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Inspection Summary


Overall summary & rating

Good

Updated 15 February 2019

Our rating of services improved. We rated it them as good because:

  • The emergency department demonstrated effective patient flow with dedicated staff utilised for handover of patients
  • Critical care services in particular were rated as outstanding overall with significant improvement since our last inspection.
  • Mandatory training compliance for nursing staff was higher than the trust target of 80% in most modules across services
  • We observed good practice of infection prevention and control (IPC) in most areas. On all wards we visited there were either low numbers or no reported infections of methicillin resistant staphylococcus aureus (MRSA), clostridium difficile (C.Diff) or methicillin susceptible staphylococcus aureus (MSSA)
  • Although staffing levels in some services did not meet the optimal target set by the trust; staff skill mixes had been adjusted to mitigate this risk and ensure safe and effective care.
  • We saw evidence of good collaborative working with external partners including local NHS ambulance services, local authority, the local NHS children’s hospital and Mental Health services
  • Services were caring with support available for patients who became distressed and an understanding demonstrated of the emotional impact of care and treatment upon patients and relatives
  • Services were responsive with processes in place at clinical service unit level to plan services to meet patient’s needs

However:

  • Mandatory training compliance for medical staff in some services did not achieve the trust target of 80%
  • Patient records and substances hazardous to health were not always securely stored in all services
  • Ligature points were observed in the mental health room on the emergency department
Inspection areas

Safe

Requires improvement

Updated 15 February 2019

Effective

Good

Updated 15 February 2019

Caring

Good

Updated 15 February 2019

Responsive

Good

Updated 15 February 2019

Well-led

Good

Updated 15 February 2019

Checks on specific services

Medical care (including older people’s care)

Good

Updated 15 February 2019

Our rating of this service stayed the same. We rated it as good because:

  • The services were safe because there were systems in place to ensure staff completed mandatory training and safeguarding training. Nursing and midwifery staff met the trust target of 80% for 13 of 15 mandatory training modules and three of the seven safeguarding training modules. Medical staff compliance was met for 11 of 19 mandatory training modules and one of the seven safeguarding training modules. In most cases where the module was not met it was just below the 80% target. The trust was working to achieve better compliance as the year progressed.
  • The ward environment was visibly clean with good infection control: in the wards we visited for the period August 2017 to August 2018 there were no or low cases of methicillin resistant staphylococcus aureus (MRSA), clostridium difficile (C. diff), or methicillin susceptible staphylococcus aureus (MSSA). The environment was clutter free overall, wheelchair accessible and with enough equipment for staff to perform their role.
  • Nurse staffing was managed using recognised tools and professional judgment. Staff had access to records which were stored securely. Medicines, including intravenous fluids, were stored and managed safely. Staff knew how to report incidents and tools such as the safety thermometer and ward metrics were used to keep patients safe.
  • The services were effective because processes were in place to ensure that guidance used by staff complied with national guidance, such as that issued by National Institute for Health and Care Excellence (NICE). Patients’ food, hydration and pain management needs were met. The service used audits within the specialities we visited to improve patient outcomes. Staff received training to ensure they were competent and this was supported by practice educators. Staff worked effectively as a multi-disciplinary team and had good knowledge about consent and mental capacity.
  • The services were caring, with response rates in the friends and family test better than the England average. The inpatient score for recommending the service to friends and family from May 2017 to April 2018 was 90%. Staff supported the emotional needs of patients and could, for example, signpost to organisations for support. Staff tried to understand and involve patients and their carers where it was safe to do so.
  • The services were responsive, with a process in place at clinical service/support units (CSU) to trust level to plan services. Wards had link nurses to champion the needs of patients with additional needs. Wards used various approaches to respond to challenges with access and flow including use of flow co-ordinators. The service was responsive to complaints and had made changes to services, such as the creation of stroke buddies.
  • The senior leadership team running the specialities were visible, approachable, and responsive and worked as a cohesive team to promote a positive culture. The trust had clear governance processes in place to drive patient safety forward; these were implemented and monitored at CSU level. Staff and the public were engaged through meetings and surveys. The specialities we visited had access to performance dashboards to help monitor patient sensitive indicators and act when necessary. The specialities we visited all had examples of innovation, learning and continuous improvement.

However:

  • Staffing levels on the hyper acute stroke unit (HASU) did not meet applicable national guidelines. However, mitigating actions were in place to keep patients safe, including drawing in additional staff, when patient acuity required it.
  • For medical non-elective patients, the average length of stay was 7.1 days, which was longer than England average of 6.4 days. Average length of stay for non-elective patients in cardiology and neurology was shorter than the England average while in stroke medicine it was much longer (21 versus England average of 10.6). Staff were aware that availability of beds in the community was a driver of increased lengths of stay and were liaising with commissioners to resolve this.
  • Trust performance in some of the national audits, for example around falls, was below national targets albeit the trust had an action plan in place to improve performance going forward.

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.

