All inspections: Leicester Royal Infirmary

Pages 1 and 2 of this report relate to the hospital and the ratings of that location, from page 3 the ratings and information relate to maternity services based at Leicester Royal Infirmary.

We inspected the maternity service at Leicester Royal Infirmary as part of our national maternity inspection programme. The programme aims to give an up-to-date view of hospital maternity care across the country and help us understand what is working well to support learning and improvement at a local and national level.

We will publish a report of our overall findings when we have completed the national inspection programme.

We carried out an announced focused inspection of the maternity service, looking only at the safe and well-led key questions.

We also inspected Leicester General Hospital and St Marys Birth Centre run by University Hospitals Leicester NHS Trust. Our reports are here:

Leicester General Hospital – https://www.cqc.org.uk/location/RWEAK

St Mary’s Birth Centre – https://www.cqc.org.uk/location/RWE10

How we carried out the inspection

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

We carried out this unannounced focused inspection of both the urgent and emergency care and medical care core service because we had concerns about the quality of services in these core services. These concerns included waiting times for patients, delays in their care and treatment, delayed discharges, and delays in being able to hand over patents waiting in ambulances. We also checked the quality of services in response to a warning notice we issued following our inspection of urgent and emergency care in January 2020.

During this inspection we inspected the urgent and emergency care and medical care core services using our focused inspection methodology. We did not cover all key lines of enquiry; however, we have re-rated some key questions based on the findings from our inspection. We rated both these core services as requires improvement. Overall, we rated safe and responsive as requires improvement in both urgent and emergency care and medical care services. We did not rate the effective, caring or well led domains.

Our rating of urgent and emergency care services stayed the same. We rated it as requires improvement and have taken enforcement action as a result of this inspection to promote patient safety. We served a warning notice to the trust requiring them to make improvements to their urgent and emergency care services, to address safety concerns in respect of staff deployment, flow in, through and out of the emergency department, timely and consistent medical in-reach processes, privacy and dignity, clarity in respect of clinical responsibility when patients were referred to speciality services and triage processes.

We did not inspect surgery, services for children and young people, outpatients or diagnostic imaging previously rated requires improvement. We are monitoring the progress of improvements to services and will re-inspect them as appropriate.

We had an additional focus on the urgent and emergency care pathway across Leicester, Leicestershire and Rutland and carried out a number of inspections of regulated services across a few weeks. This was to assess how patient risks were being managed across health and social care services during increased and extreme capacity pressures.

A summary of CQC findings on urgent and emergency care services in Leicester, Leicestershire and Rutland.

Urgent and emergency care services across England have been and continue to be under sustained pressure. In response, CQC is undertaking a series of coordinated inspections, monitoring calls and analysis of data to identify how services in a local area work together to ensure patients receive safe, effective and timely care. We have summarised our findings for Leicester, Leicestershire and Rutland below:

Leicester, Leicestershire and Rutland

Provision of urgent and emergency care in Leicester, Leicestershire and Rutland was supported by services, stakeholders, commissioners and the local authority.

We spoke with staff in services across primary care, integrated urgent care, acute care, mental health services, ambulance services and adult social care. Staff had worked very hard under sustained pressure across health and social care services.

People reported difficulties when trying to see or speak to their GP. Some GP practices had invested in new technology to improve telephone access. Staff working in GP practices signposted patients to extended and out of hours services to prevent people attending the emergency department whenever possible.

Staff working in urgent care reported an increase in demand and an increase in acuity of patients presenting to their services. Some staff reported frustrations in relation to urgent care pathways; staff working in advanced clinical practice were not always empowered to make referrals into alternative pathways.

Staff working in urgent care services reported challenges due to the volume of pilots focused on admissions avoidance running across Leicester, Leicestershire and Rutland. Many pilots ran for relatively short periods of time and were often impacted by staffing issues. This made it difficult to maintain oversight of pathways available to avoid acute services. However, some pilots had proved successful and prevented ambulance responses and hospital admissions.

Staff working across urgent and emergency care services raised concerns about their skills set. Some ambulance staff feared the shift from dealing with multiple emergencies to providing longer term care for one patient in a shift, in combination with having less time for training, impacted on their competency. Some staff in urgent care services felt they needed additional training to meet the needs of patients presenting with higher acuity.

Patients seeking advice from NHS111 in Leicester, Leicestershire and Rutland experienced some delays getting through to the service, when compared against national targets. However, at the time of our inspection, performance was better than England averages for key indicators including the percentage of calls answered within 60 seconds, and call abandonment rates. Staffing continued to be a challenge across NHS111, however recruitment was on-going.

Out of hours care had been challenging throughout the pandemic as staff were redeployed to other key services, this had particularly impacted on home visiting services.

