St James's University Hospital

On this page

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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At this inspection we rated the key question as inadequate.

The service was in breach of regulations relating to; managing risk, staffing, safe environments and infection prevention and control, medicines management.

The service did not always have a culture of safety and learning. Learning was not always evident following incident reviews. Babies were not always transferred in line with the neonatal unit criteria. There were not always enough staff with the right qualifications and skills to meet the needs of babies. The environment was not always safe and medicines were not always stored correctly.

There were clear safeguarding processes in place and staff knew how to protect babies and adults from harm.

This service scored 38 (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 did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Staff told us they knew how to and would report incidents.

We reviewed methods of shared learning and saw examples where learning points had been identified and shared through newsletters, team huddles and presentations to staff. We reviewed information shared within leaflet format for all new starters called ‘a service with a memory’. This aimed to ensure that previous learning was available to all.

We asked staff about learning from incidents. All staff told us that incidents would get reported, however, staff were unable to give specific examples of any recent incidents or learning. We heard about one incident through the patient safety lead. We saw this was included on a newsletter, however we did not see that the context, specific details of the incident and the reason behind the need for learning had been shared. Staff did not tell us about this learning.

We did not find evidence that staff were proactively engaged in learning or observed any rationale for learning by sharing of incidents. For example, we saw that group text message reminders were sent regarding learning from unplanned extubations but leaders recognised few staff read these. There continued to be repeated incidents of accidental extubations reported via the trust incident reporting system and shared with staff via a newsletter.

The service did not always work well with people and health system partners to establish and maintain safe systems of care. Staff did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

There were some joined up working processes in place to support babies and families within the neonatal service. The neonatal unit and transitional care ward worked together to support safe discharge home through step down care. The outreach team worked closely with the inpatient staff to identify babies preparing for discharge and ensured there was a timely handover of care. The outreach team met with families and babies prior to discharge to discuss and plan care following discharge home. The family integrated care team worked with all parts of the neonatal service to support care transitions. We also saw continuity of care across services and appropriate handover of care between services, for example, with the specialist transport service. There were clear transition arrangements for babies being discharged from the neonatal unit or transitional care unit.

During the inspection we reviewed babies recently admitted to the unit and found that babies did not always meet the criteria for the unit. Some babies required a higher level of care than was set out in the criteria for the neonatal unit. This was due to demand and a lack of cot spaces at the Leeds General Infirmary site. There was no clear pathway in place to ensure these babies received care on the most appropriate unit.

Following the inspection, we raised concerns with the trust regarding the transfer of babies to the neonatal unit when their needs were over and above the criteria for the unit at the St James site. We asked the trust to provide details of the MDT input when considering identification of babies who were patients at the neonatal unit at Leeds General Infirmary site to be candidates for transfer to St James Hospital neonatal unit. The trust created an action plan which provided assurances that they would work to embed monitoring and oversight of transfers and to ensure a risk stratification process was adhered to. We were also provided with confirmation from NHS England specialist commissioning that there was an understanding the unit was operating at an enhanced level with expertise beyond that of a typical special care unit. For example, there was an attending consultant neonatologist on a daily basis.

The service did not always work with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

All staff we spoke to were aware of safeguarding procedures and how to make a safeguarding referral. Staff were knowledgeable about signs of abuse or neglect. Community based staff were aware of processes to follow should they witness any concerns whilst visiting families in the community. Staff told us supervision took place regularly.

There was an up-to-date children's safeguarding policy in place. This provided guidance for recording safeguarding alerts for pregnant women. Safeguarding alerts were recorded on the trusts electronic record system. However, maternity, and neonatal services used a second electronic recording system that required an upload of safeguarding flags and alerts. There was a risk that information could be missed if both systems were not updated, but we saw no evidence of this.

There was a trust wide safeguarding team in place for support and advice. There was a named safeguard lead nurse based on the unit and named consultant lead. There was regular liaison between the neonate team and maternity team. Neonatal safeguarding team meetings were planned when time allowed, however, there was no designated time provided for this.

