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Inspection carried out on 11 – 13 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 19 March 2014

During a routine inspection

Chapel Allerton Hospital is one of seven hospitals that form part of Leeds Teaching Hospitals NHS Trust. The trust is one of the largest in the United Kingdom and includes 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. Chapel Allerton Hospital was built in the early 1990s. The hospital is home to the Chapel Allerton Orthopaedic Centre, a dedicated centre for the diagnosis, management and treatment of adult patients with upper and lower limb complaints. The hospital provides rheumatology and orthopaedic surgical services. Dermatology services have recently commenced at the hospital. The hospital has 82 beds.

Inpatient services are provided for neuro-rehabilitation, rheumatology, dermatology and orthopaedic surgery. Outpatient services are also provided in the hospital. Staff on site are managed via several trust wide clinical service units, but one management team is based entirely on site and is taking a co-ordinating role in terms of site responsibility.

There were systems to identify risk and report incidents. Lessons were learnt from the investigations of incidents from across the trust and staff felt well informed. There were effective systems in place to prevent patients suffering pressure ulcers, falls and blood clots.

Care was provided in line with national best practice guidelines. Access to services was good and patients reported that the hospital was well thought of locally due to the good outcomes experienced by patients. However, the World Health Organisation safety check list was not fully embedded into operating theatre practice.

Patients were treated with dignity and respect and felt informed about their treatment and care. Patients were positive about their experiences at the hospital.

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 reported that they felt supported locally and encouraged to participate in improvement initiatives.

Staffing

The wards and departments were adequately staffed and staff had access to training and development opportunities to improve their knowledge and skills and develop professionally. However, not all staff had completed mandatory training.

Staff were committed and enthusiastic about their work and worked hard to ensure that patients were given the best care and treatment possible.

Cleanliness and infection control

There were arrangements in place to manage and monitor the prevention and control of infection. We found ward and theatre areas were generally clean and there were no reported healthcare acquired infections at the hospital within the last year. However, we identified some issues with storage and cleanliness in parts of the operating theatres (non-patient care area).

Inspection carried out on 11 July 2012

During a routine inspection

We visited an orthopaedic ward and the rheumatology day unit.

People said they were fully involved in decisions about their treatments and the staff were very good at explaining the treatment they received. People told us that the treatment options were explained and the risks and benefits of their treatment were made clear. They said they felt safe. All seven people we spoke with told us they were happy with the care they received and they were well looked after.

Comments included:

“I agreed to the treatment and I have signed something in the past.”

“I made the decisions myself.”

“Care is very good. Staff have been attentive and efficient.”

“I can’t fault anything.”

“It has been a positive experience.”

“I am perfectly satisfied, as satisfied as I could be.”

“I had an exceptionally good discussion with the pharmacist about my medical history and suitable medication for me.”

“As hospitals go this is as good as it gets.”

“Care is better than in a private hospital.”

“They treat you like a person.”

“Care has been excellent. They are so caring.”

The people we spoke with told us there were enough staff on the ward and they were seen to promptly.

Comments included:

“Someone comes if I need help.”

“Even though staff are busy they do not rush with me.”

“Staff are prompt and they double check everything.”

Inspection carried out on 4 April 2011

During a themed inspection looking at Dignity and Nutrition

The patients we spoke with were mostly positive about their experiences of care and treatment on the wards visited. They told us that they were kept informed and were involved in making decisions about treatment options. They also commented that they were given enough information to help with this process. Most of the patients interviewed told us they had their care needs met and had been treated with respect. One patient told us how they had been upset by the comments from staff.

Examples of the positive comments included;

“I am happy with the care provided”.

“The staff are very good”; “they try to be fair sharing their time with everyone”.

“Staff call me by the name I asked them to call me by”

“I am listened to about my personal wishes”.

“I am able to choose whether I want a shower or a bath, I am very happy with the support that the staff give to me”.

“Staff explain what they are going to do”.

The negative comment was;

“The staff nurse in charge yesterday made me very uncomfortable and annoyed. She was angry and upset me because I smoke, but she is a good nurse the medical care given is great. It is their attitude because we smoke; it is like a grudge against you”.

Patients and relatives were complimentary about the process of mealtimes. They commented that the staff made an effort to make it a pleasant experience. Patients also commented that they were well supported to eat and drink.

Positive comments about the food included;

“Meal times are quiet; the other patients are nice so mealtimes are pleasant”.

“Food for a hospital is not too bad for a hospital”

“I don’t have specific needs; the staff will help with anything that I find difficult to open”.

“There is enough food to pick from; I stick to what I know I’ll eat”.

Other comments made about the food and meal times included;

“It could be more varied, particularly for patients who are in for a long period”.

“The food is not always served by staff wearing aprons and hair is not always tied back”.

“There is hand washing available but staff have to be asked to wash their hands”

“Hot food could do with being served a bit warmer”