Leeds General Infirmary

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people's care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence. We rated this key question as Requires Improvement.

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This service scored 58 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication. We saw on the maternity assessment centre that women were assessed and their care prioritised using a red amber green scale. Generic risk management plans were available, and personalised specific to women's needs such as pre-eclampsia and reduced fetal movements were used. We saw staff work together effectively to ensure women were continually assessed throughout their journey, despite the operational challenges. People’s communication methods were outlined within their care plans to enable them to receive care and treatment which worked for them.

However, some patient feedback we reviewed stated that some women told did not always feel involved in the planning and reviewing of their care as they would like to be, as staff were so busy.

The service followed both National Institute for Health and Care Excellence (NICE) guidance and the Royal College of Obstetricians and Gynaecologists (RCOG) guidance. We saw relevant clinical guidance available to staff in both paper and electronic formats with key safety issues such as escalation protocols clearly visible and display.

All policies we reviewed were found to be in date and were subject to regular review. We also reviewed a range of individual procedure guidelines that were underpinned by up to date evidence based practice and reviewed at regular intervals by appropriate team members.

Staff were encouraged to attend national events such as conferences to further enhance clinical practice and ensure staff followed best practice. We saw the preterm midwifery team were a recipient of a patient safety award from a national health publication. Their work included the early access to maternal breast milk, improving screening for sexually transmitted infections that increase preterm birth risk and also, establishing a national network of preterm midwives.

The service worked well across teams and services to support people. The service utilised a group of core staff according to service speciality but also midwives and support staff working cross site to support both locations.

Despite vacancies within the community team, we saw effective communication with colleagues to ensure women transitioning between hospital and community services was planned effectively.

We saw teams working together through referral to specialist teams such as preterm, breastfeeding and community support teams. We spoke with the preterm nursing team who told us there was now a dedicated midwife clinic in addition to the joint twice weekly consultant's clinics. This enabled the teams to deliver a personalised service.

However, support from some teams was not available once women were admitted. For example, staff told us the teenage pregnancy team did not provide in reach services, once women were admitted. We also saw there were 14.5 WTE non-clinical specialist and management role vacancies highlighted in the 2024 BR+ report. We reviewed a suite of detailed standard operating procedures (SOP) owned by The West Yorkshire Association of Acute Trusts which worked as a collaborative in bringing together local NHS trusts. The aim of the collaborative was to give patients access to the most appropriate facilities. The SOP's included but were not limited to, elective treatment access protocols.

The preterm specialist midwifery team met on a six-weekly basis with national colleagues to share best practice and share research across the service.

The service supported people to manage their health and wellbeing where able, so people could maximise their independence, choice and control.

We saw extensive information across all wards and departments we visited signposting women and their families to advice, guidance and support groups across the service. We saw QR codes were used to enable people to access the information easily.

The service had developed a monthly and quarterly audit programme across all departments. This formed part of the mandatory annual audit programme for midwifery staff. Areas audited included safeguarding, MRSA screening, and learning disability and autism. We reviewed the latest audit compliance scores dated for quarter one in 2024/25. We saw compliance scores were high with a rate of over 90% across all areas.

The service also set key performance indicators (KPI) for screening. We reviewed the latest results from 1 July to 30 September 2024 which showed most audit met the required standard. We did however note that the KPI for avoidable repeat tests, was worse than the trust target of 2%, scoring 3.4%. The service also audited modified early obstetric warning score observations (MEOWS) as part of the monthly documentation audits. We reviewed the latest documentation audit scores dated January 2025 and saw the antenatal inpatient unit scored 58%, with 12 areas for improvement. Lowest areas of compliance included sepsis screening, pain scores recorded on MEOWS, antenatal risk assessment completed at the point of discharge and smoking assessments. Therefore, there was a potential risk of delayed identification of a deteriorating patient.

The MBRRACE perinatal mortality data (based on births in 2022) showed that the stabilised and adjusted rates at the Trust, for neonatal mortality and extended perinatal mortality (stillbirths and neonatal deaths), were more than 5% higher than the average for comparable trusts and the highest in England.

The latest MBRRACE perinatal mortality data (based on births in 2023) shows that the stabilised and adjusted extended perinatal mortality rates (stillbirths and neonatal deaths) at the Trust were more than 5% higher than the average for comparable trusts from 2017 to 2023. There was also an increase in the rate from 6.68 per 1,000 births in 2020 to 8.42 in 2023.

Audit documentation for the delivery suite audit dated September 2024 achieved 81%, with the same audit completed in the post-natal ward of October 2024 achieved only 78% compliance with twos areas of improvement highlighted.

Between May and September 2024, the Trust identified between 64% and 43% of babies born below the 3rd centile, (between 36% & 57% went undetected until they were born). Fetal growth restriction (FGR) can lead to various complications for the baby, both in the short term and long term. Short-term complications include premature birth, breathing difficulties, low blood sugar (hypoglycemia) and an increased risk of infection. Long-term complications can include an increased risk of heart disease, metabolic syndrome, type 2 diabetes, and certain neurological problems. During the same timeframe the Trust identified between 51% and 38% of babies born between the 3rd and 9th centile.

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The service used a weekly risk tracker to review patient safety incidents. The Trust used an electronic incident reporting system. All incidents are graded based on the level of physical harm and level of psychological harm. The system captures the type of investigation, lessons learnt or required action and holds any documents related to the incident.

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We reviewed the most recent, submitted by the service and noted it recorded basic information with no dates for any actions or review. This meant that incidents may not have been managed as well as they could or highlight actions which could have improved the service to prevent further incidents.

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The audit which measured response times for epidurals, as at December 2024, achieved a 73% compliance which was below the service's own standard. This measured occasions where patients had waited more than 30 minutes from having requested an epidural.

We reviewed the service policy in relation to consent to examination and treatment policy and saw it was in date and had been reviewed. All staff were required to refer to and follow this policy and guidance when proposing to provide care and treatment. Consent was to be obtained prior to any care or treatment and was discussed as routine practice and where possible with families present. This ensured there was a full understanding of all care and treatment provided.

As part of medical staff induction process all FY1 and FY2 trainees were required to complete a consent learning module. Trust policy states any member of staff required to obtain consent must also be trained in the clinical setting under supervision of a consultant who performs that procedure. Some medical staff told us however, that they did not receive protected time to complete all induction training and the service did not have oversight of compliance of completed consent modules as part of the mandatory training monitoring.

All records we reviewed however, showed consent had been appropriately obtained.