The emergency department serving Leicester, Leicestershire and Rutland is within a large, city centre hospital. Poor patient flow across health and social care has further increased the significant pressure on this emergency department. This pressure has resulted in long delays in care and treatment. Long delays in ambulance handovers have, in turn, resulted in a high number of hours lost to the ambulance service whilst their crews wait outside hospital. This causes further delays in responding to 999 calls to patients in the community with serious conditions.

Ambulance crews reported an increase in the volume of patients calling 999 who told them they had been unable to see their GP and crews often signposted patients back into primary care.

We found psychiatric liaison services at the city centre hospital were well run and designed to meet people’s needs. Staff demonstrated effective partnership working with a person-centred approach and good use of alternative pathways to avoid admission into acute or social care services.

We found that staff working across specialisms in acute services did not always provide sufficient in-reach into the emergency department to improve patient flow and the care received. This was particularly apparent at night. Beds were not allocated to patients until they had been accepted by specialists, this meant some patients spent additional time waiting in ED. During our inspection, between 45 and 60 beds were needed for new patients waiting in ED. Some patient transfers to other hospitals in Leicester, Leicestershire and Rutland stopped at 8pm, this restricted patient flow out of the city centre hospital.

Some staff reported frustrations with escalation processes across health and social care in Leicester, Leicestershire and Rutland. At times when the city centre hospital and the ambulance service was under significant pressure, staff felt there was a lack of diverts available to other sites or services and that system partners were slow to respond. There was a rapid ambulance handover process when services were in escalation; however, staff reported these were not effective.

There was a high number of patients in hospital who were medically fit for discharge but remained in acute services. System stakeholders worked together to consider discharge pathways; however, at the time of our inspections the number of patients awaiting discharge remained very high. Delays were still commonplace and capacity in community and social care services impacted on the ability of staff to safely discharge patients. Communication about discharge and discharge processes were impacting on the quality of transfers of care to social care services.

People living in a social care setting experienced long delays, particularly when accessing 111 or 999 services. Although advice was provided, this had resulted in significant waits and poor outcome, especially for people who had fallen and remained on the floor. Staff working in social care services told us they had limited access to support and advice and relied on GPs, 111 or 999.

System wide collaboration, accountability and risk sharing needs to improve to alleviate pressure on key services in Leicester, Leicestershire and Rutland

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

The service did not always have enough staff to care for patients and keep them safe. Patients risks were not always assessed, and medicine administration was not always carried out in a timely manner which had the potential to cause patient harm.
Patient care, treatment and access was impacted by the lack of medical review processes within urgent and emergency care services.

However:

Local leaders and managers had the right skills and abilities to run the service and were visible to staff. They supported staff to develop their skills and take on more senior roles.
Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
The service controlled infection risk well. Staff used equipment to protect patients, themselves and others from infection. They kept equipment and the premises visibly clean.

How we carried out the inspection

During our inspection we spoke with 70 staff, of various specialty and profession including consultants, doctors, nurses, pharmacists, healthcare support staff, matrons, and senior managers. This included interviews conducted after the inspection visit on site.

During our inspection we visited the GP assessment unit, acute frailty unit, Acute Medical Unit (AMU), discharge lounge, the stroke ward 26, older people's wards 23 and 29, wards 33 and 34 and ambulatory care. We visited all areas of the emergency department.

We spoke with 24 patients and reviewed 48 patient records, including additional electronic versions.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

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

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

We rated safe, responsive and well-led as requires improvement and effective and caring as good.
In rating the hospital, we took into account the current ratings of the services not inspected this time.
Not all services had enough staff to care for patients and keep them safe. Staff in medical care (including older people’s care), maternity and services for children and young people had not received all their training in key skills. Staff in medical care (including older people’s care), maternity and services for children and young people did not always assess risks to patient’s, act on them and keep good care records.
Staff in medical care (including older people’s care) and end of life care did not always support patients to make decisions about their care as they did not always complete mental capacity assessments.
People in urgent and emergency services, surgery and maternity could not always access services when they needed it and had to wait too long for treatment.
Not all services had reliable systems to manage performance effectively. Some services had not identified and escalated all relevant risks and issues and identified actions to reduce their impact.
Information systems were not always effective in maternity and end of life care.

However:

Services understood how to protect patients from abuse. They managed medicines well. The services managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve services.
Services provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Staff worked well together for the benefit of patients and advised them on how to lead healthier lives.
Managers monitored the effectiveness of services and good outcomes for patients were mostly achieved across all services.
Services 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.
Staff understood the trust’s vision and values, and how to apply them in their work. They were focused on the needs of people receiving care.

University Hospitals of Leicester NHS Trust is a teaching trust and was formed in April 2000 following the merger of Leicester General Hospital, the Glenfield Hospital and Leicester General Hospital. The trust has 1,993 general and acute beds. Of these beds, 147 are maternity beds and 49 are critical care beds.