Critical care

Outstanding

Updated 15 February 2019

Our rating of this service improved. We rated it as outstanding because:

  • We rated caring and well led as outstanding. Safe, effective and responsive were rated as good.
  • Significant work had been undertaken within the service since the last inspection. The areas identified as requiring improvement had been a focus, alongside staff wellbeing and patient centred care delivery.
  • Nursing and medical staff met or exceeded trust expectations for mandatory training and staff demonstrated a good understanding of safeguarding and mental capacity.
  • The critical care outreach team had expanded and provided a twenty-four-hour, seven day a week service. Nurse staffing was in line with Guidelines for the Provision of Intensive Care Services (GPICS) recommendations.
  • Reliable systems and processes were in place for the management of medicines, patient records and monitoring, assessing and responding to risk.
  • Patient outcomes were in line with, or better, when compared to similar units. Care and treatment was evidence based. The units were continually working to improve their services based on data and best practice.
  • There was effective monitoring of sedation and delirium and the nutrition and hydration needs of patients were consistently met.
  • There was significant focus on the training and development of staff at all levels within the service.
  • Feedback from patients and families was consistently positive. We observed compassionate care delivery and a drive to deliver individualised patient centred care.
  • A critical care patient flow team had been established and an online system based on clinical emergency medicine books (CEM books) had been developed. This enabled oversight of access and flow and supported risk based decision making.
  • The psychological needs of patients were considered in all aspects of care and we found care to be individualised with carer involvement.
  • We observed a strong, visible leadership on the units supported by clinical leadership.
  • The team had developed a strong vision and strategy with clear system to support and monitor its delivery.
  • Governance processes were embedded and there was effective risk management in place.

However:

  • The service did not meet the GPICS standard of 50% of nursing staff having a post registration certificate in critical care.
  • Pharmacy provision did not meet GPICS guidance.

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.

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.

Outpatients and diagnostic imaging

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.

Surgery

Good

Updated 15 February 2019

Our rating of this service improved. We rated it as good because:

  • The service had escalation policies, guidance and care pathways for deteriorating patients. We saw national early warning scores (NEWS) and observations were calculated and escalated in line with trust guidance. Resuscitation trolleys we viewed had tamper proof seals, with few exceptions were regularly checked, and all equipment was found to be in date.
  • The service had systems in place for the identification and management of adults and children at risk of abuse. Key mandatory training target compliance rates (including those for safeguarding training) were often surpassed or close to being met for nursing staff. The service had systems in place for reporting, monitoring and learning from incidents.
  • National audit outcomes were typically good or showed improved performance. Patient reported outcome measures at the trust were similar to national averages.
  • Surgical service bed occupancy and theatre utilisation rates were high. Overall, there was a lower than expected risk of readmission for non-elective admissions compared to the national average. 18-week referral to treatment time (RTT) for admitted pathways for surgery at the trust was similar to or better than the national average. There was a relatively low proportion of delayed discharges within the service.
  • Clinical service groups (CSUs) had stable management structures in place, with clear lines of responsibility and accountability. We saw considerable evidence of learning, continuous improvement and innovation within surgical services at the location.

However:

  • Medical staff did not achieve compliance targets for level two resuscitation training and advanced resuscitation training modules, and higher-level safeguarding training targets were not attained.
  • We observed good use of the WHO surgical safety checklist during our inspection. However, audit data for the location showed low team brief and de-brief compliance. Data also showed variable compliance with blood clot risk assessment (within 24 hours of admission) across surgical service areas at ward level.
  • We found patient records and substances hazardous to health were not always securely stored on wards.
  • From April 2016 to March 2018, the percentage of patients whose operation was cancelled and were not treated within 28 days, and the percentage of cancelled operations as a percentage of elective admissions, were consistently higher at the trust when compared to national averages. Vascular surgery and spinal surgery patients had a higher than expected risk of readmission for elective admissions when compared the national average.

Urgent and emergency services

Good

Updated 15 February 2019

Our rating of this service stayed the same. We rated it as good because:

  • The emergency department’s culture was positive. Staff we spoke with felt valued, appeared happy and enthusiastic and spoke positively about working in the department.
  • Our observation of the emergency department showed patient flow was effective. Dedicated staff were utilised for ambulance handover which contributed to maintaining effective patient flow.
  • The mental health liaison team provided cover within the department 24 hours a day, seven days a week.
  • The department supported patients who become distressed. Medical and nursing staff clearly understood the emotional impact of the patients’ care and treatment potentially had on the patient’s and their relative’s overall wellbeing.
  • The department utilises incident reporting and incorporates learning from incidents within the departmental culture.
  • Staff applied safeguarding procedures for adults and children appropriately supported by the safeguarding lead, a senior member of nursing staff so that patients presenting with complex safeguarding needs were safely protected from abuse.
  • Personal development reviews included interaction to support the staff member’s development and an action log was completed and signed within two weeks of the appraisal. A structured induction programme was in place for new staff which encompassed supernumerary work and a preceptorship.
  • Collaborative working with external partners was effective and included arrangements with the local NHS ambulance service, the local authority and the local NHS children’s hospital to increase staff knowledge and experience.

However:

  • The Department of Health’s standard for emergency departments is that 95% of patients should be admitted, transferred or discharged within four hours of arrival in the emergency department. From July 2017 to June 2018 the trust failed to meet the standard and performed generally worse than the England average.
  • The emergency department participated in the national RCEM audits to benchmark its practice, results of audits were beneath the level required, however, they scored highly when compared to other trusts.