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Leeds General Infirmary Requires improvement

Reports


Inspection carried out on 10 – 13 & 23 May 2016

During an inspection to make sure that the improvements required had been made

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

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

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

We inspected the following locations:

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

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

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

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

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

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

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

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

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

Our key findings were as follows:

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

We saw several areas of outstanding practice including:

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

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

Importantly, the trust must:

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

In addition the trust should:

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

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 17-20 and 30 March 2014

During a routine inspection

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

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

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

We inspected the following locations:

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

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

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

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

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

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

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

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

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

Our key findings were as follows:

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

We saw several areas of outstanding practice including:

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

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

Importantly, the trust must:

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

In addition the trust should:

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

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 14, 15, 16, 17 October 2013

During a routine inspection

We visited maternity wards L36, L44, the Delivery Suite, the Maternity Assessment Centre (MAC) and the paediatric and adult Accident and Emergency (A&E) departments, both of which are in the Clinical Service Unit of Urgent Care. We also visited the Child Assessment and Treatment Unit (CAT) to gain their views and experiences of being admitted to the ward from A &E.

We reviewed the care and treatment records of 38 patients; spoke with 51 patients or their representatives and 92 staff. Speaking with staff included the holding of a staff forum which enabled us to elicit staff’s views on patient’s care, the quality of the service and how staff were able to raise concerns or gain feedback on the way the Trust managed the service.

We found that patients received well organised and effective care that they needed in the areas of the hospital we visited. The vast majority of the patients we spoke with were positive about the care and treatment received. Patients using the maternity services said they were well informed on risks and benefits of their treatment and had their choices respected regarding their birth plans.

Patients using the A&E departments were satisfied with their treatment. They said they did not have to wait long to be seen and felt they were kept informed on their treatment and plans for admission or discharge.

These are some of the comments we received:

“We were seen very quickly, we were told what to expect.”

“I’m mesmerised by how nice they all are. They’ve said I can go home soon. We are just waiting for an ambulance to take me.”

“I have had plenty of help and information, everything I needed.”

“The nurse listened and took notice of what I had to say, she seemed very experienced.”

“I think the care is superb.”

“I’ve been well looked after. They’ve given me a cup of tea. They keep checking on me every so often, I think it’s because I’m on my own.”

“The nurses were brilliant and they seemed to really care that I was ok”.

“Staff have been so kind and nice. They were brilliant on delivery suite, so supportive, got me through.”

Patients told us they thought there were enough staff in A&E and maternity services. One patient said, “They all seem to be doing something but there are plenty of staff around.” Another said, “Plenty of staff and all so nice.”

We found that the provider had satisfactory systems and processes in place to manage complaints and quality assurance after recently identifying the need to improve on these areas. We found there were new initiatives in place to make sure patients who complained about the service were responded to in a timely manner. We also saw that a review of quality monitoring systems had taken place to ensure this resulted in the continuous improvement of patients’ care.

Inspection carried out on 3, 4 October 2012

During an inspection in response to concerns

We visited ward L25, a neuro-surgical and spines ward and L34, a day surgery and mixed speciality assessment area (MSAA), spoke with patients, their relatives and staff and reviewed case notes. We also observed the care being delivered. Most of the people we spoke with were positive about their care and about their experience during their time at the hospital. Comments from patients included, “Staff explain what is happening” and another told us “The doctors and the nurses take time to explain everything.” However on L25 patients and their relatives raised concerns about communication and said the ward was busy and sometimes not enough staff. Comments included “I had to ask for medication on three occasions” and “Staff struggle especially on the evening.” We observed staff treating people with respect, being polite and courteous. Patient’s privacy and dignity were respected well.

We spoke with ten members of staff, three ward sisters, two matrons and a divisional nurse. Staff told us patients received good, safe care and their essential needs such as washing, toileting, medication and observations were appropriately met. However, most staff on L25 we spoke with said they were too busy to provide the ‘quality’ of care they would like to give, such as spending more time interacting with people and explaining things better to people. Records showed there were times on L25 when staff were overstretched as it was not always possible to find staff to cover additional shifts.

Inspection carried out on 18 April 2012

During an inspection to make sure that the improvements required had been made

The last time we visited the service in February/March 2012 we found the delivery of care was not always safe and effective and there were often times on wards 53 and 55 when there were insufficient staff. We therefore issued warning notices. The purpose of this review was to see what action the care provider has taken in order to comply with Regulations 9 and 22.

We visited three wards in the hospital during this inspection. Two were orthopaedic wards and one was a cardiology, medical admissions ward. On all three wards visited most of the patients we spoke with were very complimentary about the care and treatment they were receiving. Comments included:

“The doctors are excellent and they explain everything.”

“Nurses look after us.”

“They make sure you get your medication.”

“I have had excellent treatment and I have no concerns.”

“You are made to feel important because they tell you are you are doing really well.”

“Only wait a minute for staff to come if you call them.”

