Updated
20 May 2025
Glenfield Hospital Leicester is part of the University Hospitals of Leicester NHS Trust which formed in 2000, with the merger of the Leicester General Hospital, Glenfield Hospital and Leicester Royal Infirmary. The trust serves 1 million residents of Leicester, Leicestershire and Rutland and provides increasingly specialist services over a much wider area. It is a teaching hospital, working closely with partners at the University of Leicester and De Montfort University. Glenfield Hospital provides acute and tertiary hospital services for over 1 million people.
The surgical service at Glenfield Hospital Leicester is made up of 10 theatres including a hybrid theatre, a surgical enhanced care unit and 9 inpatient surgical wards. A wide range of specialist surgical services are provided including cardiac, thoracic, renal transplant, hepatobiliary, vascular and breast specialities.
We carried out an unannounced focused assessment of cardiac, thoracic, vascular and hepatobiliary specialities and services. The onsite assessment took place on 3, 4 and 9 June 2025. The assessment was carried out as we had concerns about the culture in cardiac surgery and the potential impact this had on patient safety. We assessed 33 quality statements across safe, effective, caring, responsive and well-led.
We did not cover the full range of surgical services provided at Glenfield Hospital. The report therefore does not update the ratings for surgical services at this time, and we will return at a future date to carry out a more comprehensive inspection. The previous rating of requires improvement overall remains.
As part of our assessment, we visited 4 surgical wards, 5 theatres and the surgical enhanced care unit. We looked at 16 patient records including consent forms and safer surgery checklists. We spoke with 7 patients, 2 carers and 64 staff members. This included service leaders, managers, matrons, ward and team leaders, nurses, operating department practitioners, anaesthetists, perfusionists, consultants, doctors, healthcare assistants, therapy staff, administrative and domiciliary staff.
We found:
Specialities we assessed did not always work with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Specialties we assessed did not always work collaboratively to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Specialities we assessed did not always detect and control potential risks in the care environment. Staff did not make sure that all equipment, facilities and technology supported the delivery of safe care. Specialities we assessed did not always have enough qualified, skilled and experienced staff. They did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.
Specialities we assessed did not always supply appropriate and accurate information in formats that were tailored to individual needs. Patients were not always kept up to date about their treatment plan. Specialities we assessed did not always make sure that people could access the care, support and treatment they needed when they needed it.
There was 1 speciality where more focused work was needed to improve the culture amongst a minority of staff. Specialities we assessed did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.
However, we found:
Most staff reported incidents in line with trust policy. Specialities we assessed generally had a proactive and positive culture of safety, based on openness and honesty. Lessons were learnt to continually identify and embed good practice. Managers listened to local concerns about safety and investigated and reported safety events. Staff were provided with safeguarding training specific to their role. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. Specialities we assessed shared concerns quickly and appropriately. They provided continuity of care, including when people moved between different services. Staff worked together well to provide safe care that met people’s individual needs. Mandatory training and annual reviews with staff were compliant with trust standards. Specialities we assessed made sure that medicines and treatments were safe and met people’s needs, capacities, and preferences.
People’s outcomes were consistently good, and people’s feedback confirmed this. Patients were involved in the assessment of their needs. Staff gave people clear information about their care and treatment needed to support both their physical and mental health. Patients received co-ordinated and effective care and treatment from members of the multidisciplinary team. Staff supported people to manage their health and wellbeing to maximise their independence, choice and control. Staff routinely monitored people’s care and treatment to continuously improve it. People’s views and wishes were considered when their care was planned.
People felt well-supported, cared for and treated with dignity and respect. People’s privacy and dignity was respected, staff treated people with kindness, empathy and compassion. Staff listened to and understood people’s needs, views and wishes. Staff treated people as individuals and made sure people’s care, support and treatment met their needs and preferences. Specialities we assessed generally cared about and promoted the wellbeing of their staff.
Specialities we assessed made sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs. They understood the diverse health and care needs of people and their local communities. Staff and leaders actively listened to information about people who were most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.
The service had a shared vision, strategy and culture of which the specialities we assessed were aligned to. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. Specialities we assessed had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. They valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them. Specialities we assessed understood their duty to collaborate and work in partnership, so services worked seamlessly for people. Specialities we assessed focused on continuous learning, innovation and improvement across the organisation and local system.
We found 4 breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to safe care and treatment, environment and equipment, governance and safe staffing.
Specialities we assessed did not ensure safe care and treatment was provided in a safe way as staff did not always implement the safer surgery checklist in line with best practice. Venous thrombosis embolism assessments were not repeated in line with best practice and trust policy. The risk of infection was not always prevented and controlled within theatres. Staff did not always comply with infection, prevention and control practice. Patients who experienced long waits for surgery did not have the risk associated with their long waits routinely assessed to monitor for clinical deterioration/harm.
Specialities we assessed did not ensure the environment in theatres was clean, well maintained and safe. They did not ensure equipment in theatres was readily available and safe to use. Sepsis boxes on emergency trolleys were not always appropriately stocked or safety checked. They did not ensure all equipment was secure. Oxygen cylinders were not always securely stored. Not all ward areas had secured access.
Specialities we assessed did not always assure effective collaboration across clinical management groups in addressing issues and concerns. Risk registers were not always effective in mitigating environmental risks where it involved multiple clinical management group oversight.
Specialities we assessed did not have sufficient numbers of suitably qualified, competent, skilled and experienced staff.
We requested an action plan to address these concerns.
