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Leicester General Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 14 March 2018

Our rating of services stayed the same. We rated it as requires improvement

A summary of this hospital appears in the overall summary above

Inspection areas

Safe

Requires improvement

Updated 14 March 2018

Effective

Requires improvement

Updated 14 March 2018

Caring

Good

Updated 14 March 2018

Responsive

Requires improvement

Updated 14 March 2018

Well-led

Requires improvement

Updated 14 March 2018

Checks on specific services

Outpatients and diagnostic imaging

Requires improvement

Updated 14 March 2018

We rated it as requires improvement because:

  • Outpatient services did not always manage patient records effectively. Patient records were not always available for clinics, the quality of some records was poor and we saw staff did not always write patients records in a way that met national guidelines. The inspection team were concerned about the cleanliness of clinic one due to poor audit scores and the inspection team finding dust in high level areas.
  • Patients experienced long waiting times for some clinics. This was an issue we found on our last inspection. In addition, we saw the trust consistently did not meet the cancer 31 day and 62 day targets (however, performance was improving in these areas). Data from the trust showed 25,863 patients were potentially overdue requiring a follow up appointment, 7,108 had been waiting over seven months.
  • Governance arrangements for outpatient services were complex. This meant multiple clinical management groups (CMG) and structures were involved delivering outpatient services. This led to inconsistencies in practice, performance and some concerns around a ‘them and us’ culture between staff in different CMGs. This contributed to some issues we identified in our last inspection not being addressed for example, clinic waiting times. We heard examples of staff not being supported by senior managers.
  • Staff had challenges with the local environment. The lack of clinic space and design of the environment meant we saw an example of staff compromising patient dignity to conduct pre clinic observations (height, weight and blood pressure checks). In addition, we saw staff had to store clean and dirty linen in a corridor and had a lack of office or changing space.
  • Leaflets, signage and information were mainly in English. This included pre-appointment letters outpatient services sent to patients. We observed non-English speaking patients having difficulty finding where there appointment was.
  • While staff collected the views of patients we saw little evidence managers analysed, responded and improved services because of patient feedback. You said, we did posters on walls did not provide any information on actions take in response to patient concerns. Response rates to feedback initiatives such as message to matron were low.

However:

  • We found the diabetes clinic to be an example of outstanding practice. The service was completely multidisciplinary with clinics and care plans centred around the patient. Patient could access different types of clinical and lifestyle advice from different clinicians and therapy staff. The clinic environment was bright, clean and modern which made patients feel comfortable. The service also undertook teaching other staff in the hospital and delivering clinics out in the community. The service demonstrated positive patient outcomes and based their services on National Institute for Health and Care Excellence (NICE) guidance and standards.
  • Staff assessed the nutrition and hydration requirements of patients. They also assessed pain levels during procedures and examinations. Staff also said they received meaningful appraisals and spoke positively about training and development opportunities. Staff were competent in their roles and understood their roles and responsibilities regarding consent and the Mental Capacity Act 2005. We saw staff try to meet the needs of patients wherever possible including those with a learning disability or those living with dementia.
  • Staff demonstrated knowledge about safeguarding and understood their responsibilities when protecting patients from avoidable harm and abuse. Staff demonstrated good practice regarding hand hygiene and trust audits for the period August 2017 to November 2017 showed staff scored 100%. Staff managed medicines in safe way and also had procedures to manage the treatment and care of deteriorating or seriously unwell patients. Staff were caring, compassionate and involved patients in their care and treatment.
  • Outpatient services had oversight of performance and risk. Despite poor performance in some areas outpatient services could assess the risk to patients for example, staff conducted harm reviews on patients overdue for their appointments. We saw outpatient services were committed to continuous improvement including setting up an outpatient transformation programme and developing efficient patient pathways. Leaders were proud of their staff.

Maternity and gynaecology

Good

Updated 14 March 2018

However:

  • The service did not always control infection risk well. In the obstetric theatre the premises and some equipment was not kept clean or monitored regularly.
  • The service did not always use safety monitoring results. Senior staff collected safety information, but sharing with staff, women and visitors was limited. The information collected was not rated for comparison to national data. However, the service used elements of the information to improve the service.
  • The service did not always store medicines well. Medicines were stored in areas accessible to members of the public, and although fridge temperatures were checked, staff did not act on out of range temperatures. However, staff prescribed, gave, and recorded medicines well. Women received the right medication at the right dose at the right time.

Medical care (including older people’s care)

Good

Updated 26 January 2017

We rated medical care services as good overall.

