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St James's University Hospital Requires improvement

Reports


Inspection carried out on 21 Aug to 27 Sept 2018

During a routine inspection

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

  • We found that nurse staffing did not always meet the minimum levels to ensure patients received safe care and treatment and there was a high turnover of nursing staff. This was observed in multiple services at the hospital
  • We found that mandatory training compliance in multiple services was below the trust target of 80%
  • We observed that effective infection prevention and control protocols were not consistently followed on all wards and theatres and we had concerns about the number of healthcare acquired infections in surgical services at the hospital
  • We observed that substances hazardous to health such as cleaning solutions and alcohol gels were not always stored securely and in some cases were accessible to patients
  • We observed that the mental health assessment room did not meet recommended standards and that staff understanding of mental capacity and consent was variable
  • We had concerns about patient privacy and dignity in some areas of the urgent and emergency care service

However:

  • Patients we spoke to told us that staff were polite and professional and treated them with care and compassion. This was observed on all services we inspected.
  • Appropriate escalation policies were in place at the hospital and National Early Warning Scores were calculated and escalated in line with these polices
  • We observed safe medicines management, resuscitation trolleys were regularly checked with tamper proof seals in place and all medicines and items were found to be in date

Inspection carried out on 20 December 2017

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

We carried out a focused inspection on 20 December 2017, to follow up on concerns we identified during routine engagement, regarding the safe use of additional beds in non-designated areas during times of increased demand.

Intelligence data showed that at times of increased demand, staff placed additional beds/trolleys in non-designated areas. The use of non-designated areas included placing patients in ward corridors, using additional areas to nurse patients (such as treatment rooms, day rooms, and sensory rooms) and increasing the capacity of ward bays by placing patients in beds in the middle of the bay.

We raised the use of non-designated areas with the trust in May 2016, during a follow-up to a comprehensive inspection. At that time risk assessments of the use of non-designated areas were not consistently undertaken or applied, and there was a lack of robust assurance of the oversight of patients waiting on trolleys. A requirement notice was served to the trust, to ensure there were appropriate arrangements in place for assessing the suitability of patients to wait on trolleys on the assessment ward. Since the 2016 inspection, the trust had reviewed documentation, including risk assessment and standard operating procedures, for placing patients in non-designated areas; and they had commenced weekly and quarterly audits of the results.

In September 2017, through routine reviews of the National Reporting and Learning System (NRLS) data, we observed a number of reports that showed patients were still being placed in non-designated areas. Staff raised concerns that on some occasions, risk assessments of these patients had not been carried out appropriately; and some patients were being nursed in non-designated areas (including corridors) for a number of days. We discussed this with the trust. The trust explained that at times of increased demand for beds, capacity was increased by placing additional beds/trolleys in (what the trust termed) “non-designated areas”; such as ward corridors and in the middle of bays, and using treatment rooms, day rooms, and sensory rooms as escalation areas. The trust had identified two different occasions when non-designated areas could be used; and classified in there full capacity plans.

Information provided by the trust showed that between October 2017 and December 2017, non-designated areas within the trust were in use on the majority of days. The number of patients per day in non-designated areas ranged between six to 40 patients. During this inspection, we saw five patients nursed in non-designated beds in the areas we visited; three on the corridor, one located in the middle of a bay, and one located in a treatment room. At the time of the inspection, the trust was not able to provide length of stay data for patients in non-designated areas. However, during the inspection, we saw two patients that had been nursed in non-designated beds for a period of four days.

Information we reviewed showed that between March to December 2017, the trust had received seven formal complaints and eighteen patient advice and liaison service (PALS) concerns relating to the use of non-designated areas.

We asked the trust how they received assurance that patients in non-designated areas were receiving safe care and treatment. We reviewed the information provided by the trust, and discussed this at management review meetings. We concluded that a focused inspection was required to identify if a breach of the regulations had occurred.

To get to the heart of patients’ experiences of care and treatment we always ask the same five questions of all services: are they safe, effective, caring, responsive to people’s needs, and well-led? Where we have a legal duty to do so, we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

At this inspection we inspected the core service of medicine only and the safe, responsive and well-led domains; we did not rate the services.

During the inspection we identified the following concerns:

  • There was a lack of robust assessment and documentation of decision making for patients being nursed in non-designated areas.

  • There was a lack of suitably qualified staff; when taking into account best practice, national guidelines and patients’ dependency levels. In addition, staffing levels were not altered to reflect the use of non-designated areas.

