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Leicester Royal Infirmary Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 30 April 2020

We carried out an unannounced focused inspection of the emergency department at the Leicester Royal Infirmary on 27 January 2020, as part of our winter pressure resilience programme. The decision to inspect was based on intelligence we held about the department and was associated to a potential increase in risk in patient harm.

At the time of our inspection the department was under adverse pressure.

We did not inspect any other core services or wards at this hospital. During this inspection we inspected using our focused inspection methodology. We did not cover all key lines of enquiry. We found that:

  • There were delays in ambulance handovers and resultant delays in assessment and treatment for some patients.
  • Whilst the service mostly had suitable premises, there were insufficient cubicles to accommodate all the patients in the department when it was overcrowded. As a result, patients were being cared for in a corridor at the time of the inspection.
  • Triage times were not completed in line with guidance. Some patients waited a considerable time to be assessed.
  • Whilst risks to patients were assessed and their safety monitored and managed, not all patients received treatment in a timely manner.
  • Some doctors told us they needed more emergency department consultants to keep the department safe when it was overcrowded.
  • Patients could not always access the service when they needed to due to the volume of patients arriving in the department. Some patients access to emergency care and treatment was significantly delayed.
  • Specialty doctors were unable to respond to all patients in a timely manner.
  • There was insufficient patient flow across the trust to admit all of the patients who required a hospital admission.
  • Some senior medical staff told us the POD facility had been implemented without full and proper consultation or input from the emergency department team, and the extra ambulance capacity had increased the workload on an already over stretched department.
  • Patient privacy and dignity was not always protected. Specifically, when patients were in the POD facility and the corridors. Patients privacy and dignity was not protected at the booking in desk and when speaking to the visual assessment clinician nurse. Patients and their relatives could hear conversations which were personal and private.
  • Not all patients using the service had had all their relevant clinical assessments carried out. Patients waited on trolleys in the ambulance corridor for long periods of time without having had a tissue viability assessment or a falls assessment.

However,

  • Staff cared for patients with compassion. Staff were friendly, professional and caring even when under extreme pressure.
  • There were processes to escalate concerns regarding patients’ safety and care or treatment once they were admitted to the department.
  • Patients admitted to the department and in the ambulance assessment area had evidence that regular clinical observations had been undertaken, and that an accurate early warning score had been recorded.
  • Although there were gaps in the nurse staffing rota, the emergency department was staffed with nurses who had the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care.
  • The service had sufficient quantities of suitable equipment which was easy to access and ready for use.
  • Staff and managers across the emergency department promoted a positive culture that supported and valued each other. Staff were respectful of each other and demonstrated an understanding of the pressures and a common goal.
  • The emergency paediatric department was managed by competent and skilled consultants in paediatric emergency medicine. Nurses in the department had the right skills knowledge and experience to keep children safe.
  • Children attending the department were clinically reviewed and triaged in a timely way.

Following our inspection, we issued the trust with a section 29A Warning Notice to significantly improve the safety and care of patients by 4 March 2020.

Importantly, the trust must:

  • The trust must ensure that ambulance handovers are timely and effective.
  • The trust must ensure that all patients are assessed in a timely manner and ensure that patients receive assessment and treatment in appropriate environments.
  • The trust must ensure that patients receive medical and speciality reviews in a timely manner.
  • The trust must ensure all risks are assessed to patients using service, particularly the risks of developing pressure ulcers while waiting on trolleys for long periods in the ambulance corridor.
  • The trust must ensure that the dignity of all patients using the service is always protected. This includes specifically the booking in process at the front desk and when speaking to the visual assessment clinician nurse, and for all patients cared for in the ambulance corridor.

In addition, the trust should:

  • The trust should ensure that there are enough consultants working in the department to keep patients safe, even in times of overcrowding.
  • The trust should ensure that its nurse vacancies are fully recruited to in order to keep patients safe, even in times of overcrowding.
  • The trust should address the cultural challenges in the department and ensure there is a cohesive and multi-disciplinary approach to the management of patients in the department.
  • The trust should consider improving emergency department consultant representation at board level.

