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Inspection Summary

Overall summary & rating


Updated 27 September 2016

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 areas



Updated 27 September 2016



Updated 1 July 2014

Surgical services were effective. We do not currently rate whether outpatient services are effective. Care and treatment was delivered in accordance with best practice guidelines.

Patient reported outcome measures for surgery were within expected limits and reviews showed there were no mortality outliers for the service. Emergency re-admissions following elective surgery compared favourably with national comparators.

Staff were using guidance developed and provided by the trust. Nursing documentation was completed appropriately. Multidisciplinary team work was effective and we found several examples of the hospital working well with others.



Updated 1 July 2014

Patients were treated with dignity and respect, and feedback from patients was positive about their experiences in the hospital. However, we did find patient’s dignity compromised in the pre-operative waiting area of theatre, where male and female patients had to wait wearing their dressing gowns.

Analysis of patient feedback survey information showed that the majority of patients had a positive experience of services at the hospital, although there was some frustration over cancelled appointments and waiting times in outpatients.

Patients felt involved in their care and were given the opportunity to speak with the consultant looking after them. The outpatients department had systems in place to identify in advance patients with special needs such as someone living with dementia or a learning disability and put support in place.



Updated 1 July 2014

Chapel Allerton was regarded by patients as a local hospital, which met people’s needs. Patients told us they had accessed the service without difficulty. Patients were pre-assessed for their suitability for surgery prior to their admission to hospital, and their discharge was planned from admission.

Support was available for patients with dementia and the hospital recognised patients with special needs. There was access to a telephone translation service and an interpreter could be arranged if needed. There was a range of information leaflets that covered health condition, after care and information about the hospital services.

Discharge letters were sent to the patient’s GP within a week of treatment or consultation at the hospital. Discharge packages were put in place to ensure that patients were fully supported, particularly if they had a special need after leaving hospital.

The department understood the needs of the different communities it served and reviewed clinic statistics monthly to improve efficiency and reduce waiting times. The department had improved its clinic attendance rate using electronic messaging to contact patients. Patients with a dementia related condition, with a learning disability, a visual or hearing impairment were supported. Car parking was available at the hospital on payment of a fee, although some patients felt this was an issue.



Updated 1 July 2014

The surgical and outpatients’ services were well led. Staff across the hospital felt that the changes in the trust leadership were positive and that executive team were visible. Staff felt informed about the changes within the trust and familiar with the trust’s vision, strategies and values. Staff reported being engaged in the development of services in their own hospital and that they were encouraged to get involved in innovation to improve the quality of services.

The surgical and outpatient services had been part of the trust-wide clinical services units, but recently the hospital had become a clinical service unit in its own right. There were good arrangements in place for the assessment and monitoring of risk. Staff were confident of reporting incidents. Lessons were learnt following investigations, including from those that occurred in other hospitals. However, we found that the monitoring and auditing programme had not identified some risk in the operating theatres around the storage and handling of waste.

Services were responsive to patient needs and patients were on the whole very positive about the care and treatment at the hospital. Patient feedback was acted on and staff were continually looking for ways to improve services.

Staff felt well supported at local level. However, there were difficulties over accessing mandatory training and staff felt frustration with cancelled training and a long wait to attend courses.

Checks on specific services

Outpatients and diagnostic imaging


Updated 1 July 2014

Overall patients received safe and appropriate care in the department. The outpatient areas were clean and well maintained and measures were taken to control and prevent infection. The outpatient department was adequately staffed by a professional and caring staff team.

We do not currently assess whether the outpatient’s services are effective. Regular audits of patient records were undertaken, although staff told us that work to improve the quality of patient records was ‘work in progress.’ Care was delivered in line with best practice guidelines.

Outpatient services were caring. Patients visiting the outpatients department were treated with respect, dignity, and compassion. Patients were supported when they received a difficult diagnosis and staff explained choices of treatment. On the whole analysis of patient feedback survey data was positive, although cancelled appointments and waiting in clinics was a frustration for patients and their carers.

The outpatients’ service was responsive. The department understood the needs of the different communities it served and reviewed clinic statistics monthly to improve efficiency and reduce waiting times. The department had improved its clinic attendance rate using electronic messaging to contact patients. Patients with a dementia related condition, with a learning disability, a visual or hearing impairment were supported. The hospital wrote to patients and their GP within one week of the outpatient clinic. Car parking was available at the hospital on payment of a fee, although some patients felt this was an issue.

The service was well led. Staff liked working for the hospital and felt well informed and supported. Executive directors visited the service and staff knew who they were. Risk management processes were in place and each CSU operated its own risk register. The potential of staff of various grades and disciplines was developed. Staff recognised the need to develop more nurse led clinics for the department.



Updated 27 September 2016

We rated surgical services as good because:

  • We found that the concerns raised from the previous inspection which resulted in a ‘requires improvement’ rating had been fully addressed.

  • We found that there were appropriate incident reporting arrangements and there were suitable processes in place to support learning from incidents; this included dissemination of learning across the hospital and more widely across the trust.

  • The ward performed well against performance measures including safety thermometer and ward health checks. The ward and theatre environments were in a good state of repair and the general environment in these areas was clean and free from clutter. Compliance with mandatory training for ward and theatre staff was above the trust target of 80% and the processes for monitoring mandatory and appraisal worked well. Nurse staffing levels for both theatres and the ward were in-line with the assessed levels of safe staffing. Staff understood the early warning score process and how to escalate concerns appropriately and there were specific patient transfer guidelines for the transfer of the deteriorating patient to another hospital site.