  • There was a lack of robust documentation in relation to the requirements of the Mental Capacity Act (2015) and consent to being nursed in non-designated areas.

  • The non-designated areas being used to nurse patients were not always suitable and did not meet all patients’ needs.

  • At the time of the inspection, the trust was not able to always meet patient’s privacy and dignity in relation to the environment they were nursed in. The single sex accommodation annual declaration 2017, outlined that when patients were allocated to corridors, the trust required they were always allocated on same gender wards. However during the inspection, we did not see that the trust always achieved this. On ward J14 a mixed male and female ward we saw a male and a female patient located on the same ward corridor

  • The use of non-designated areas reduced the privacy of patients and compromised their dignity.

  • A number of incident forms we reviewed indicated a theme of nursing staff being overruled in decision making processes about placing patients on corridors. A number of reports also highlighted patients (or their relatives and representatives) who were unhappy or upset about being nursed in non-designated areas.

However, we also saw several areas of good practice including:

  • We observed that during the inspection, staff treated patients with compassion and respect.

  • Patients we spoke with said they felt listened to, they felt safe, and that they were treated with kindness.

  • The service had systems in place for reporting, monitoring, and learning from incidents. Staff we spoke with knew the procedure for reporting incidents, and described completing an incident form each time a non-designated bed space was used.

  • We also found effective communication between teams to ensure patients in non-designated areas were medically reviewed, as appropriate.

  • The trust had developed a number of initiatives to improve patient flow, and relieve capacity and demand pressures.

  • We found that all members of staff approached were happy to speak with us and share concerns, discuss challenges faced, and highlight good practice to us.

Importantly, the trust must:

  • Ensure there are suitably skilled staff available to care for patients being nursed in non-designated areas; taking into account best practice, national guidelines, and patients’ dependency levels.

  • Ensure that when non-designated areas are in use, the privacy and dignity of patients being nursed in bays or corridors are respected and not compromised, and that the areas are suitable to meet patients’ needs.

  • Ensure there is robust assessment and documentation of decision making for patients being nursed in non-designated areas,; including assessment of patients’ mental capacity, reasons for deviation from the operating procedure, patient preferences, and patients’ right to consent.

  • Ensure data is collated on the numbers, location, and length of stay of patients in non-designated beds.
  • Ensure that staff reporting concerns about the use of non-designated areas are supported and receive feedback.

Ellen Armistead

Deputy Chief Inspector of Hospitals

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 review the function of the pre theatre waiting area in Geoffrey Giles theatres and ensure that the appropriate checks and documentation are in place prior to patients leaving ward areas.
  • 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, 19-20 and 30 March 2014

During a routine inspection

St James’s University Hospital is one of seven hospitals forming the Leeds Teaching Hospitals NHS Trust, which is one of the largest in the United Kingdom. St James’s University Hospital is one of the largest teaching hospitals in Europe. The trust serves a population of 751, 485 in Leeds and surrounding areas. In total, the trust employs around 15,000 staff. St James’s University Hospital has 1113 inpatient beds.

The hospital provides accident and emergency services for adults as well as surgical, critical care, maternity and family planning services. The hospital also provides general and acute medical services. Cardiology, neurology and stroke services are concentrated at Leeds General Infirmary.

Many new initiatives were in the process of development or introduction in the hospital, including the new management and governance structure, which has created 19 Clinical Service Units across the hospital sites. It is acknowledged that these have yet to have time to become fully established, and some services had adapted more quickly than others.

Staff reported that there had been a positive change in the leadership at trust level and that the executive team were more visible, especially the Chief Executive. Staff felt much more positive and better informed over what was happening within the hospital and the trust as a whole. Staff across the hospital reported a much more open and honest culture, with patient care a priority.

A safety culture was not yet fully embedded in the hospital. We found that not all staff groups were consistently reporting incidents, although this was more fully embraced by the nursing staff. Although there were several formal processes in place for sharing learning, such as a trust-wide Learning Points Bulletin we still found that lessons were not being learnt from investigations across clinical service units and other hospitals in the trust, which was a missed opportunity to improve the quality and safety of services.

Care was provided in line with national best practice guidelines and the trust performed well in comparison to other hospitals providing the same type of treatment. However, more work was needed with auditing, particularly of the implementation of trust policies, guidelines and clinical audit. Generally, there was good access to services and the hospital was able to respond to patient’s needs.