University Hospitals of Leicester NHS Trust provide specialist and acute services to a population of one million residents throughout Leicester, Leicestershire and Rutland. The trust’s nationally and internationally-renowned specialist treatment and services in cardio-respiratory diseases, cancer and renal disorders reach a further two to three million patients from the rest of the country. The trust provides services from three hospital sites, Leicester Royal Infirmary, Leicester General Hospital and the Glenfield Hospital.

Leicester Royal Infirmary is close to Leicester city centre and provides Leicestershire’s only emergency department. The hospital has approximately 937 inpatient beds and 85 day-case beds.

We carried out an unannounced inspection of maternity wards at the Leicester Royal Infirmary on 8 May 2019 in response to three incidents reported by the trust between January and May 2019. The inspection was not intended to re-rate the service. The previous ratings of the maternity service will still stand and will not be affected by this inspection.

We did not inspect any other core services or wards at this hospital. During this inspection we focussed on the key questions of safe and well led.

There were some areas where the trust needs to make improvements.

Importantly, the trust must:

Ensure there is sufficient consultant presence in Maternity Assessment Unit (MAU).
Ensure there is clear escalation guidance for staff in MAU when medical staff are busy or unavailable.

In addition, the trust should:

Ensure the MAU phone line is managed effectively, including timely triage and advice for women.
Ensure the physical environment of MAU provides privacy for assessments of women and staff handovers. Also, privacy for staff managing phone calls into MAU.
Ensure the abdominal pain guidance and pre-term labour guidance link with each other and include current NICE guidance and recommendations.
Ensure the requirement notice relating to equipment servicing from the previous inspection is met.

Professor Ted Baker Chief Inspector of Hospitals

University Hospitals of Leicester NHS Trust is one of the biggest acute trusts in England. Formed in April 2000, it is a teaching trust which provides specialist and acute services to a population of around 100,00,000 patients throughout Leicester, Leicestershire and Rutland. The Trust’s nationally and internationally-renowned specialist treatment and services in cardio-respiratory diseases, cancer and renal disorders reach a further two to three million patients nationally.

The trust operates acute hospital services from three main hospital sites:

Leicester Royal Infirmary
Leicester General Hospital
Glenfield Hospital

Leicester Royal Infirmary is close to Leicester city centre and provides Leicestershire’s only emergency department. The hospital has approximately 982 inpatient beds and 66 day-case beds.

We served a warning notice under Section 29A of the Health and Social Care Act 2008 in December 2017. The warning notice was served as we found evidence to suggest the quality of health care in relation to management of insulin for diabetic patients’ required significant improvement. We carried out an unannounced focused inspection on 29 May 2018 to follow up actions taken following the issue of the warning notice and to see if significant improvements had been made.

We inspected the safe domain in the core service of Medicine at this location. We did not inspect any other core services or wards at this hospital. This was a focused inspection. Information for the location as a whole can be found in our previous report published in March 2018. This can be accessed at http://www.cqc.org.uk/sites/default/files/new_reports/AAAH1561.pdf.

Our key findings for this focussed inspection were as follows:

There had been improvements in the care of patients with diabetes since our last inspection, however, further improvement was required in the monitoring and embedding of the actions taken as we found that people did not always receive their medicines as prescribed. The process of prescription of when required insulin was inconsistent.
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 always complete fluid balance charts meaning staff did not always have the complete information they needed before providing care and treatment.
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:

There 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.

There were areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

The trust must ensure that all staff follow the prescription and trust guidance when monitoring patients blood glucose levels and administering as required insulin.
The trust must ensure medicine fridge temperatures are recorded daily to ensure medicine are stored at the correct temperature.
The trust must ensure staff have up to date mandatory training.
The trust must ensure staff complete accurate fluid balance charts to support safe care and treatment of patients.

In addition the trust should:

The trust should ensure staff follow a consistent process when prescribing as required (PRN) insulin to patients.

Professor Ted Baker

Chief Inspector of Hospitals

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

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

University Hospitals of Leicester NHS Trust is a teaching trust formed in April 2000 following the merger of Leicester General Hospital, the Glenfield Hospital and Leicester Royal Infirmary. The trust has 1,978 general and acute beds. Of these beds, 141 are maternity beds and 49 are critical care beds.

University Hospitals of Leicester NHS Trust provide specialist and acute services to a population of one million residents throughout Leicester, Leicestershire and Rutland. The trust’s nationally and internationally-renowned specialist treatment and services in cardio-respiratory diseases, cancer and renal disorders reach a further two to three million patients from the rest of the country. The trust provides services from three hospital sites, Leicester Royal Infirmary, Leicester General Hospital and the Glenfield Hospital.

Leicester Royal Infirmary is close to Leicester city centre and provides Leicestershire’s only emergency department. The hospital has approximately 967 inpatient beds and 68 day-case beds.

We carried out this unannounced focused inspection of wards 42 and 43 on 18 July 2017, in response to concerning information we had received about patient care on these wards.

