Nuffield Health Leeds Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Staff within the surgery teams told us patient safety was a priority, and people told us they received care and treatment that made them feel safe. Leaders ensured there were enough skilled people to deliver safe care. All staff understood safeguarding processes. Medicines were safely stored, administered and managed. The service had a culture of learning and improvement. However, safety was not always a priority. Solutions to risks were not always developed collaboratively. Risk concerns reported by staff were not always acted upon. The environment was not always safe. We found breaches of regulation in premises and equipment, safe care and treatment and good governance.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Most of the people we spoke to during inspection felt able to raise concerns although had no experience of raising concerns.

Staff we spoke with told us they knew how to raise incidents and concerns and they did this as needed. Staff told us that learning from incidents was shared. Staff told us there were weekly safety meetings and information would be shared from these meetings.

Leaders told us there had been recent training provided through a lunch and learn session regarding reporting of incidents. Sessions were available for all staff to attend. These sessions were in addition to mandatory training to support additional learning where needs were identified. There was no guarantee that all staff would be able to attend and we saw a range of attendance levels for different sessions. We saw that where session attendance was low the session could be repeated and additional information shared through team meetings. For example, we saw attendee numbers for a recent incident reporting session were six. A further session had been booked to reach more staff. We saw this topic was also followed up through team meetings.

Some staff told us about incident reports that had been raised over a number of months regarding safety that had not been responded to in a timely way and risks had not been dealt with. For example, multiple concerns had been raised regarding the safe use of a set of theatre doors. There were concerns regarding infection prevention and control risk and a risk of injury to staff and people using the service due to poor repair of doors.

Processes were in place to report incidents through an electronic incident report system. Incidents were reviewed by one of two identified members of the senior leadership team who would determine if the incident was rated appropriately. Learning was identified through review of reported risks. We saw meeting minutes demonstrating increasing concern regarding haematomas. Following a number of reported incidents we saw a clear need to change practice was identified. Interim changes were shared with staff whilst waiting for the proposed changes to be presented to the Medical Advisory Committee (MAC) for agreement. We saw that Duty of Candour processes were followed. We observed a weekly safety meeting with members of the senior leadership team on two consecutive weeks. We reviewed notes from safety meetings where incident reports for the past week were reviewed. There was no clear documentation regarding how actions would be taken forward from this meeting. Team meeting notes made reference to concerns and incidents reported, however, we saw no evidence within team meeting minutes regarding clear follow on actions. For example, one set of team meeting minutes identified that there were 'issues with allergies being reported late or not at all'. It was recognised that a more robust system was needed. We did not see clear evidence of how this would be taken forward. Complaints that also met criteria for incidents were not recorded as incidents. We were not assured, therefore, that incidents and complaints were always appropriately investigated or reported.

Staff told us people were reviewed by the same Consultant pre and post operatively. People using the service whom we spoke to confirmed they had a named consultant throughout their care. We also heard that peoples wound care would be reviewed by the consultant should there be a need for review up to three months post operatively.

Physiotherapists were involved from pre-assessment stage to support discharge planning and follow up care.

We observed a daily ward multidisciplinary team (MDT) meeting. This included a nurse in charge, physiotherapist, housekeeper, hostess and pharmacy assistant. We observed each person on the ward was discussed including any expected admission.

Staff told us about weekly patient safety meetings within surgery. We heard that people with co-morbidities would be taken into consideration as regards the support that might be required post-surgery. We reviewed meeting minutes that demonstrated there was a process in place for known risk information to be discussed and acted on.

Staff told us there were times when information was not always available within pre-assessment. However, safety would be prioritised and information sought before people progressed to surgery. We reviewed incidents and found a number of incidents where incorrect patient details, such as date of birth were documented, or patient stickers did not match patient details. Incident reports identified that staff had identified the issue before progressing to treatment through use of pre-operative checking processes.

Staff explained clear processes for transfer to the Critical Care Unit (CCU). Patients were routinely transferred there following cardiac surgery.

Staff told us there was a resuscitation huddle that happened twice daily. This allowed for roles to be allocated to staff for each shift to ensure continuity of care when individual needs changed.

Nursing and medical staff were clear on circumstances when a patient may require transfer to the local acute hospital.

There were clear systems for ensuring review by responsible medical officers (RMO). There were always two RMO’s on site. The RMO’s we spoke to were clear about their role within the hospital.

Feedback from a referrer was positive and identified timely information was shared. However, we also saw from incident reports that some letters were returned from General Practitioner (GP) surgery’s because letters had been sent to incorrect GP’s. This was monitored and there was recognition that numbers were proportionately low.