The trust target for compliance with children and adult safeguarding was 80%. Staff on the neonatal unit met the trust target for compliance with safeguarding adults and safeguarding children level 1, 2 and 3. However, transitional care staff were 73% compliant for both and medical staff were 69% compliant with safeguarding children level 3 and 65% compliant with adult safeguarding.

The service did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We reviewed notes and saw risk assessments were completed, and clear plans of care were in place. Ward rounds and daily handovers took place to support risk review. We observed a weekly multi-disciplinary (MDT) meeting and heard that family involvement was considered.

Staff told us that family involvement at ward rounds and with care of babies on the unit was encouraged. However, we reviewed feedback from the parent and staff survey from 2024 and saw that timely encouragement to attend ward rounds was not always given, therefore families were not always supported to feel part of the team and be involved in managing risk. One comment was that ‘more staff education was required to empower staff to feel confident in supporting families’. We also saw staff education listed as an idea on an improvement board.

Allied health professionals were understaffed. Because of this they were not able to provide the amount of time recommended to each individual baby. This meant that families were not always involved in supporting and managing the needs of their baby.

The neonatal service was involved in a working group regarding the implementation of Martha’s rule. Martha’s rule supports families to have a voice and raise concerns regarding deterioration of their babies and children whilst in hospital.

Basic life support videos were provided for families prior to discharge from the neonatal unit.

The service did not always detect and control potential risks in the care environment. Staff did not make sure that equipment, facilities and technology supported the delivery of safe care.

During the inspection we identified there were occasions when babies had been admitted to the unit with greater need than the criteria the unit provided for. We reviewed the environment and equipment and found that the equipment was not sufficient to meet the possible needs of the babies admitted requiring a higher level of care. The unit was set up to meet the needs of a special care baby unit, a level 1 unit. Staff told us throughout the inspection that they understood the unit to provide care at level 2 (high dependency care). There was a risk of harm to babies because of this. Cot side resuscitation equipment did not meet the resuscitation council best practice guidance for a level 2 unit. We raised this concern with the trust following the inspection. The trust provided assurance that babies with greater need than what should be provided for on the special baby care unit would not be admitted to the unit. The trust also identified a plan to expedite the purchase of necessary equipment to meet the needs should there be an agreed change of admission criteria in the future.

We found a number of doors propped open on the neonatal unit. We found one fire door into the family kitchen area that did not fit. We found a toilet area that was in use for visitors with various equipment stored in a room used to access the toilet, including a mirror placed on the floor.

In the parent kitchen there was food stored in the fridge that was not labelled or dated. There was no record of fridge temperatures for this fridge.

We found a number of stock items which had expired in the gas analyser room (the door was propped open by a waste bin and members of the public had access). Stock items out of date included kidney dishes, Jugs, McGills forceps and blood gas bottles. We escalated these concerns with the team at the time of inspection. The concerns were addressed, doors were fixed, areas were cleared and out of date items were removed.

We found frozen expressed breast milk in the freezer that had not been removed in line with the trust guideline for expressing, storing and administration of breast milk. We raised this at the time of inspection. The storage of breast milk was reviewed and an improved system put in place during our inspection.

Whilst staff responded to concerns during the inspection, and we saw improvements we were not assured that there were suitable processes in place to support oversight and timely management of environmental concerns that could pose a risk to people.

The neonatal unit was accessed from the main corridor through door entry buzzer. There was CCTV in operation for staff to view people entering the unit. There was a sign on the door asking people not to hold the door for visitors of other babies as each visitor must buzz in separately. Letters were missing off the sign on the main door that should have read ‘ring bell for attention’. This read as ‘ring be or atten on’ which could be confusing for some visitors. The transitional care ward was accessed through the antenatal maternity ward. This relied on staff from the antenatal ward allowing access through the ward and families then buzzing again for access from there to the transitional care unit.

The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always work together well to provide safe care that met people’s individual needs. The service ensured staff received effective support, supervision and development.