“Staff lovely I would give them 10/10.”

“Staff are prompt and give assurance.”

“When I use my call buzzer I am seen more or less immediately.”

“When I get home I will defend the hospital (had seen recent bad publicity and doesn’t agree with it.) I have had excellent treatment and I have no concerns.”

“The staff are discreet and my dignity and privacy is respected all the time.”

A small number of patients told us they didn’t think there were enough staff on the wards, however they said they were being properly cared for and their needs met. Their comments included:

“Staff are doing their very best, they are young and efficient but there is not enough staff.”

“Pleased with staff but sometimes can take a while to get to me. “Maybe three or four times it has taken 30 minutes to get to me but generally it is within five minutes.”

“Think would benefit from one or two more staff.”

“Ward very busy and sometimes not enough staff but the nurses still check on you.”

“Had no wash this morning could do with one.”

We also looked at survey information on the wards and saw the positive comments patients had made about their care and support. These included:

“All the staff have been fantastic – I can’t thank you enough.”

“I was very impressed by the thorough method used by a cleaner on the ward when cleaning the bed. My confidence and opinion of the ward staff increase as a result.”

“My treatment has been wonderful, efficient and friendly but I still want to go home.”

“All staff were thoughtful and attentive. This experience re-affirms my beliefs in the NHS. The LGI is a great hospital.”

Staff told us during this visit, they felt good care was given to patients. All of the staff we spoke with said they were using new care planning documentation and had been trained to do so. They said that care plans were now more about the ‘individual’ and focussed on how people wanted their care delivered, including the identification of people’s likes and dislikes. Staff also said they were now meeting people’s needs better due to ward re-organisations, better staffing levels and good direction and leadership. Comments from staff included:

“Things are much better recently, the change is great, feel I am fulfilling being a nurse properly.”

“Go home feeling I have done a good job.”

“Enough time now to meet people’s needs properly, better communication with patients, getting to them quicker.”

Inspection carried out on 1 March 2012

During an inspection to make sure that the improvements required had been made

We visited ward 22, which specialises in ear nose and throat surgery, maxillofacial surgery and has six orthopaedic beds, ward 53 (orthopaedics) and ward 55 (orthopaedics) for this visit over a two day period. We spent time observing how care was delivered to people who use the service on these wards. We spoke with a number of people who use the service and staff and we looked at medical and nursing records for some people using the service.

The majority of people we spoke with were, in the main dissatisfied with their care and support, saying this was mainly due to shortage of staffing. Comments we received from people on ward 53 included:

“Staff are slow to answer the call bell. One day I had to wait between 30 minutes and 45 minutes for a nurse to answer the bell.”

“Some staff can be a bit sharp but I think this is because they are so busy.”

“Nurses don’t always have time to explain what is happening.”

“Staff are good but they are very busy and can not spend time with you.”

“Unless you ask they do not tell you what is going on.”

“Staff give good care but they are very busy and always rushed.”

There were a number of times when we observed care that was not appropriate or given in a timely manner on ward 53. People did not receive the assistance they needed at meal times. People’s requests for assistance or reassurance were at times ignored. We saw that people were laid in their beds in undignified or uncomfortable positions and we had to intervene to get staff to attend to people. We saw a person spoken to quite sharply by a staff member.

Staff on wards 53 and 55 told us they were often short staffed and this affected their ability to give people adequate care. They said, they feel rushed, and have no time to interact with people who use the service when short staffed. They said people often have to wait over 30 minutes to go to the toilet and on occasions there is frequent bed wetting and poor personal care given as a result of being short staffed.

People we spoke with said the wards were very clean. Comments included:

“Seems clean, always see plenty of cleaning.”

“Very clean.”

“They clean like maniacs.”

“The ladies then come round and inspect the cleaning.”

“They are pretty thorough.”

“Washing of hands and wearing aprons is standard procedure, they all do it.”

Inspection carried out on 4 August 2011

During a routine inspection

We undertook a simultaneous review of three hospitals managed by the Leeds Teaching Hospital NHS Trust.

As part of our review we undertook an unannounced inspection on 4th and 5th August 2011 of St James’s University Hospital, Leeds General Infirmary and Wharfedale Hospital.

During our inspections we spoke to a number of patients. Most people were satisfied with, and were positive about the care they received. They said they were treated with respect and that their privacy was maintained and their dignity was upheld.

At St James’s University Hospital, people’s comments included, “They always pull the curtains round when dealing with you, “Nurses approach in a very nice way and explain what they are doing. A few don’t and just deal with the necessary care” and “Treated very well”.

At Leeds General Infirmary, people said, “Couldn’t fault the care”, “Staff are cheerful and seem to listen” and “Staff have been very good”.

At Wharfedale hospital we received comments that included, “Have been in a few hospitals, this is one of the best. Staff are polite and friendly. Would choose this hospital in the Leeds area” and “Hospital is first rate, come in regularly, have got to know nurses, they are all very nice.” One person stated that there are more staff than patients. During our visit, we observed staff tending to patients and did not see any issues relating to staffing levels on the ward.

