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Leicester Royal Infirmary Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 14 March 2018

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

A summary of this hospital appears in the overall summary above.

Inspection areas

Safe

Requires improvement

Updated 14 March 2018

Effective

Good

Updated 14 March 2018

Caring

Good

Updated 14 March 2018

Responsive

Requires improvement

Updated 14 March 2018

Well-led

Requires improvement

Updated 14 March 2018

Checks on specific services

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.

Maternity and gynaecology

Good

Updated 14 March 2018

We previously inspected maternity jointly with gynaecology so we cannot compare our new ratings directly with previous ratings.

We rated it as good because:

  • The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave women and families honest information and suitable support.
  • The service controlled infection risk well. Predominantly, staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance, which was up to date.
  • Staff of different kinds worked together as a team to benefit women. Doctors, midwives nurses and other healthcare professionals supported each other to provide good care.
  • Staff cared for women with compassion. Feedback from women confirmed that staff treated them well and with kindness.
  • Women could access the service when they needed it. Access to and availability of the service was in line with guidance.
  • The service took account of women’s individual needs. A wide variety of specialist midwives enabled care to be tailored too individual needs.
  • The homebirth and midwife led birth centre ensured women had choice in the birth they required.
  • The trust had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care.
  • Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. Communication throughout the unit was described by staff as good.

However:

  • The service did not always use safety monitoring results. Senior staff collected safety information, but sharing with staff, women and visitors was limited. The information collected was not rated for comparison to national data. However, the service used elements of the information to improve the service.
  • The service had suitable premises; however, not all equipment was serviced or looked after well. Equipment did not have tracking numbers on or evidence of recent servicing.
  • The service did not always store medicines well. Medicines were stored in areas accessible to members of the public, and fridge temperatures were not always checked. However, they prescribed, gave, and recorded medicines well. Women received the right medication at the right dose at the right time.
  • The service did not always have enough staff. Medical and midwifery staffing figures were below the nationally recommended levels.

Medical care (including older people’s care)

Requires improvement

Updated 29 June 2018

  • Despite improvements since our last inspecrtion,people did not always receive their medicines as prescribed. The process of prescription of when required insulin was inconsistent. Patients did not receive prescribed insulin in response to increasing blood glucose levels.

  • Medicine fridge temperatures were not always checked in line with trust guidance. Staff could not be assured medicines were stored at a correct temperature.

  • Staff did not complete fluid balance charts meaning staff did not always have the complete information they needed before providing care and treatment.

  • There were periods of understaffing which the trust were unable to address.

  • Some wards demonstrated a 25% compliance with the hand hygiene audit. Others did not manage or sustain improvement in the audits.

  • Entrance and exit areas to ward 43 remained cluttered and a hazard for rapid entry or exit to the ward.

  • Staff were not consistent in their use of I am clean stickers.

However:

  • The was a clearly defined incident reporting process to keep people safe, although staff did not always report staffing concerns.

  • The trust were increasing data collection to monitor at risk patients and monitor trends in the incidents around insulin safety.

  • Ward areas were visibly clean and infection rates were better than the national average.

  • We saw some improvements in the care of patients with diabetes.

  • Safeguarding adults at risk was given sufficient priority.

  • Patient’s risk assessments were predominantly completed appropriately and patient observations were completed and where necessary escalated appropriately.

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.

Urgent and emergency services (A&E)

Requires improvement

Updated 14 March 2018

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

  • The department had not achieved the trust target of 95% for staff mandatory training. Not all staff had received the appropriate levels of safeguarding training for both adults and children and appraisal rates for staff had not achieved the 95% trust target.
  • Patients with mental health issues were not always fully assessed in the emergency department and a service level agreement with the local mental health trust was not in place for Mental Health Act Administration functions.
  • Patient group directives for medicines were not always up to date and a list of staff who used them was unavailable.
  • The emergency department had not achieved the Department of Health’s 95% performance target from October 2016 to September 2017 and there were sometimes delays for emergency medical staff being able to refer patients to specialty services in a timely manner.

However:

  • There were effective streaming and triage processes in place. Adults and children were assessed at point of entry to the emergency department by a visual acuity nurse and sent to the most appropriate area for their need. The trust’s median time to initial assessment had shown a trend in improvement from April 2017 (median nine minutes) through to August 2017 (four minutes) where the trust performed better than the England average of seven minutes. During our inspection patients were mostly seen and assessed within 15 minutes.
  • Identification and treatment for patients with sepsis had improved since our last inspection. A clearly identified sepsis nurse was on duty 24 hours a day to ensure treatment for patients was not delayed.
  • Care and treatment was provided in line with national guidance and pain levels were assessed with medication provided appropriately.
  • Cleanliness of all areas had improved and staff observed infection control measures. Sepsis identification and treatment in the emergency department had improved. A sepsis nurse was available 24 hours a day to ensure treatment for patients was not delayed.
  • There was a strong culture of patient focussed care with staff providing compassionate care and emotional support ensuring patients privacy and dignity was protected. Where possible staff involved patients and relatives in decisions about their care and treatment.
  • Patient transfer delays between ambulances and the emergency department had improved.
  • Leaders were visible and supportive and had the knowledge, skills and experience to provide a well-led service.