Medical staffing

Leaders had previously identified safety concerns regarding the medical cover available for the neonatal unit. Medical cover at weekends had been shared between St. James Hospital site and Leeds General Infirmary. At the time of inspection there had been improvements made, and each site had a separate rota. We saw that the number of consultants had been increased to support this and had improved cover. However, we saw there were still gaps on rotas and consultants worked long hours to cover these gaps.

Consultant cover was variable. A review completed in May 2024 identified that the medical staff numbers did not meet the requirements specified within the British Association of Perinatal Medicine (BAPM) standards for tier 3 Doctors due to cross site working and lack of separate on call arrangements at weekends for each site. This risk was documented on the service risk register.

The current consultant WTE is 16 from the beginning of October 2024. As the team increase in WTEs the Trust will gradually separate out the weekend on call arrangements to facilitate single site responsibility. On call Consultant cover is increasingly provided at both locations as the Consultant recruitment plan is progressed. From November 2024, 18 out of 26 weekends had been scheduled to have on call consultant cover on each site.

Nurse staffing

The neonatal unit had the required number of registered nurses in post to meet the national guidance and the skill mix was appropriate to make sure people received consistently safe and good quality care. However, the nurse staffing levels did not meet the required percentage of staff qualified in speciality (QIS) to ensure people received consistently safe and good quality care. At the time of inspection there were 61% with QIS. This was due to increase to 64% in February 2025 as staff completed the qualification. We raised this concern with the trust following the onsite inspection. Leaders provided an action plan to increase the number of nurses able to complete the QIS training.

Staffing levels per shift were reviewed throughout the day. Staff would move between sites as needed. Bank staff were employed by the trust and used to cover shifts as required. Bank staff received the same training as required by the substantive nursing team. There was an escalation process in place when staffing levels were below what was required. There was guidance in place to determine when the unit may be closed to admissions, for example, where staffing skill mix was not sufficient. This was in line with regional guidance set out for all regional neonatal units. The service ensured there was always one band 6 sister and a QIS nurse on shift. A recognised safe care staffing tool was used daily. The Neonatal unit and transitional care unit could support each other; however the transitional care unit was staffed by midwives.

There was a structured induction process for new staff that included a rotation round each neonatal area across both hospital sites. All new staff were required to complete competencies before carrying out specific clinical skills.

All new neonatal nurses were supported to complete a recognised foundation training programme. This equipped them to be ready to start the QIS training.

Not all staff had timely appraisals. Appraisal percentage for the neonatal unit was 81.53%. The trust expected this would meet full compliance by the end of March 2025. However, the figure for transitional care across both sites was 65.52%, which was below the trust target.

Turnover rates for nurse staffing had improved from 7.65% in March 2022 to 4.04% in 2024. Although an action plan to put together a staff retention survey was proposed, we did not see evidence of its completion at the time of inspection.

Sickness rates for registered and unregistered nursing staff were consistently recorded as red on the ward dashboard for the past year with the exception of three months of reduced sickness during the year for registered nurses. This was reflected in the planned versus actual staffing levels. We saw that staffing did not always meet planned levels. The trust had an escalation process to follow when staffing did not meet planned numbers.

The transitional care unit on both sites were staffed by midwifery staff, registered nurses and nursery nurses.

Allied Health Professionals (AHP)

The service had specialist AHPs with time specified for neonatal care, however, there were significant gaps in the provision due to underfunding. There were significant gaps in AHP provision and levels did not meet the requirements set out in the Neonatal service specification. The team were understaffed in dietetics, physiotherapy, occupational therapy and speech and language therapy due to underfunding. Lack of AHP provision not only impacts on compliance with National Institute for clinical excellence (NICE) guidance for the neonatal follow up programme and early intervention needs for these infants, but this could also seriously compromise neurodevelopmental outcomes for babies having a long-term impact on their care needs for the future.

This was on the children’s service risk register. Ockenden funding had been invested to support this staff group, however, the team had struggled to recruit.