Patients had a detailed care record. These records provided information to the clinical team to ensure provision of treatment and care reflected the patients individual clinical needs.

There was a standardised discharge criteria in place for the MDT to determine when patients were ready for discharge.



We saw staff had identified ward rounds did not always take place at weekends and were aware that these needed restarting.



We saw staff had raised concerns regarding discharge letters being saved in different places making this difficult for admin staff to find and process. There was no evidence that staff were following a clearly documented pathway for completing and saving discharge letters.



There was an up-to-date process and service level agreement for transfer of care to the local NHS organisation should an increased level of critical care become necessary. There were transfer forms in place to be used that were supported by the West Yorkshire Critical Care and Major Trauma Operational Delivery Networks.

People we spoke to felt safe at each stage of their care journey.

All staff we spoke with understood safeguarding policies and processes and were able to articulate particular vulnerable patient needs. Staff were also provided with flow charts to guide them, when making a safeguarding alert. Ward staff were able to provide examples of safeguarding alerts they had raised and how patients had been protected from risk of abuse or harm.

The provider had developed a policy which referenced appropriate child and adults safeguarding process. This was in line with intercollegiate guidance. At the time of inspection the clinical director was the designated lead for safeguarding within the hospital.

During inspection we reviewed compliance figures for individual departments and saw compliance targets had not been met. We saw safeguarding level 2 adults training compliance was 64% and Mental Capacity Act training was 76%. Following inspection, the provider submitted data to show compliance levels had improved. We reviewed mandatory training compliance figures for staff across all departments and saw compliance met with the organisations target of 90% for level 2 and 3 of safeguarding training. Safeguarding awareness was also covered as part of induction training. Safeguarding alerts were also discussed as part of ward meetings.

Patients we spoke to felt they had been fully informed regarding their planned care. Patients had access to information within the pre-assessment areas regarding advice on staying well for surgery.

We saw pre-operative advice leaflets were provided to patients with basic advice on how to look after yourself pre and post operatively. There were QR codes within the leaflet for more detailed information to be accessed.

Patients on the wards were able to access help if they had concerns through use of call bell systems.

Staff told us about processes for escalation of patients. There was a nationally recognised system in place based on clinical assessment of patients to determine level of deterioration.

We saw from team meeting minutes that staff recognised improvements were needed in ensuring all risk information was gathered from patients in a timely way as described in the section below. We also saw one Doctor reported to have lost faith in the escalation process. However, we did not see clear processes for ensuring the implementation and monitoring of change.

We were told alert cards were issued for patients prescribed blood thinners. These were for patients to carry to alert other healthcare professionals.

We saw evidence of nationally recognised risk assessments in patient notes including for falls, nutrition, pressure ulcers and VTE (venous thromboembolism). We saw that risk assessment documentation was available in a document for staff to complete. We reviewed four patients records and saw these were fully and appropriately documented. We also reviewed the NEWS (National Early Warning Score) and VTE audit scores on the inpatient ward for the last six months and saw consistently high scores. However, on review of incidents reported we saw evidence of concern regarding a NEWS score that had not been followed up and a further concern of a score not recorded where no observations had been taken within the recommended timescales.

We reviewed further audits and saw there had been some non-compliance with documentation within pre-operative assessment, including for example, falls risk assessments. We saw actions to speak to staff, however, there was no date to complete the action and these actions had not been marked as completed on the departmental audit spreadsheet provided.

We were not assured that follow up actions always took place with staff to ensure that all patients were invovled fully in managing risks.

We reviewed feedback from people through patient feedback. Most feedback identified patients had a positive experience. The building was accessible by steps and ramp. Lifts were accessible from reception for all floors. The reception desk was obvious and patients were immediately directed to the appropriate part of the building where there were sufficient seating areas. Limited seating was available within the main reception area. There were seating areas near to lifts on each floor that had patient areas.

The wards were accessible and spacious. Patients had private rooms with accessible ensuite wet room facilities.

Theatre staff told us incidents had been reported regarding the safety of doors within theatre and occasions when lifts were not working. Staff were not aware of risk assessments in place to mitigate such risks. Staff told us they regularly reported risks regarding the environment through the appropriate incident reporting system. We saw evidence of risks reported, for example, staff injury and a near miss of injury to patient under anaesthetic due to disrepair of doors in theatre. Staff expressed frustration at the lack of visible action over prolonged time periods to resolve issues that posed a risk to staff and patients. Staff also expressed concern that senior leaders were not fully cited on the continued risk to staff and patients due to limited awareness of how the risks impacted day to day working. During inspection we asked for risk assessments regarding the theatre doors and safety concerns raised to us. Staff and leaders were not able to provide all risk assessments. There was a lack of shared oversight and management of risks related to environmental safety between staff and leaders. Risk assessments regarding non compliant fire doors were completed and provided on site.