We did not inspect any other core services or wards at this hospital or any of the other locations provided by University Hospitals of Leicester NHS Trust. During this unannounced focused inspection, we only inspected the key questions of safe and caring.

We did not rate the two key questions at this inspection because the scope of the inspection was limited to two wards.

Our key findings were as follows:

Safety concerns were not consistently identified or addressed quickly enough. We found staff were not always reporting staffing shortages as incidents and on a number of occasion we had to prompt staff to consider reporting concerns we identified as incidents.
Systems, processes and standard operating procedures were not always reliable to protect patients from avoidable harm as staff were not following these, for example medicines, infection prevention and control and completion of patient records.
Compliance with resuscitation, fire safety and safeguarding adults and children training was low particularly amongst medical staff.
Staff did not always assess, monitor or manage the risk to patients for example we saw fluid balance charts which were not up to date and patients did not always get their medicines when required. Care records were not always completed or updated appropriately.
The risks associated with anticipated events and emergency situation were not fully recognised, assessed or managed.
Staff mostly responded compassionately when patients needed help and support, however we observed isolated cases where patients were not treated with compassion or afforded dignity and respect.
We found there was little evidence of patients receiving regular two hourly care rounding. Whilst staff were in and out of the bays we did not always see they checked on each patient’s needs.
Feedback from patient and relatives was mostly positive about the way staff treated them.
Staff helped patients and those close to them to cope emotionally.
Staff explained the treatment and care they were delivering to patients in a way patients could understand. We also heard staff talking to patients who required support with their personal hygiene, involving them in their care.
We saw clinical nurse specialists on the wards providing reassurance for patients who were anxious. This included spending time with the patient, explaining what the patient should experience and how staff would help.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

The trust must take action to ensure that there are sufficient number of suitably qualified, competent, skilled and experienced staff to make sure that they can meet peoples care and treatment needs.
Ensure fire exit doors and entrances to wards are not blocked.
Ensure staff are aware of and receive training in specific fire evacuation plans for the wards and that staff are familiar with the trust major incident and business continuity plans.
Ensure staff receive training in the use of evacuation equipment.
Ensure there are sufficient numbers of nursing and medical staff trained and in date with resuscitation and safeguarding adult and children training.
Ensure nurses follow systems and processes to ensure they minimise the risk of spreading infection when patients are being barrier nursed in side rooms.
Ensure nurses follow national guidelines and local policies when administering medication to patients.
Ensure medications are stored securely and at the correct temperature.
Ensure staff follow instructions on prescription charts including supplementary insulin charts so that all medicines are administered as prescribed.
Ensure patient records are complete, including the completion of end of life care plans, fluid balance charts risk assessments and care rounding documentation.
Ensure staff report incidents in line with their incident reporting policy.
Ensure systems are put in place to enable staff to identify whether a piece of equipment such as a commode has been cleaned between patient use.

In addition the trust should:

Ensure cleaning products are locked away and are not accessible to patients on Wards 42 and 43.
Ensure staff follow the correct procedure for the partial closure of sharps bins in line with their sharps management policy.
Ensure oxygen cylinders are stored securely to minimise the risk of injury if they are knocked over.

Professor Ted Baker

Chief Inspector of Hospitals

University Hospitals of Leicester NHS Trust is a teaching trust that was formed in April 2000 following the merger of Leicester General Hospital, the Glenfield Hospital and Leicester General Hospital. The trust has 1,959 general and acute beds. 147 of these beds are maternity beds and 49 are critical care beds. 975 inpatient beds and 66 day-case beds are located at Leicester Royal Infirmary.

University Hospitals of Leicester NHS Trust provide specialist and acute services to a population of one million residents throughout Leicester, Leicestershire and Rutland. The trust’s nationally and internationally-renowned specialist treatment and services in cardio-respiratory diseases, cancer and renal disorders reach a further two to three million patients from the rest of the country. The trust provides services from four hospital sites, Leicester Royal Infirmary, Leicester General Hospital,Glenfield Hospital and St Mary's maternity hospital.

Leicester Royal Infirmary is close to Leicester city centre and provides Leicestershire’s only emergency department. The hospital has approximately 975 inpatient beds and 66 day-case beds. There were 86,943 inpatient admissions, 511,864 outpatient attendances and 135,111 emergency department attendances between April 2015 and March 2016.

We inspected Leicester Royal Infirmary in January 2014 under our new inspection methodology and rated it as requiring improvement. We also undertook an unannounced focused inspection of the emergency department at Leicester Royal Infirmary on the evening of 30 November 2015 because we were concerned about potential risks to patient safety in the emergency department. Following this inspection, we undertook urgent enforcement action to protect patients from the risk of harm.

During this inspection we followed up on the identified areas that required improvement from the 2014 inspection. We looked at a wide range of data, including patient and staff surveys, hospital performance information and the views of local partner organisations. The announced part of the inspection took place between the 20 and 23 June 2016, but the critical care service was inspected between the 25 and 27 July 2016. We also carried out unannounced inspections to Leicester Royal Infirmary, the Glenfield Hospital and Leicester General Hospital on 27 June, 1 July and 7 July 2016.