Safety of medical services was rated as requires improvement. Patients were at risk of not receiving the correct treatment in a timely manner. Nursing staff were not consistently adhering to trust guidelines for the completion and escalation of early warning scores (EWS); frequencies of observations were not always appropriately recorded on the observations charts and medical staff had not always documented a clear plan of treatment if a patient’s condition had deteriorated. Where patients had met the trust criteria for sepsis screening, not all patients were screened appropriately.

Potential risks to medical care services were anticipated and planned for in advance. However, not all staff were aware of the arrangements in place to respond to emergencies and major incidents.

There were systems, processes and standard operating procedures in infection prevention control, records, medicines management and maintenance of equipment which were mostly reliable and appropriate to keep patients safe. Patients were protected from abuse and staff had an understanding of how to protect patients from abuse.

We rated medical care services in effective, caring and responsive as good.

Care and treatment was planned and delivered in line with current evidence based guidance, standards, best practice and legislation and patients received effective care and treatment. Where outcomes for patients were below expectations when compared with similar services action plans had been put in place.

Patient’s symptoms of pain were effectively managed in both ward and department areas with good comfort outcomes for patients in endoscopy. Staff were proactive in assessing the patient’s nutrition and hydration needs.

We observed staff positively interacting with patients and patients were treated with kindness, dignity, respect and compassion while they received care and treatment. Feedback from patients was consistently positive about the care and treatment they had received.

Medical care services were mostly responsive to patient’s needs; patients could access services in a way and at a time that suited them and there was a proactive approach to understanding and meeting the needs of individual patients and their families. However, referral to treatment times (RTT) for the cancer standards and access to diagnostic tests were worse than the England average.

We rated well led as good.There was a vision and strategy for this service and whilst it was very strategic staff were able to describe this to us during our inspection.Staff were consistent in delivering care and demonstrating behaviours in line with the trust vision and strategy.Staff reported good nursing leadership from their line managers and matrons of the service. Nursing staff felt ward sisters, matrons and heads of nursing were visible and provided a good level of support.

Diagnostic imaging

Requires improvement

Updated 14 March 2018

  • There was a good reporting culture within the imaging departments. Radiation incidents were well managed and thoroughly investigated.
  • We saw excellent working relationships between the staffing groups within the imaging and medical physics departments.
  • All patients we spoke to spoke positively about the care they had received in the department and told us they had received reassurance and support whilst using the service
  • Image report turnaround times were good despite the numerous IT issues the trust had experienced. The imaging department had reduced its reporting backlog from over 12,000 waiting over eight weeks for a report to less than 2,000 in five months.

Surgery

Requires improvement

Updated 26 January 2017

We rated surgery care services as requires improvement overall

Safety was not a sufficient priority, for example the delay in recognising and reporting a never event. Staff did not always recognise concerns, incidents or near misses for example not reporting missing medical notes, or the lack of computers in theatre.

Venous thromboembolism (VTE) assessments were not  reviewed after 24 hours for patients preparing for surgery.

Staff were unaware of the correct use of the Mental Capacity Act (MCA) 2005 and the Deprivation of Liberty Safeguards (DoLs) when caring for patients in vulnerable circumstances.

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 anaesthesia.

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

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

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.

There was strong local leadership with staff respecting line managers and feeling supported in their roles.

Intensive/critical care

Good

Updated 26 January 2017

We rated critical care services as good overall.

Safety thermometer data showed there was a high incidence of harm free care delivered to patients. We saw that evidence based best practice guidance was being used to determine care.

We saw patients, their relatives and friends being treated with dignity and respect. Staff demonstrated that they understood the impact of critical care on people and their families both socially and emotionally.

There was a vision and strategy for the reconfiguration of critical care service at Leicester General Hospital despite the current hold on progress being made as a consequence of financial pressures.

There was an effective governance structure in place which ensured that risks were recognised and discussed including mitigating actions, timescales and ownership.

There had been a delay in the timely reporting of a recent never event. Not all the staff on duty on the day of the inspection were aware of the never event and the subsequent changes to practice.

The environment fell short of the current Health Building Notes (HBN 04-02) for critical care.

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There was a delay in patients being transferred out of critical care when their condition improved. The critical care outreach service was not provided 24 hours a day, seven days a week.

End of life care

Requires improvement

Updated 26 January 2017

We rated end of life care services at the Leicester General Hospital as requires improvement. We rated responsive and caring as good with safe,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 12 ‘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 12 DNACPR orders, six were completed correctly (50%). 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).