The environment in all areas we visited was observed to be tidy and organised. However, the building was dated and there were doors in need of repair on some patient bedroom areas. For example, some doors did not fit correctly and one patient had asked for the bedroom door not to be closed fully due to concern that it might get stuck and the patient would be unable to open it independently.

We observed that three sets of fire doors leading to ward areas did not fit correctly. We raised this with senior leaders during the inspection. There were no risk assessments immediately available that demonstrated awareness or risk mitigation of these risks. We also heard from staff that not all lifts were functioning. We asked for evidence that all staff were aware of risk mitigations and actions to take in the event of an incident such as fire. Records could not be located to evidence this training. Incident controller training was provided to staff whilst we remained on site. Risk assessments were completed and provided whilst we were on site.

We observed theatre doors that were taped around the edges to prevent framework falling off.

We saw daily checks of all equipment had taken place. Appropriate resuscitation equipment was available and checked accordingly in each area we visited.

We found some storerooms and clean utility cupboards were not locked.

We reviewed incidents and found 7 incidents reported since January 2023 to the time of inspection regarding concern over unsafe theatre doors. These included injuries to staff and near miss of a patient when a part fell from the top of the door. We also saw that the doors had been identified on the risk register since 2017. There was an action following an incident in September 2023 stating the doors were to be looked at. At the time of inspection there was no risk assessment with mitigations or actions to be taken to minimise the known risk. We also saw repeated incident reports regarding functioning of lifts. This was raised to leaders at the time of inspection. There was no assurance of effective arrangements to maintain the safety and upkeep of the premises. There were known risks and repeated incidents recorded regarding the same risks. Staff and patients were at risk of repeated harm.

Feedback from people demonstrated they felt there were enough skilled staff to meet their needs. Feedback provided to us by people included ‘the care has been really good, I’ve had positive interactions with staff and the nurse comforted me when I came in for surgery’ ’brilliant care’.

Staff told us staffing levels were reviewed on a daily basis. Staff told us if patients required additional 1:1 support this could be accommodated within the staffing numbers. Critical care unit (CCU) staff told us that there was always one staff member on shift even when the unit was empty. We heard that a second staff member would be available to call in.

We also reviewed staffing levels on the inpatient ward and saw a 1:6 patient to staff ratio. On the children's ward it was 1:4, which met with safer staffing levels given the acuity of the patients.

Nursing staff told us that all new staff would have an induction, during this time they were super-nummery, and the induction would be tailored to meet their needs depending upon previous experience. We reviewed the induction and saw it was detailed and could be tailored to specific roles.

Practice educator and assessor training was available for staff to complete. This was made available in addition to mandatory requirements and supported staff in keeping up to date with for example the New Nursing Standard Framework. Non attendance was monitored and managed by the heads of department and we saw effective oversight of this system.

Nurses working on the inpatient ward were allocated additional roles, for example spinal and cardiac specialist. The requirement to continue learning was part of the providers employment contracts and we spoke with several nurses whom had all been supported to extend their clinical skills. Staff told us the provider offered frequent opportunities to extend their clinical skills and support with new courses was continuous.

We met with one of the nurse educators who provided a list of courses for staff to undertake. These included mandatory training and additional courses. We also saw a number of in house training sessions, which were delivered by existing staff. Training was offered as lunch time sessions to enable as many staff to attend as possible.

However, we saw some challenges with the providers nationally facilitated training. We saw a long list of staff waiting for courses such as resuscitation. Staff told us they were unable to book onto these as they were often oversubscribed due to small numbers of slots available. Staff expressed frustration at these lengthy delays, as it impacted their overall training compliance figures.

Staff described appropriate processes in place to ensure there were enough qualified, skilled and experienced people to provide safe care. Staff described effective support, supervision and development opportunities.

Patients we spoke to told us that infection prevention and control (IPC) was discussed with them before and after their surgery. A patient told us that they were provided with a post-surgery package, which the IPC nurse explained how to use to prevent infection.

Staff worked to ensure infection and prevention control measures were in place and escalated concerns regularly and when appropriate. Staff told us that estates issues were impacting on some of the IPC audit results. These were identified as a source of concern and frustration. Staff used initiative to manage these concerns on a daily basis.

Staff were able to access IPC policies and guidance.

All departments including waiting areas and corridors were visibly clean. Hand gel was available at each doorway. Areas accessed by children had hand sanitiser stations placed lower down and obviously marked for children to use. Housekeeping staff were active throughout the ward areas.