Professor Edward Baker

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 30 April 2020

Effective

Good

Updated 30 April 2020

Caring

Good

Updated 30 April 2020

Responsive

Requires improvement

Updated 30 April 2020

Well-led

Good

Updated 30 April 2020

Checks on specific services

Medical care (including older people’s care)

Requires improvement

Updated 5 February 2020

Our rating of this service stayed the same. We rated it as requires improvement because:

  • The service did not always have enough staff to care for patients and keep them safe. Staff had not received all their training in key skills. Staff did not always assess risks to patients. Staff did not always fully complete care records.
  • Staff did not always support patients to make decisions about their care as they did not always complete mental capacity assessments.
  • Staff did not always communicate clearly or in a timely way with families and carers.
  • The service did not always meet people’s individual needs as staff could not easily access interpreting services. Staff often moved patients at night including patients living with dementia.
  • Leaders and teams did not have reliable systems to manage performance effectively. They had not identified and escalated all relevant risks and issues and identified actions to reduce their impact.

However:

  • Staff understood how to protect patients from abuse. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers made sure staff were competent. Staff worked well together for the benefit of patients and advised them on how to lead healthier lives. Key services were available seven days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
  • The service had plans to cope with unexpected events. Staff contributed to decision-making to help avoid financial pressures compromising the quality of care.

Services for children & young people

Requires improvement

Updated 5 February 2020

Our rating of this service stayed the same. We rated it as requires improvement because:

  • The service did not have enough nursing staff to care for children and young people and keep them safe. Not all staff had training in key skills. Staff did not always assess risks to children and young people, act on them and keep good care records.
  • Managers monitored the effectiveness of the service. However, good outcomes for patients were not consistently achieved.
  • Staff did not always feel respected, supported and valued.
  • Information systems were not always effective.
  • Not all risks we identified were on the risk register.

However:

  • Staff understood how to protect children and young people from abuse, and managed safety well. The service controlled infection risk well. Staff managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff provided good care and treatment, gave children and young people enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of children and young people, advised them and their families on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
  • Staff treated children and young people with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to children and young people, families and carers.
  • The service planned care to meet the needs of local people, took account of children and young people’s individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
  • Leaders ran services well and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. They were focused on the needs of children and young people receiving care. Staff were clear about their roles and accountabilities. The service engaged well with children, young people and the community to plan and manage services and all staff were committed to improving services continually.

Critical care

Good

Updated 26 January 2017

We rated critical care services at Leicester Royal Infirmary as good overall.

There were sufficient numbers of suitably qualified staff to care for patients. We found a culture where incident reporting was encouraged and understood by staff.

Patients and their relatives were cared for in a supportive and sympathetic manner and were treated with dignity and respect.

There was strong clinical and managerial leadership at both unit and management group level. The service had a vision and strategy for the future.

There was an effective governance structure in place, which ensured that the risks to the service were known, recorded on the trust risk register and discussed. The framework also enabled the dissemination of shared learning and service improvements.

However, we also found some issues with access and flow. In 2015, 47 patients had their elective surgery cancelled because there was no critical care bed available.

Bed occupancy levels were consistently higher than 90% for 2015 thus making it difficult to respond to individual needs. The trust target was 85%.

There were higher levels of non-clinical transfers when compared with similar units.

Pharmacy provision for the critical care service did not fully meet the D16 service specification, and the trust was not compliant with all aspects of NICE guidance 83 ‘Rehabilitation after Critical Illness’.

End of life care

Good

Updated 5 February 2020

Our rating of this service improved. We rated it as good because:

  • The service had enough staff to care for patients and keep them safe. Staff understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them but did not always keep good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients but did not always support them to make decisions about their care, and had access to good information. Key services were available seven days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However:

  • DNACPR orders were not always clear and up to date.
  • Staff were not familiar with the strategy’s aims or how to achieve them.

Outpatients and diagnostic imaging

Requires improvement

Updated 14 March 2018

We previously inspected outpatients jointly with diagnostic imaging so we cannot compare our new ratings directly with previous ratings

We rated it as requires improvement because:

  • Staff did not always manage medicines in a safe way. Medicines were locked in fridges or cupboards and staff regularly checked fridge temperatures however they were not always monitoring the high, low and actual temperatures as they were using old documentation. Staff were unsure of the management of prescription pads and each clinic had a different recording procedure.
  • Patients experienced long waiting times for some clinics. This was an issue we found on our last inspection. In addition, we saw the trust consistently did not meet the cancer 31 day and 62 day targets (however, performance was improving in these areas). Data from the trust showed 25,863 patients were potentially overdue requiring a follow up appointment, 7,108 had been waiting over seven months.
  • Governance arrangements for outpatient services were complex. This meant multiple clinical management groups (CMG) and structures were involved delivering outpatient services. This led to inconsistencies in practice, performance and some concerns around a ‘them and us’ culture between staff in different CMGs. This contributed to some issues we identified in our last inspection not being addressed for example, clinic waiting times. We heard examples of staff not being supported by senior managers.
  • While staff collected the views of patients we saw little evidence managers analysed, responded and improved services because of patient feedback. You said, we did posters on walls did not provide any information on actions take in response to patient concerns. Response rates to feedback initiatives such as message to matron were low
  • Outpatient services did not always manage patient records effectively. Patient records were not always available for clinics, the quality of some records was poor and we saw staff did not always write patients records in a way that met national guidelines.
  • Staff had challenges with the local environment. The lack of clinic space and design of the environment meant we saw an example of staff compromising patient confidentiality to conduct certain procedures. In addition, we saw staff had to store and transport clean and dirty linen in a corridor and had a lack of office or changing space.
  • Leaflets, signage and information were mainly in English. This included pre-appointment letters outpatient services sent to patients. We observed non-English speaking patients having difficulty finding where there appointment was.

However:

  • We found the oncology clinic to be an example of good practice. The service provided multidisciplinary clinics centred around the patient. Patient could access different types of clinical and lifestyle advice from different clinicians and therapy staff. The team based their services on National Institute for Health and Care Excellence (NICE) guidance and standards.
  • Staff assessed the nutrition and hydration requirements of patients. Staff also said they received meaningful appraisals and spoke positively about training and development opportunities. Staff were competent in their roles and understood their roles and responsibilities regarding consent and the Mental Capacity Act 2005. We saw staff try to meet the needs of patients wherever possible including those with a learning disability or those living with dementia.
  • Staff demonstrated knowledge about safeguarding and understood their responsibilities when protecting patients from avoidable harm and abuse. Staff demonstrated good practice regarding hand hygiene and trust audits for the period August 2017 to November 2017 showed staff scored 100%. Staff had procedures to manage the treatment and care of deteriorating or seriously unwell patients. Staff were caring, compassionate and involved patients in their care and treatment.
  • Outpatient services had oversight of performance and risk. Despite poor performance in some areas outpatient services could assess the risk to patients for example, staff conducted harm reviews on patients overdue for their appointments. We saw outpatient services were committed to continuous improvement including setting up an outpatient transformation programme and developing efficient patient pathways. Leaders were proud of their staff.

Surgery

Good

Updated 5 February 2020

Our rating of this service stayed the same. We rated it as good because:

  • Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed most risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
  • Staff monitored the effectiveness of care and treatment. They used the findings to make improvements. Outcomes for patients were positive and mostly met expectations, such as national standards.
  • The service ensured staff were competent for their roles across all areas of the service. Managers appraised staff’s work performance and held supervision meetings with them to provide support and development.
  • Staff treated patients with compassion and kindness most of the time, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service took account of patients’ individual needs and made it easy for people to give feedback.
  • Leaders used reliable information systems. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However:

  • The service did not always have enough nursing staff to care for patients and keep them safe.
  • The service planned care but this did not always meet the needs of local people. People could access the service when they needed it urgently but some had to wait too long for treatment.
  • Systems to manage current and future performance were not always effective.

Urgent and emergency services

Requires improvement

Updated 30 April 2020

We carried out an unannounced focused inspection of the emergency department in response to intelligence we had about the department which was associated to a potential increase in risk. We did not inspect any other core service or wards at this hospital. We did not cover all key lines of enquiry.

At the time of our inspection, the department was under adverse pressure with significant overcrowding. Whilst staff did their best to care for patients with compassion, we found some patients had delays to initial assessments and timely treatments. The trust was implementing a range of actions to reduce overcrowding.