Training

Staff told us nurses at band 6 and above completed Advanced Resuscitation of the Newborn Infant (ARNI) course. All staff further enhanced their neonatal life support skills and knowledge through attendance at regular simulation sessions and clinically based training. We reviewed mandatory training matrix figures for the neonatal service and saw that the service did not always achieve the trust target for mandatory training. For example, adult resuscitation training level 1 was 66.67% compliant. Neonatal basic life support level 1 was 67.16% compliant. However, we were also provided with information that stated the trust neonatal basic life support compliance rate was 90.5%. It was not clear that the trust had assurance regarding compliance rates within each unit.

The team has 0.8 whole time equivalent (WTE) band 7 prenatal resuscitation officers. This role focussed on resuscitation training and governance around resuscitation equipment, crash call attendance and delivery of the resuscitation algorithm.

The service did not always assess or manage the risk of infection. Staff did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

We saw information for families and visitors regarding infection, prevention and control (IPC) practices as they entered the unit. Hand gel was available immediately entering the unit. Visitors were let into the unit through a door entry system before walking down a corridor and through two further doors to access the unit. This required visitors to be vigilant at each area regarding hand hygiene. We entered the unit multiple times during our inspection and were not verbally prompted to wash or gel hands on entering. We were not aware of any staff member taking responsibility for ensuring visitors to the unit did carry out hand hygiene. Staff told us families were educated around the importance of infection prevention and control by the matrons or band 7 staff. However, we did not see evidence on how effective this communication was. We observed one cot where a soft toy had been left in the cot by a parent. Staff understood this should not have been left and moved the toy from the cot. Leaflets were available providing written information.

There was a trust wide IPC policy in place. There was a process in place for additional actions where an outbreak was suspected. We saw hand hygiene audits were completed monthly as per the policy.

We reviewed IPC audits for the previous six months. We saw mixed results. Some areas of practice scored consistently high for IPC compliance. Some areas scored consistently below 90% of the expected standard, for example, line IPC booklet daily reviews and terminal cleaning. We reviewed an action plan that was created through the fortnightly IPC meetings regarding the areas of concern identified through the audits.

During our inspection we identified there had been cases of serratia on the unit and there was a positive case at the time of visiting. Serratia is a bacterial disease most commonly spread on the hands of healthcare professionals. We saw that this baby was isolated and had 1:1 care. We saw that there were regular IPC meetings and that there had been extensive review of the serratia cases evidencing appropriate actions had been taken.

There were a greater number of cots on the unit than commissioned for and space was tight between cots. Babies were also moved around the unit to accommodate babies according to need and staffing levels. The trust had recognised that the current estate did not support best IPC practices. There was a business case that had been approved to make changes to the clinical area to allow improved flow, larger cot spaces and to reduce the need for movement of babies. Water safety had also been reviewed in detail and there was an action plan in place for further improvements.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Staff did not always follow systems and processes in the safe and secure storage of medicines.

We were not assured that stock control systems were effective as we found 13 medicines that were out of date with one dating back to February 2024.  This was escalated whilst on site, however, staff could not tell us clear roles and responsibilities for ward stock management despite their being a trust policy in place.

We also found medicines for patients that were no longer admitted to the ward in stock cupboards for ward use and some cupboards were unlocked; this was not in line with trust policy.

Controlled drugs were managed in line with the trust policy and pharmacy controlled drug checks were taking place.

Emergency trollies were in place on the ward. Data provided from the trust showed electronic checks were at 100% compliance however we did find one medical device out of date. This was escalated on inspection, and we were told that some medical devices did not require inputting of an expiry date raising concerns of the robustness of this electronic system.

We raised concerns regarding contradictory emergency medicine protocols attached to resuscitation trollies, this was acted on immediately by senior staff.

We reviewed five patient records including medication charts and found that medicines were prescribed appropriately. Weights were recorded and updated in line with guidance to ensure accurate prescribing.

The pharmacy team completed a safe and secure storage of medicines audit in July 2024 but this had not identified concerns we raised on inspection.