Overall we found the Leicester Royal Infirmary was performing at a level which led to the judgement of requires improvement. We inspected all eight core services at this hospital; two were rated as good and six were rated as requires improvement.

Our key findings were as follows:

There was a good incident reporting culture in the trust and systems were in place to enable staff to report incidents. Staff were aware of their responsibilities in relation to reporting incidents, managers undertook incident analyses and investigations to determine any areas of improvement and staff were provided with feedback.
Staff had a varied understanding about the duty of candour regulation and we saw examples where duty of candour had been applied appropriately.
Recognised staffing assessment tools were used to assess the required numbers and skill mix of staff.
Like many trust's in England, there were staff shortages in some areas for doctors, nurses and allied health professionals. Some areas had higher vacancy levels than others. The trust had recruited a number of registered nurses from overseas. The trust also used bank and agency staff to meet the needs of patients.
There were effective safeguarding procedures in place for both adults and children. However, staff were not always sure of the level of safeguarding children training they had received.
Emergency equipment was checked on a daily basis. We found that relevant checks had been undertaken and documented.
We were concerned about the trust’s management of deteriorating patients and those who presented with sepsis. This is a severe infection which spreads in the bloodstream and if left untreated can lead to death. Where patients had met the trust’s criteria for sepsis screening, they were not all screened in accordance with national guidance. This put patients at risk of not receiving the correct treatment in a timely manner.
Medicines in the emergency department were not always securely stored.
Staff mostly followed infection prevention and control policies and cleansed their hands between tasks and contact with patients.
It was not always clear to see whether equipment was cleaned following use as it was not always labelled appropriately to indicate it had been cleaned. In some areas effective cleaning would not be possible due to aging and damaged furniture.
Until May 2016, cleaning services had been contracted out to a private provider. There had been problems with cleanliness prior to our inspection which were identified through the trusts own audits. During our inspection, we found that environmental cleanliness had not always been given sufficient priority, especially in public areas such as toilets.
In most of the services, patients’ needs were assessed and care and treatment was delivered in line with legislation, evidence based practice.
Staff on all the wards were mostly observed to be polite and courteous to patients and saw a number of examples of good care.

We saw several areas of outstanding practice including:

Staff in the paediatric emergency department told us about the development of ‘greatix’, this was to enable staff to celebrate good things in the department. Staff likened it to ‘datix’, which enabled staff to raise concerns. Staff used greatix to ensure relevant people received positive feedback relating to something they had done. Many staff throughout the emergency department told us of times when they had received feedback though greatix and told us how this made them feel proud and valued.
On Ward 42, we attended a ‘posh tea round’. This took place monthly on the ward and provided an opportunity for staff and patients to engage in a social activity whilst enjoying a variety of cakes not provided during set meal times.
During our visit to Ward 23, a patient was refusing to eat. The meaningful activities facilitator sat and had their dinner with the patient. They told us by making it a social event they hoped the patient would eat.
Within oncology and chemotherapy, a 24-hour telephone service was available for direct patient advice and admission in addition to a follow up telephone service to patients following their chemotherapy at 48 hours, one week and two weeks post treatment.

The trust had introduced a non-religious carer to provide pastoral support in times of crisis to those patients who do not hold a particular religious affiliation .Also to provide non-religious pastoral and spiritual care to family and staff.

Midwifery staff used an innovative paper based maternity inpatient risk assessment booklet which included an early warning assessment tool known as the modified early obstetric warning score (MEOWS) to assess the health and wellbeing of all inpatients. This assessment tool enabled staff to identify and respond with additional medical support if required. The maternity inpatient risk assessment booklet also included a situation, background, assessment, recommendation (SBAR) tool, a sepsis screening tool, a venous thromboembolism (VTE) assessment tool which also had a body mass index chart, a peripheral intravenous cannula care bundle, a urinary catheter care pathway and assessment tools for nutrition, manual handling and a pressure ulcer risk score. This meant that all assessment records were available together.
The pain management service won the national Grünenthal award for pain relief in children in 2016. The Grünenthal awards recognised excellence in the field of pain management and those who were striving to improve patient care through programmes, which could include the commissioning of a successful pain management programme.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

Urgent & emergency services

The trust must take action to ensure nursing staff adhere to the trust’s guidelines for screening for sepsis in the ward areas and in the emergency department. This also applies to medical areas.
The trust must take action to ensure standards of cleanliness and hygiene are maintained at all times to prevent and protect people from a healthcare-associated infection. This also applies to medical areas and outpatient and diagnostic areas.
The trust must ensure that patients in the emergency department have venous thromboembolism (VTE) risk assessments completed.
The trust must ensure the privacy and dignity of patients within the majors area and the assessment area of the emergency department.