Patients were positive about their experience in the hospital and reported that staff were kind, kept them informed and they were involved in decisions over their treatment. Patients felt treated with dignity and respect. On the whole feedback from patient surveys was good, although some concerns had been raised about communication with some clinicians, staffing levels and some staff attitudes. We did, however have concerns about the assessment of mental capacity and patient involvement in end of life decisions.

Staffing

Nurses worked hard to meet the needs of patients and took pride in working in the hospital. However, there were nursing and medical staff shortages across a number of areas, which meant that the necessary experience and skills mix, did not always meet Royal College and national recommendations for best practice. Medical cover out of hours was a particular concern, particularly on elderly care and surgical wards.

There was a training programme in place, but not all staff had completed their mandatory training. Staff, particularly junior doctors reported that access to training could at times be problematic due to staff shortages. Staff reported that they felt supported locally, although some staff had not had an appraisal.

Cleanliness and infection control.

There were arrangements in place to manage and monitor the prevention and control of infection, with a dedicated team to support staff and ensure policies and procedures were implemented. We found all areas visited clean. The trust’s infection rates were within a statistically acceptable range, but there was an elevated risk for Clostridium difficile infections and there been a number of cases, although investigations had failed to identify any common cause.

Medicines Management

There were good arrangements in place to ensure the safe storage, administration, handling and recording of medication. Generally medication was managed appropriately; however, oxygen was not always prescribed according to trust policy.

Complaints Management

When we carried out this inspection we worked with colleagues from the Patients Association and looked at how complaints were managed in the trust. In January 2014, a revised Complaints Policy was implemented across the trust with the strategic intention of improving the management of complaints, attitude to complainants and to provide all those involved in the complaint handling with training. A new team had been established and this was impacting positively on the receipt and handling of complaints. The executive team was found to be committed to a cultural change in the handling of complaints and an improved response to patients concerns. Work was progressing, but further areas for improvement included the increased capacity of the Patient Advice and Liaison Service, embedding the monitoring and auditing of complaints including performance information and better sharing of lessons learnt.

Seacroft Hospital

As part of this inspection we visited the outpatient clinics at Seacroft Hospital where 51,000 patients attended outpatient clinics in 2012-2013. During the week of our inspection there were 16 speciality services providing outpatient clinics at Seacroft Hospital. We found that the services at Seacroft Hospital were safe, responsive and patients were highly satisfied with their care. The services formed part of the outpatients’ clinical service unit. Staff reported that they felt well informed and part of the trust as a whole with good local support and leadership. The findings of this inspection can be found in the outpatients service section of this report.

Inspection carried out on 17 March 2014

During Reference: not found

Inspection carried out on 1, 2, 3 May 2013

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

This inspection was carried out as a result of concerns raised with us regarding staffing levels, patient care and the use of a day surgery unit for in-patients. We visited J96, an oncology assessment ward, a day surgery unit and J8, a care of the elderly ward.

We spoke with eleven patients or relatives of patients. Most of the people we spoke with were positive about their care and their experience. Comments included, �They look after you very well�, " We are extremely satisfied with dads care", �I have total trust in the staff� and "Very good response from staff, nurses, doctors and others." Patients also said the environment was clean.

We spoke with thirty-nine members of staff. This included nursing, housekeeping and medical staff, ward managers and matrons and a number of senior managers and heads of nursing. Staff told us patients received good, safe care and their essential needs were met well. Patients said their needs were met in a timely manner and that there were enough staff available who were always friendly and polite.

Staffing levels were observed to be sufficient in all areas we visited. Staff said they felt well supported in the areas they worked. They said leadership, communication and teamwork was good.

We saw that the day surgery unit was being used appropriately. However records of use for in-patients were not always completed fully.

Inspection carried out on 3, 4 December 2012

During an inspection in response to concerns

We visited wards J26 and J29, medical admissions wards, J12, a respiratory medicine ward and J15 a medical ward for older people.

We spoke with twenty one patients and fourteen visitors. The vast majority of people we spoke with were positive about their care and about their experience during their time at the hospital. Comments included:

�The doctors and nurses are very good at explaining things and don�t mind if you keep asking questions.�

�The nurses are wonderful, I can�t say a bad word against them.�

�It is quite alright here, we are treated very well.�

�Brilliant Care and they explain everything.�

�The staff are very busy but they are fantastic.�

We observed staff treating people with respect, being polite and courteous. Patient�s privacy and dignity were respected well.

We spoke with twenty members of staff, which included ward sisters, matrons and doctors. Staff told us patients received good, safe care and their essential needs such as washing, toileting, medication, assistance with meals and observations were appropriately met.