not assessed for their risk of developing blood clots in their leg. Nurses did not always follow best practice guidance in relation to the use of clinical risk assessment tools for managing individual patients. The risk assessment tools used to assess a patients risk of developing pressure ulcers and care assessments did not always consider the full needs of patients. Patients were not always assessed for their requirements for pain control in a timely manner. Insufficient priority was given to the nutrition and hydration status of patients within the majors area of the department. Patients could not always get the attention of nurses to let them know they were thirsty, especially when the department was overcrowded. Mental Capacity Assessments were not always appropriately undertaken. However, we also found evidence of effective multidisciplinary working with staff, teams and services working together to deliver effective care and treatment. Staff were qualified and had the skills they needed to carry out their roles effectively and, staff were supported to maintain and further develop their professional skills and experience.

We rated the care provided to patients within urgent and emergency services as requires improvement because there were times when patients told us they did not feel well supported or cared for. Although staff were kind and caring and did their best to meet the care needs of patients, they did not always see people’s privacy and dignity as a priority. No consideration was given to the gender or culture of patients who were being nursed in the middle area of the majors department. However, we also found that at times when the department was calmer, staff demonstrated compassion and we saw a number of examples of good care.

We rated the responsiveness of urgent and emergency care as inadequate because the service was not planned or delivered in a way that met patient’s needs. Despite the demographic population of Leicester and Leicestershire, signage in different languages within the department was poor. Leaflets were printed in English, although staff told us they could be obtained in different languages, but they often found it difficult to access the translation service. Flow through the department was slow because of delays in transferring patients to ward areas, which often occurred later at night. Some patients experienced unacceptable waits to be transferred to a ward because beds were not available. Because patients remained in the department, they were unable to access the ongoing care they needed. The emergency department did not have a clear plan in place to meet the needs of patients who had long waits to be transferred to a ward as well as provide essential emergency care for patients entering the department. We observed frail elderly patients who had no pillow to rest their head on. However, we also found that staff could access specialist support services such as a learning disability nurse if they needed to.

We rated the leadership of urgent and emergency care services as requires improvement because the leadership, governance and culture did not always support the delivery of high quality person-centred care.

We found that departmental governance and risk management arrangements were not robust and as such were not effective in protecting patients from avoidable harm. Risks, issues and poor performance had not always been dealt with appropriately or in a timely way. Staff did not always raise concerns because they felt they would not be listened to or that anything would change.

Surgery

Good

Updated 26 January 2017

We rated surgical care services at the Leicester Royal Infirmary as good.

On all the wards and departments we visited, we saw staff acting in a kind and caring way towards patients and the public. Relatives and carers told us they felt involved and informed.

Patients had access to a wide range or resources and materials, both online and in paper formats, which were individualised and tailored to their needs. For example enhanced recovery programmes.

We found nursing staff consistently followed trust guidelines for the completion and escalation of deteriorating physiological observations and early warning scores (EWS).

However;

Staff did not always recognise, concerns, incidents or near misses for example not reporting missing medical notes, or the lack of computers.

The pathway for pre-operative and high-risk anaesthesia patients was not consistently followed causing potentially avoidable delays and cancellations. Some patients were not having pre-operative assessment despite being identified as high risk for anaesthetic.

Departmental governance and risk management arrangements were not robust and as such did not always protect patients from avoidable harm.

Intensive/critical care

Good

Updated 26 January 2017

We rated critical care services at Leicester Royal Infirmary as good overall.

There were sufficient numbers of suitably qualified staff to care for patients. We found a culture where incident reporting was encouraged and understood by staff.

Patients and their relatives were cared for in a supportive and sympathetic manner and were treated with dignity and respect.

There was strong clinical and managerial leadership at both unit and management group level. The service had a vision and strategy for the future.

There was an effective governance structure in place, which ensured that the risks to the service were known, recorded on the trust risk register and discussed. The framework also enabled the dissemination of shared learning and service improvements.

However, we also found some issues with access and flow. In 2015, 47 patients had their elective surgery cancelled because there was no critical care bed available.

Bed occupancy levels were consistently higher than 90% for 2015 thus making it difficult to respond to individual needs. The trust target was 85%.

There were higher levels of non-clinical transfers when compared with similar units.

Pharmacy provision for the critical care service did not fully meet the D16 service specification, and the trust was not compliant with all aspects of NICE guidance 83 ‘Rehabilitation after Critical Illness’.

Services for children & young people

Requires improvement

Updated 26 January 2017

We rated services for children and young people at the Leicester Royal Infirmary as requires improvement overall.

Mandatory training levels for Advanced Paediatric life support, mandatory training and level three safeguarding training did not meet the trust target. The trust did not meet Royal College of Paediatrics and Child Health (RCPCH) standards for sufficient paediatric consultants.

The service could not provide at least one nurse per shift in each clinical area trained in Advanced Paediatric Life Support (APLS) or European Paediatric Life Support (EPLS) training.