Medicine

The trust must ensure patient side rooms with balconies have been risk assessed in order to protect vulnerable patients from avoidable harm.

Critical Care

The trust must ensure 50% of nursing staff within critical care have completed the post registration critical care module. This is a minimum requirement as stated within the Core Standards for Intensive Care Units.

Surgery

The trust must ensure DNACPR decisions are documented fully in accordance with the legal framework of the Mental Capacity Act 2005.

Maternity and gynaecology

The trust must ensure there are sufficient numbers of suitably qualified, competent, skilled and experienced persons to meet the requirements of the maternity and gynaecology service.
The trust must ensure that midwives have the necessary training in the care of the critically ill woman and anaesthetic recovery in line with current recommendations.

Services for children and young people

The trust must ensure at least one nurse per shift in each clinical area is trained in APLS or EPLS as identified by the RCN (2013) staffing guidance.
The trust must ensure Neonatal staffing at the Leicester Royal Infirmary (LRI) neonatal unit is compliant with the British Association of Perinatal Medicine Guidelines (BAPM) (2011).
The trust must ensure children under the age of 18 years are not admitted to ward areas with patients who are 18 years and above unsupervised.
The trust must ensure nursing staff have the appropriate competence and skills to provide the required care and treatment for children who require high dependency care.

End of life

The trust must ensure 'do not attempt cardio-pulmonary resuscitation' (DNACPR) forms are completed appropriately in accordance with national guidance, best practice and in line with trust policy.
The trust must ensure there are sufficient numbers of suitable syringe drivers with accepted safety features available to ensure patients receive safe care and treatment.

Outpatients & Diagnostic Imaging

The trust must ensure the waiting environment for ophthalmic patients and eye casualty is fit for purpose.
The trust must ensure that all equipment, especially safety related equipment is regularly checked and maintained.
The trust must ensure it has oversight of planning, delivery and monitoring of all care and treatment so it can take timely action on treatment backlogs in the outpatient departments.

In addition the trust should:

The trust should ensure cleaning products are locked away and are not accessible to patients on Ward 23.
The trust should ensure patient side rooms with balconies have been risk assessed in order to protect vulnerable patients from avoidable harm.
The trust should ensure medical notes, for patients who have been discharged are locked away and are not accessible to patients or the public on Ward 23.
The trust should ensure patient’s individual care records are written and managed in a way that keeps patient’s safe. This includes ensuring patient records on ward 26 are up to date.
The trust should ensure assistance with mealtimes is carried out in a timely way and provision of food outside of mealtimes is sufficient and includes access to a hot meal.
The trust should ensure Deprivation of Liberty Safeguards (DoLS) are always applied appropriately.
The trust should ensure male and female patients are not occupying the same bed bay unless there is a clinical need to do so.
The trust should consider reviewing the numbers of patients being moved between wards out of hours.
The trust should consider reviewing the process of referral to the General Medicine Assessment Unit.
The trust should ensure that the actions initiated after the recent never event in the critical care unit and include re-enforcing the importance of the timely reporting of all incidents.
The trust should ensure that it works to improve the access and flow issues within critical care with focus on the high occupancy and its impact on the numbers of non-clinical transfers and cancelled elective surgical cases.
The trust should consider how it is going to meet the existing areas of non-compliance with the D16 National Service Specification for Adult Intensive care. More specifically, the shortfall in allied health professional support and NICE guidance compliance.
The trust should ensure that staff are aware of the level of safeguarding training they have received.
The trust should develop a transition pathway for children from children’s services to adult services.
The trust should identify a non-executive director lead for children’s services to represent the service at board level.
The trust should improve compliance of reviewing a child within four hours of being admitted.
The trust should improve compliance with the three non-compliant standards of the five standards of the neonatal audit programme (NNAP) 2014.
The trust should improve staff knowledge of the duty of candour processes throughout children’s services.
The trust should continue to work with outside agencies to reduce the backlog of 4565 letters for paediatric services and closely monitor the progress.
The trust should ensure medical records are kept securely throughout all services.
The trust should ensure that within children’s services, patient names are not visible for the public to see.
The trust should monitor did not attends in clinics and ensure staff are aware of the policy guidance.
The trust should audit data on the length of time children spend in the children’s assessment unit.
The trust should consider its procedures for retrieving syringe pumps from the community to ensure there are sufficient numbers for patients requiring them in the hospital.
The trust should review the leadership arrangements and focus on end of life care to ensure it is given sufficient priority at directorate and board level.
The trust should consider formulating an overall strategy for end of life care across the trust which is disseminated to all staff across all sites.
The trust should consider the redesign of services to match capacity to demand and reduce in-clinic waiting times.
The trust should ensure that needs for nutrition and pain relief are acted upon in cases of patients waiting in outpatients for a delayed appointment.
The trust should ensure governance arrangements enable services to take timely action to address delays and problems, and effectively identify risks.