Surgery

Good

Updated 26 January 2017

We rated surgical care services at the Leicester Royal Infirmary as good.

On all the wards and departments we visited, we saw staff acting in a kind and caring way towards patients and the public. Relatives and carers told us they felt involved and informed.

Patients had access to a wide range or resources and materials, both online and in paper formats, which were individualised and tailored to their needs. For example enhanced recovery programmes.

We found nursing staff consistently followed trust guidelines for the completion and escalation of deteriorating physiological observations and early warning scores (EWS).

However;

Staff did not always recognise, concerns, incidents or near misses for example not reporting missing medical notes, or the lack of computers.

The pathway for pre-operative and high-risk anaesthesia patients was not consistently followed causing potentially avoidable delays and cancellations. Some patients were not having pre-operative assessment despite being identified as high risk for anaesthetic.

Departmental governance and risk management arrangements were not robust and as such did not always protect patients from avoidable harm.

Intensive/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’.

Services for children & young people

Requires improvement

Updated 26 January 2017

We rated services for children and young people at the Leicester Royal Infirmary as requires improvement overall.

Mandatory training levels for Advanced Paediatric life support, mandatory training and level three safeguarding training did not meet the trust target. The trust did not meet Royal College of Paediatrics and Child Health (RCPCH) standards for sufficient paediatric consultants.

The service could not provide at least one nurse per shift in each clinical area trained in Advanced Paediatric Life Support (APLS) or European Paediatric Life Support (EPLS) training.

The service had a backlog of children needing to be seen for certain specialities which meant children waiting long periods of time for surgical procedures.

Staff were not always trained to care for complex patients requiring high dependency care.

Medical records were not always kept safely and securely.

Learning from incidents was shared with staff through emails and team meetings. There were robust safeguarding policies and procedures in place.

Equipment was checked and available for staff to be able to carry out their role.

The service offered a holistic range of services to meet children and young people’s needs.

Medication monitoring practices were effective and medications were administered safely.

Patients received evidenced based care and there was good multi-disciplinary working between nursing and medical teams.

However we also found staff were caring, compassionate and respectful to children, young people and their families.

End of life care

Requires improvement

Updated 26 January 2017

We rated end of life care services at the Leicester Royal Infirmary as requires improvement. We rated safe, responsive and caring as good with effective and well led as requires improvement because.

The medical staffing levels were not in line with the recommendations from the National Council for Palliative Care who recommend there should be one whole time equivalent (WTE) consultant for every 250 beds. The service had 3.5 WTE consultants and would require 7.0 WTE to provide cover to the three sites. The staffing was 50% lower than recommended.

The trust had 82 syringe drivers that were in line with best practice guidelines. However, only ten were ready for use. This meant the trust was reliant on using syringe drivers, which did not meet the NHS patient safety guidance.

We looked at 23 ‘Do Not Attempt Cardio Pulmonary Resuscitation’ orders (DNACPR) across the trust and found there were inconsistencies in how these were completed. We found that out of 23 DNACPR orders, six were completed correctly (25%). We found staff had not always followed trust policy when they completed DNACPR orders.

The trust had taken part in the National Care of the Dying Audit 2016 and had achieved three of the eight organisational Key Performance Indicators (KPIs). The trust scored lower than the England average for all five Clinical KPIs. The trust had undertaken an audit in April 2016 in response to the National Care of the Dying Audit 2016, and an action plan had been developed to address the KPI’s that had not been achieved.

The service did not have its own risk register and risks were not recorded on the trust wide risk register.

There was no strategic plan for end of life care throughout the trust.

The service did not have a non-executive director representing end of life care at board level.

However, we also found that care records were mostly maintained in line with trust policy.

Staff understood their responsibilities in following safeguarding procedures and care and treatment was delivered in line with recognised guidance and evidence based practice. The last days of life care plan was in use throughout the trust.

The trust had effective multidisciplinary working in place and staff were seen to be compassionate and we observed them treating patients and their families with dignity and respect.

A bereavement service was available to support family members with practical and support issues after the death of a patient. The chaplaincy service provided a 24 hour, seven days a week on call service for patients in the hospital, as well as their relatives.

The specialist palliative care team were committed to ensuring that patients receiving end of life care services had a positive experience.

The trust had a rapid discharge home to die pathway. Discharge in these circumstances was arranged by the specialist discharge sister and could be facilitated within a few hours for patients wishing to return home.

Staff spoke positively about the service they provided for patients. High quality, compassionate patient care was seen as a priority. Staff within the specialist palliative care team spoke positively and passionately about the service and care, they provided for patients.

The trust had recruited a bereavement nurse specialist in July 2015 who worked across the three hospital sites and closely with the specialist palliative care team (SPCT).