Maternity

Good

Updated 5 February 2020

Our rating of this service stayed the same. We rated it as good because:

  • Staff understood how to protect women from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it. The service used monitoring results well to improve safety.
  • The service controlled infection risk well. Staff used equipment and control measures to protect women, themselves and others from infection. They kept equipment and the premises visibly clean.
  • Staff monitored the effectiveness of care and treatment. They used the findings to make improvements and mostly achieved good outcomes for women. The service had been accredited under relevant clinical accreditation schemes.
  • The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and development.
  • Staff treated women with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.
  • Staff provided emotional support to women, families and carers to minimise their distress. They understood women's personal, cultural and religious needs.
  • Staff supported and involved women, families and carers to understand their condition and make decisions about their care and treatment.
  • The service was inclusive and took account of women’s individual needs and preferences. Staff made reasonable adjustments to help women access services. They coordinated care with other services and providers.
  • Women could access the service when they needed it and receive the right care promptly.
  • It was easy for people to give feedback and raise concerns about care received. The service treated concerns and complaints seriously, investigated them and shared lessons learned with all staff. The service included women in the investigation of their complaint.
  • Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. The service promoted equality and diversity in daily work and provided opportunities for career development. The service had an open culture where patients, their families and staff could raise concerns without fear.
  • Leaders operated effective governance processes, throughout the service and with partner organisations. Staff at all levels were clear about their roles and accountabilities and had regular opportunities to meet, discuss and learn from the performance of the service.

However:

  • Not all staff completed and updated risk assessments for each woman or took action to remove or minimise risks.
  • The service did not always have enough staff with the right qualifications, skills, training and experience to keep women safe from avoidable harm and to provide the right care and treatment. Staff collected safety information but did not always share it with staff, women and visitors.
  • Staff on the wards could not find the data they needed, in easily accessible formats, to understand performance. At times, staff found it difficult to navigate the maternity dashboard.

Maternity (inpatient services)

Updated 13 August 2019

We did not re-rate this service. During this inspection we found:

  • There was not always sufficient consultant presence in Maternity Assessment Unit (MAU).
  • Staff tried to manage the MAU phone line as well as care for women attending the unit which meant triage of women calling the unit was often delayed.
  • The physical environment of MAU did not provide privacy for assessments of women, staff handovers or for staff managing phone calls into MAU.
  • The service had guidance on abdominal pain in pregnancy and guidance on pre-term birth, however, these were not linked as easy reference for staff. Also, the abdominal pain in pregnancy guidance did not include current NICE guidance and recommendations.

  • Two pieces of essential equipment in MAU were not serviced within the due date.

  • Serious incidents were identified and investigated but action to improve the service was not always taken in a timely way.
  • Not all equipment in Maternity Assessment Unit (MAU) was serviced within date, despite this being raised for the maternity service at the previous inspection.

However:

  • The service had enough midwives to care for women attending Maternity Assessment Unit (MAU).
  • The service identified and investigated incidents within timescales and kept women and families informed.
  • The service had made some improvements following recent incidents.
  • The service had governance structures in place to manage incidents.
  • Learning from serious incidents was shared with staff in a timely way.
  • Managers used various formats to promote sharing and learning with staff.

Diagnostic imaging

Requires improvement

Updated 14 March 2018

We previously inspected diagnostic imaging jointly with outpatients so we cannot compare our new ratings directly with previous ratings.

We rated it as requires improvement because:

  • Quality assurance and scientific support for staff was not given sufficient priority. Equipment was not consistently checked and there was a lack of dedicated time from the imaging department to ensure the ionising radiation regulations were adhered to.
  • The governance processes in relation to policy, guidelines and dosing levels was not robust. Patient doses were not kept ‘as low as reasonably practicable’, as required under the ionising radiation (medical exposures) regulations 2000.
  • There was a lack of awareness and understanding of dose levels and staff were not always using exposure charts.
  • We found staff were sometime accessing paper files which were not always the most recent documentation, and lacked awareness of how to access information on the most current procedures.
  • Staff were not consistently checking resuscitation trolleys as per trust policy across the majority of the imaging departments. We found some trolleys had out of date, missing or inappropriate stock stored in them.
  • There were no sufficient mechanisms in place regarding the handover and handback of equipment prior to and following manufacturer visits

However:

  • All patients we spoke to spoke positively about the care they had received in the department and told us they had received reassurance and support whilst using the service. Staff showed an encouraging, sensitive and supportive attitude to people who used the services and we saw they responded in a compassionate and appropriate way when people experienced distress.
  • The imaging services within the new emergency department were more convenient and were a more positive patient experience.
  • Imaging backlogs were being reduced despite significant IT issues.