Professor Sir Mike Richards

Chief Inspector of Hospitals

We inspected Leicester Royal Infirmary on the evening of 30 November 2015 as part of a focused inspection. This was an unannounced inspection where we looked at the provision of services in the Emergency Department (ED). We undertook this focused inspection because we were concerned aboutpotential risks to patient safety in the ED.

We inspected the majors area, resuscitation and assessment areas of the ED. We did not inspect paediatric ED, the minors area or the Urgent Care Centre as part of the unannounced inspection. Our inspection focused on the key question of safe for Urgent & Emergency Services delivered at the ED.

We did not inspect any other services provided at Leicester Royal Infirmary, which is part of the University Hospitals of Leicester NHS Trust (the trust).

We inspected but have not rated the key question of safe for Urgent & Emergency Services delivered at the ED, Leicester Royal Infirmary. However, we found the delivery of services in the areas we inspected was inadequate.

Our key findings were as follows:

The skill mix of nursing staff in ED was not always appropriate to meet the health, welfare and safety of patients attending ED.
When the assessment bay was full to capacity, some patients remained on ambulances and the responsibility for on-going clinical care remained with the ambulance crew until such time that handover could be completed. We were therefore concerned that patients were not being handed over in a timely manner.
The trust did not have an effective system in place to ensure patients received appropriate initial clinical assessment by appropriately qualified clinical staff within 15 minutes of presentation to the ED in line with best practice.
The trust failed to ensure that all patients received adequate care and treatment in accordance with the trust’s sepsis clinical pathway. A sepsis clinical pathway was in place but we found this was not always completed for patients, despite there being evidence of escalating Early Warning Scores. In addition, staff were not always appropriately escalating elevated Early Warning Scores in a timely manner.
Documentation of records was variable for patients in different areas of ED.
We observed some good practice such as staff following hand hygiene, ‘bare below the elbow’ guidance and wearing personal protective equipment such as gloves and aprons, whilst delivering care. However we also saw one incident where a patient’s personal care was not delivered in line with infection control best practice.

We found there were areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

The trust must operate an effective system which will ensure that all patients attending the Leicester Royal infirmary Emergency Department (ED) have an initial clinical assessment of their condition carried out by appropriately qualified clinical staff within 15 minutes of the arrival of the patient at the ED in such a manner that is in line with the Guidance issued by the College of Emergency Medicine and others in their “Triage Position Statement” (“the CEM standard”) dated April 2011, or such other recognised professional processes or mechanisms as the Registered Provider commits itself to.
The trust must ensure that at all times, there are sufficient numbers of suitably qualified, skilled and experienced staff with sufficient skills in the Leicester Royal Infirmary ED to ensure people who use the service are safe and their health and welfare needs are met.
The registered provider must ensure that there is an effective system in place to deliver sepsis management, in line with the relevant national clinical guidelines. So as to identify patients with sepsis, stratify sepsis risk, determine appropriate levels of care and treatment and continue to provide appropriate care and treatment for patients with sepsis attending Leicester Royal Infirmary ED.

Following our unannounced inspection and because of our concerns about potential risks to patient safety in the ED, we issued an urgent Notice of Decision to the trust on 4 December 2015. The Notice of Decision imposed conditions on the trust’s registration as a service provider under S31 of the Health and Social Care Act 2008. The trust did not challenge or appeal the findings from our inspection. The trust has fully co-operated with CQC and continues to report to CQC in line with the requirements of the Notice of Decision.

Professor Sir Mike Richards

Chief Inspector of Hospitals

University Hospitals of Leicester NHS Trust is a teaching trust that was formed in April 2000 through the merger of Leicester General Hospital, Glenfield Hospital and Leicester Royal Infirmary. St Mary’s Birth Centre provides care for pregnant women and their families for the trust. The trust provides care to the people of Leicester, Leicestershire and Rutland as well as the surrounding counties. Some of its specialised services provide care and treatment to people from all over the UK.

Leicester Royal Infirmary, which has approximately 963 beds, provides Leicestershire’s only accident and emergency service. This site also provides a Children’s Hospital offering a range of conditions from surgery and cancer to emergencies and broken bones. In addition to the on-site services within the Children’s Hospital, it provides a range of outreach services within Leicestershire and other counties within the Midlands area. We spoke to 135 patients and their relatives while visiting the wards and departments in the hospital. We also held a listening event on 13 January where we spoke with around 80 people who came to provide their views on this and the other hospitals managed by this trust. We undertook two unannounced visits to the Leicester Royal Infirmary on Friday 31 January 2013 where we reviewed the gynaecological wards and the discharge lounge.