The provider had appointed an IPC lead, who held overall responsibility for audit completion and the submission of audit results. We saw the provider participated in several infection prevention and control audits, supported by action logs following completion. On a daily basis heads of departments were required to undertake daily compliance checks lists, which focused on the visible cleanliness of the departments. A further monthly audit was completed, and a department was selected at random by the IPC lead, to ensure compliance was met. The provider also participated in the national cleaning standards audit and had volunteered to be be part of the national pilot within the organisation, by way of improving standards across the hospital. This audit covered a number of areas such as the checking of equipment, linen, lighting and replenishment of consumables. We saw audits in some areas some as theatres, scored consistently low, due to a number of estates concerns. These included damaged doors and flooring, which impacted on the ability to ensure the areas were clinically clean. We saw repeated low scores as a result of these issues, despite regular escalation by the IPC lead. We reviewed emails sent by the hospital IPC lead chasing outstanding work overdue for completion. Staff however continued to drive improvement, and demonstrated a commitment to ensure infection prevention and control measures remained a priority.

We observed hand hygiene audits on the inpatient ward and saw these were 86% for quarter one and again for quarter two slightly below the providers target of 90%.

People received their medicines as prescribed, and discharges were completed in a timely manner. Members of the pharmacy team ensured wards were stocked to appropriate levels and patient’s drug cards remained on wards to prevent disruption to drug rounds. Incident logs showed that where drug errors were made there was not always immediate learning.

Patient’s regular medicines were prescribed during their stay and checked by a ward pharmacist daily.

Resuscitation trolleys were available on wards and checked routinely by staff in case they were needed for an emergency.

Discharges were processed pre-emptively, once the pharmacy team were made aware of a patient’s discharge date.

Out of hours medicines cupboards were used for frequently prescribed medicines, so discharges could be completed at ward level rather than having to go to pharmacy outside of normal working hours.

Incidents were reported using an online logging system, so staff could be educated on any recent events, and these could be investigated.

Staff told us they were still using paper drug cards to administer medicines from, rather than an electronic system. This posed a risk as some of the drug names were hard to read and could be misinterpreted as something else. Ward staff also told us they had a good relationship with the pharmacy team and the wards always had a pharmacist available to complete medicines reconciliations and process discharges efficiently.

Staff told us they had a good relationship with the pharmacy team and could rely on them for help if needed.



Pharmacists completed discharges for patients in a timely manner at ward level.

Pharmacists expressed they would prefer an electronic drug administration system, as the current drug cards are hard to navigate and there is nowhere to sign for a daily clinical check.

The pharmacy department worked core hours with an on-call pharmacist available out of hours.

We were told staffing had improved from last year, and this had benefited the efficiency of the service.

The pharmacy team were supported and encouraged by leaders to do further training or education.

We observed helpful staff that worked well together within a team. Medicines were stored appropriately and safely within the wards. Resus trolleys were available and checked routinely. Staff knew where these were located in the event of an emergency.

Medicines were kept in locked cupboards and fridges within clinical rooms which needed keypad access to enter.

Appropriate stocks of medicines were kept on each ward and staff informed us they didn’t have problems accessing more from pharmacy if needed.

Pharmacy staff were seen to be completing ward ‘top-ups’ so levels of medicines would be available for staff on wards.

Patient records were kept neatly in folders by room number and were tidied away once used. The care pathway booklet where the patient’s drug history was documented stayed with the patient throughout their stay, to ensure it was easily located if needed.

The medicine administration records we looked at weren’t always clear and some handwriting was illegible. This could lead to a risk of patients receiving the incorrect drug or dose.

The pharmacy team showed us how they use an electronic calendar to display when audits are due. They also use a central temperature logging system which ensures medicines were kept in appropriate environments. Near miss logs were shown to educate staff to minimise the risk of these errors happening in future. As the hospital had a fast turnover of patients, routinely most people stayed between 24 and 36 hours, discharges were done in advance at ward level. This avoided the unnecessary need for drug cards to go to pharmacy to be dispensed and made the discharge process faster.

Temperature logs for clinical rooms and medicine fridges were documented automatically on the central electronic system. This notified pharmacy if the temperatures went out of range.

Controlled drug stock checks were routinely completed by two members of staff.

Venous Thromboembolism (VTE) risk assessments were carried out pre-operatively to ensure patients would be prescribed the correct anticoagulant during their stay.

During the inspection, we did not see any documented missed doses on patient’s drug administration records.

Audits and near miss logs were regularly reviewed by staff to ensure education between teams.