The service had a backlog of children needing to be seen for certain specialities which meant children waiting long periods of time for surgical procedures.

Staff were not always trained to care for complex patients requiring high dependency care.

Medical records were not always kept safely and securely.

Learning from incidents was shared with staff through emails and team meetings. There were robust safeguarding policies and procedures in place.

Equipment was checked and available for staff to be able to carry out their role.

The service offered a holistic range of services to meet children and young people’s needs.

Medication monitoring practices were effective and medications were administered safely.

Patients received evidenced based care and there was good multi-disciplinary working between nursing and medical teams.

However we also found staff were caring, compassionate and respectful to children, young people and their families.

End of life care

Requires improvement

Updated 26 January 2017

We rated end of life care services at the Leicester Royal Infirmary as requires improvement. We rated safe, responsive and caring as good with effective and well led as requires improvement because.

The medical staffing levels were not in line with the recommendations from the National Council for Palliative Care who recommend there should be one whole time equivalent (WTE) consultant for every 250 beds. The service had 3.5 WTE consultants and would require 7.0 WTE to provide cover to the three sites. The staffing was 50% lower than recommended.

The trust had 82 syringe drivers that were in line with best practice guidelines. However, only ten were ready for use. This meant the trust was reliant on using syringe drivers, which did not meet the NHS patient safety guidance.

We looked at 23 ‘Do Not Attempt Cardio Pulmonary Resuscitation’ orders (DNACPR) across the trust and found there were inconsistencies in how these were completed. We found that out of 23 DNACPR orders, six were completed correctly (25%). We found staff had not always followed trust policy when they completed DNACPR orders.

The trust had taken part in the National Care of the Dying Audit 2016 and had achieved three of the eight organisational Key Performance Indicators (KPIs). The trust scored lower than the England average for all five Clinical KPIs. The trust had undertaken an audit in April 2016 in response to the National Care of the Dying Audit 2016, and an action plan had been developed to address the KPI’s that had not been achieved.

The service did not have its own risk register and risks were not recorded on the trust wide risk register.

There was no strategic plan for end of life care throughout the trust.

The service did not have a non-executive director representing end of life care at board level.

However, we also found that care records were mostly maintained in line with trust policy.

Staff understood their responsibilities in following safeguarding procedures and care and treatment was delivered in line with recognised guidance and evidence based practice. The last days of life care plan was in use throughout the trust.

The trust had effective multidisciplinary working in place and staff were seen to be compassionate and we observed them treating patients and their families with dignity and respect.

A bereavement service was available to support family members with practical and support issues after the death of a patient. The chaplaincy service provided a 24 hour, seven days a week on call service for patients in the hospital, as well as their relatives.

The specialist palliative care team were committed to ensuring that patients receiving end of life care services had a positive experience.

The trust had a rapid discharge home to die pathway. Discharge in these circumstances was arranged by the specialist discharge sister and could be facilitated within a few hours for patients wishing to return home.

Staff spoke positively about the service they provided for patients. High quality, compassionate patient care was seen as a priority. Staff within the specialist palliative care team spoke positively and passionately about the service and care, they provided for patients.

The trust had recruited a bereavement nurse specialist in July 2015 who worked across the three hospital sites and closely with the specialist palliative care team (SPCT).

Outpatients

Requires improvement

Updated 26 January 2017

We rated outpatient services and diagnostic imaging at Leicester Royal Infirmary as requires improvement overall.

The individual patient risks associated with anticipated events were not fully recognised, assessed or managed, as the hospital did not schedule follow up appointments for eye patients. Ophthalmology and rheumatology specialities had backlogs of follow up patients. The hospital had not fully assessed their clinical priority for appointments, which meant patients were at risk of harm. Outpatient services and diagnostic imaging learned from incidents and there was an open reporting culture.

The approach to assessing and managing day-to-day risks to people who use services did not take a holistic view of patient’s needs. Standards of hygiene were not met in some outpatient clinic rooms, waiting areas and toilets. Overcrowding in the eye clinic was unpleasant and unsafe for patients. There were periods of understaffing. Nurse staffing levels, at Leicester Royal Infirmary (LRI), based on information given to us by the trust, were 18.5% below the planned level.

Patient care and treatment were planned and delivered in line with current evidence-based guidance, standards, and legislation. This was monitored to ensure consistency of practice.

Patient privacy and dignity was not protected in the eye clinic. Overcrowding long waits and cancellations led to a poor quality outpatient experience. However, patients told us that nurses and doctors were kind, caring and courteous.

The trust had backlogs of patients waiting for initial and follow up appointments. It did not meet its target for two-week cancer waits, although performance was improving. Managing outpatient capacity was complicated by overbooking and clinical schedules, which did not reflect appropriate consultation times.

Clinical outpatient services lacked regular dashboards to show performance against quality, safety activity and financial indicators. Clinical management group (CMG) level plans were not clear about how they would match capacity with demand for outpatient services. Staff spoke highly about senior leadership and there were effective staff and public engagement initiatives.