Prior to and during our inspection we heard from patients, relatives, senior managers, and all staff about some key issues which impacted on the service provided at this hospital. Across the trust there were three issues that the trust’s management team had alerted us to, which impacted at all locations. These included staff shortages, pressures on all areas from the A&E department and the impact of the contracted out services. These three issues are discussed in detail in the trust overview report. The issues of most concern in this location include:

Staffing

At this location the shortages of staff impacted on the safety of patients with in the A&E department, medicine, surgery, maternity and within the Children’s Hospital. This often led to delays in patients receiving the care that they required. Due to the shortages of staff there was a lack of reporting of issues in some areas.

Pressures in the A&E department

Demand for A&E services has been one of the key challenges at Leicester Royal Infirmary for some time. New arrangements for people coming into the department and the processes in place for discharging patients within the hospital are beginning to have an impact on the A&E department. However, the challenges of working in a department that was built for 100,000 people now seeing over 140,000 are ever present. This includes where patients wait while tests are completed and beds on wards are found. However, staff within the department ensure the comfort of patients through intentional rounding and ensuring that they are kept informed of what is happening. This is reflected in that patients report that they experience good care within the department.

Capacity

This is the main location of the trust and provides a number of services which have increased beyond the physical capacity of the building. The increasing numbers of patients attending the A&E department requiring admission to hospital and the delays in discharges put significant pressure on the whole system at this location. The bed management meetings and the buy-in to the problem from other specialities are two of the innovative ways in which the trust is beginning to tackle these issues.

Unfortunately this issue relates not only to the acute areas of the hospital but to outpatients, where the number of outpatients clinics held at this site and extensive delays in some specialities, such as ophthalmology, impact on the patient’s experience. This leads to cancellation of appointments and delays with waiting times from overbooked clinics. In maternity the increased number of midwife and consultant posts that remain outstanding impact on the experiences of mothers giving birth to the extent that delivery suites are not always available for birthing. Despite these capacity issues, the staff provide a service that is caring and most of the time safe.

We did not speak with people using the service on this occasion. People's views were sought at the last inspection and included within the inspection report of August 2012.

We followed up the areas of non-compliance identified at the last inspection. We found the trust had carried an audit to assess the risk with regards to the management of medicines. People were protected against the risks associated with medicines because the trust had appropriate arrangements in place to manage medicines. Provision of suitable medicine storage was in place and security had improved. There were regular audits of compliance and staff reported and escalated issues promptly.

People were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard. Staff received timely appraisals, informed of the developments and the consulted on the proposed improvements. There were a range of meetings and forums where staff received information about developments, met members of the trust board and shared their views.

The trust had improved the systems in place to identify, assess and manage risks to the health, safety and welfare of people who use the service and others. Management information, analysis and action plans produced were measureable, time bound and lead personnel identified to manage the improvements.

During our inspection of over two days we spoke with a number of patients and in some instances their family members or carers, on the maternity wards, emergency department and planned care wards. We asked patients for their views on their experiences of the care and treatment received. Patients were complimentary about the treatment received and most patients had not expressed any concerns.

Patients told us they were satisfied with the care and treatment received, all treatments were explained and they were involved in the decisions about their health needs.

Some of the comments we received from patients included 'The consultant has been outstanding and I've always seen the same consultant. I've received bespoke treatment and have been very involved in decision making' and 'the staff were very good they always explained what they were going to do.'

Patients told us they received their medication on time and staff had explained to them why they had been prescribed the medicines.

Patients told us they felt safe to and were comfortable to when they spoke with members of staff if they had any worries. One patient told us staff members in that ward were 'approachable.'

Patients said there were enough staff available to meet their needs. Patients acknowledged that staff at times were very busy but that had not affected the care and treatment they had received.

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

During our inspection visit on 4 May 2012 we spoke with two patients. They told us they were satisfied with the care they had received during their time on the ward. Neither of them had had to wait on a trolley for a bed to become available. One told us, 'I saw the doctor very quickly. Staff have looked after me very well and staffing levels seem good.' Another said, 'There are plenty of staff around. Staff attitudes are good and I haven't had any problems.'

During our inspection visit we spoke to a number of patients on the ward. None of these people had experienced any lengthy delays in being allocated a bed but they had been surprised to arrive on the ward without a bed being available. Those we spoke to told us that this had not been explained to them when they left the emergency department.

Leicester Royal Infirmary is a large acute hospital in Central Leicester. It has over 1000 bed spaces, an emergency department and deals with many out-patients on a daily basis. Therefore our team of inspectors were able to talk to a wide sample of people who use the services during the day of the inspection.

It should also be noted that we take into account to the views of those members of the public who express concerns or compliments through Local Involvement Networks (LINk). We took into account information provided by the Leicester City LINk and Leicestershire LINk. We also take into account the Leicestershire, Leicester and Rutland Health Overview and Scrutiny Committee (OSC). This enables the voice and concerns of the public and its communities to be heard by hospitals, such as the Leicester Royal Infirmary.

All Inspections

Professor Edward Baker

Chief Inspector of Hospitals

Professor Sir Mike Richards

Professor Sir Mike Richards

Staffing

Pressures in the A&E department

Capacity