Some staff at St James’s University Hospital and Leeds General Infirmary told us that they did not believe there were sufficient staff at all times and as a result some people do not receive care in a timely way. For other people it was sometimes difficult to ensure their dignity was maintained while receiving care.

At St James’s University Hospital, staff said that at times they could not always manage people’s continence needs and they sometimes had to feed two people at once.

At Leeds General Infirmary one staff member said they felt that patient care suffers due to staffing levels and that as a result beds aren’t made, patients aren’t helped with food and observations are not done. Another said they had worked many shifts where there were only two qualified nurses on the ward in the day time when they have been assessed as needing three for dependency levels. They stated that this affects patient care as the nurses will not get to review pressure areas for every patient on these days and will have limited time to spend with each patient.

Some staff said there were sufficient staffing levels on the ward and that attendance is quite good.

People said they were given good information about their treatment and care and were able to ask questions. They said they felt included in decisions made about their care and were given time to consider any treatment options and procedures.

In the main, people said that hospital staff communicated well with them and that they received their test results in a timely manner.

Some people said they were not always kept informed and were not told when tests such as x-rays or scans would be carried out and sometimes did not know they were going for a test until the porter arrived to take them. One person at Leeds General Infirmary said, “You don’t know from one day to the next when you are having your scan”. Another at St James’s University Hospital said that this lack of information was leading to worry and anxiety as to whether they could go home that day.

From our inspection of St James’s University Hospital, we received comments such as, “They explain everything with courtesy and understanding, from health care assistants to consultants”, “Communication has got better, they have started to communicate more”, “They make themselves available to ask you if you have any concerns or worries, they treat me like an adult” and “They keep you well informed on treatment and such things as medication”.

At Wharfedale hospital people said they had been given enough written information to take home. They said:

“Fantastic, one of the best hospitals I’ve been in”

“Polite, lovely staff – can’t do enough for you”.

People at St James’s University Hospital, and Wharfedale Hospital said they were satisfied with the food and choices available to them. We also saw that people were given the support they needed to eat and drink comfortably.

At the Leeds General Infirmary most people told us that the food was good and that they received plenty to eat and drink. However we did receive some negative comments about the quality of the food. These included, “The food is so so”, “Food could be better” and “There are only 2 decent meals on the menu in a whole week”. Others said, “You can choose what to eat” and “The food is exceptional and I am not easily pleased”.

People told us they felt safe at all three hospitals and security is well managed.

At the Leeds General Infirmary, all the people we spoke to told us that they felt the ward was clean and we received comments such as “The cleaners are always about making sure its clean” and “Staff are very good they are always washing their hands or using the hand gel”.

Similar comments were received at St James’s University Hospital. These included, “Very clean everywhere”, “Very good, very clean, my wife is very pernickety and she has also been impressed”, “Staff look clean and tidy, nice clean overalls, gives you confidence in them” and “The staff always wash their hands, they all do it. You see them rub, rub”.

At Wharfedale Hospital people we spoke with said that they felt the hospital was “very clean” and others said it was “spotless”.

People who use the service were generally very complimentary about the staff at all the hospitals we visited. Most people said there were enough staff to meet their needs. People who use the service at St James’s University Hospital said, “Overall the nurses and physios have been really good. At times they are short staffed. They are stretched and sometimes we’ve struggled to find nurses”, “Staff are polite, they’re nice and look after me well” and “Usually enough staff, can be short on a night”.

At St James’s University Hospital and the Leeds General Infirmary, most staff told us that they didn’t feel they had enough staff at times which could result in people not getting the care they needed. For example, at St James’s University Hospital, staff said, “The managers try their best but there is not enough staff. I do worry. You hear they have to do budget cuts but I fear there is not enough staff and you hope it doesn’t happen on your shift. They have to stop it before something happens. It is a risk. Elderly wards are generally not staffed well”, “We are so often short staffed, I have brought it up but it seems so difficult to get approval for staff cover, I feel budgets are controlling everything, shifts get cancelled, you get sent to cover at other wards” and “Generally there is enough staff. Everyone works really well as a team”. One person said they had been having trouble sleeping. They said they did not feel they could discuss this with nursing staff as they said “They are always too busy”.

At Leeds General Infirmary one staff member said staffing levels had been ‘terrible’ and that low staffing levels caused a lot of stress, that patients would not get washed and pain relief could take a long time to be administered, leading to frustration for patients. They said things were improving as more staff had been recruited recently. Another said they were often short staffed and they felt this is unsafe and means answering call bells takes a long time and nurses miss things or don’t do observations.

At Wharfedale Hospital we spoke with a number of the staff. They told us that there is enough staff “most of the time”. The staff told us that the staff group is stable and has worked together for a number of years. We were told that the staff are flexible and “cover” for each other.