Services for children & young people
Updated
26 January 2017
We rated the children’s and young people’s service as good overall because there was a positive incident reporting culture. Staff knew how to report incidents and gave examples of when they had done so. There was appropriate incident investigation with actions and learning shared amongst staff. Staff adhered to trust infection prevention and control policies and we saw staff using hand sanitiser between patient contacts. All equipment including resuscitation equipment had been tested and checked regularly.Escalation plans were available for the Children’s Hospital, paediatric intensive care and the ECMO Unit.Staff conducted nursing handovers called ‘safety huddles’ to ensure all staff had up to date information about patients. Staff discussed new and existing patients, their medical history and care plans highlighting any key information including potential risks to patients.Medicines management was mainly in line with trust policy.
We observed positive, compassionate care and staff were sensitive to the needs of babies, children, young people and those close to them. Without exception, patients and those close to them were positive about their care and treatment. Patients felt involved in their care and treatment. Staff communicated in ways, which enabled patients and those close to them to understand what was happening.
The hospital provided specialist services for patients, including the Congenital Heart Centre and extracorporeal membrane oxygenation (ECMO) care. Staff met patient’s individual needs and could access specialist support such as interpretation, spiritual support and specialist nurses.
Staff assessed and responded to pain appropriately therefore patients had timely access to pain relief. Staff had access to a children’s pain team who performed daily ward rounds.
Services for Children and Young people conducted audits to monitor patient outcomes. The majority of the results of these audits were positive or showed improvement.
There was a clear vision and strategy for the service. There was a positive and open culture and staff were proud to work at the hospital. Leaders were visible and they engaged and listened to staff. We saw positive examples of innovation to improve services delivered.
However;
There were shortfalls regarding the numbers of staff training in Advanced Paediatric Life Support (APLS) and European Paediatric Life Support (EPLS). The service could not provide at least one nurse per shift in each clinical area trained in APLS or EPLS as identified by the Royal College of Nursing (RCN) 2013 staffing guidance.
The service did not meet the trust target of 95% for all subjects covered under mandatory training for both medical and nursing staff.
Updated
26 January 2017
Overall we rated the critical care service as good.
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.
There was strong clinical and managerial leadership at both unit and management group level and 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 and discussed. The framework also enabled the dissemination of shared learning and service improvements.
Patients and their relatives were cared for in a supportive and sympathetic manner and were also treated with dignity and respect. However, There were some issues with access and flow. In 2015, 21 patients had their elective surgery cancelled.
The critical care unit did not achieve the intensive care core standard (ICS) of 50% of staff having a post registration course in critical care, 29% of staff had completed this.
Updated
26 January 2017
Overall, we rated end of life care services as requires improvement.
The medical staff levels were not in line with the recommendations from the National Council for Palliative Care who recommend that there is one whole time equivalent (WTE) consultant for every 250 beds. The service had 3.5 WTE 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 another syringe driver was being used instead, which did not meet the NHS patient safety guidance.
Out of 25 Do Not Attempt Cardio Pulmonary Resuscitation’ orders (DNACPR), nine were completed correctly (38%).
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 KPIs that had not been achieved.
There was no strategic plan for end of life care throughout the trust and there was no non-executive director representing end of life care at board level.
We found care records were mostly maintained in line with trust policy. Staff understood their responsibilities in following safeguarding procedures.
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.
Outpatients and diagnostic imaging
Updated
26 January 2017
Overall we rated Glenfield Hospital Outpatient and Diagnostic Imaging services as requires improvement.
There were outpatient delays and cancellations across the trust. Some people were not able to access services for assessment, diagnosis and treatment when they needed to. The trust recognised this but arrangements to match future capacity to demand were not in place. Governance arrangements for better waiting list management were in development
Some arrangements lacked controls to keep patients safe. Fridge temperatures for medicines were not safely monitored but this was rectified during our inspection.
There was no audit process or record of the use of some FP10 prescription pads, which was a risk that the prescription issuing process could be abused.
The trust had not implemented and audited use of the WHO safety checklist across the trust.
Patient dignity was compromised in some areas . Some reception arrangements, for example diagnostic imaging reception, were not conducive to privacy or confidentiality. The ‘shuttle walk’ test, which formed part of the cardiac rehabilitation programme, was not performed in a location that respected dignity or privacy of patients.
Leadership for outpatient services was fragmented. Risks, issues and poor performance were not always dealt with appropriately or in a timely way, and this meant patients sometimes had long waits for new or follow up appointments and experienced in-clinic delays.
However, staff understood and fulfilled their responsibilities to raise safety concerns and report incidents and near misses; managers supported them when they did. If something went wrong, there was a thorough review or investigation involving all relevant staff and people who used services. Lessons were learned and communicated widely. Equipment checks were up to date and clinical areas were clean on the day we inspected. Staff had a good knowledge of safeguarding and the Mental Capacity Act or knew who they could go to for expertise. They knew what to do if a patient’s health started to deteriorate.
Diagnostic imaging services learned from incidents and improved safety. They used diagnostic reference levels to check dosage and had a range of safety related policies which staff understood and used. Imaging services were available seven days a week. GPs could refer patients to Glenfield for diagnostic imaging procedures with a 48 hour turnaround.
Patients, those who were close to them and stakeholders gave positive feedback about the way staff treated people. Glenfield based specialties had high ‘would recommend’ scores from patients. Patients we spoke with were happy with their care and spoke highly of staff at Glenfield hospital.
Care was planned and delivered in line with current evidence-based guidance. Examples of good practice included the Rapid Access Heart Failure Clinic. The services used local and national audit arrangements to maintain the effectiveness of treatment. Clinicians worked effectively in multidisciplinary teams to find solutions for complex patients. There were one-stop clinics in breast care and pulmonary embolism ambulatory clinic This meant patients could discuss a range of related issues on the same visit to the hospital. There was a positive working culture at Glenfield, and innovative practices, particularly in cardiac and respiratory rehabilitation.