Glenfield Hospital

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

At our last assessment we rated this key question good. At this assessment we did not rate this key question as it was a focused inspection where we only looked at specific specialities. The rating for effective has remained as good. This meant 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.

We have not awarded this service a score for Effective.

Find out about when we will not publish a key question score and what we look at when we assess Effective.

Specialities we assessed made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

Patients had their individual health risks assessed. Patients attended a pre-operative assessment where their suitability for surgery was checked. A nursing assessment was undertaken on admission. They considered the patient’s health, care, wellbeing, and communication needs, to enable patients to receive care or treatment that had the best possible outcomes. This included but was not limited to fitness for surgery, safer surgery checklists, nutrition, hydration, falls and skin integrity. Where a risk was identified we saw staff completed care plans to mitigate the risks. Records were up to date and showed comprehensive assessments undertaken leading to effective ongoing care. Observations of vital signs were undertaken and electronically recorded.

Patients we spoke to were complimentary about the care and treatment they had received and in general felt well informed about their surgery, hospital stay and post-operative care.

Staff assessed and met patients’ needs for nutrition and hydration using a nationally recognised tool. We reviewed 16 patient records and found each patient had undergone a nutritional assessment. Where there was a risk of malnutrition there were plans to mitigate the risk and re-assess the patient.

Patients received post-operative support from therapy teams which were tailored to their individual needs. Advice was given about recovery post discharge and referrals were made to support recovery.

Tissue viability nurses were available to support staff in the management of complex wounds. They provided advice on care planning and referrals to specialists upon discharge.

Staff assessed patients’ pain using a recognised tool and gave pain relief in line with individual needs and evidence-based guidance. This was regularly documented in all 16 patient records we reviewed. Pain audits were carried out in theatres and on surgical wards. Data provided to us following our site visit showed from 1 December 2024 to 31 May 2025, 100% patients had regular pain assessments carried out. However, they did not generally achieve expected compliance for pain being re-assessed within an hour of administration of pain relief. Patients we spoke to confirmed they had been offered regular pain relief and staff provided this in a timely manner. Patients were prescribed pain relief to take home when they were discharged on the day of surgery.

Patient’s care needs were routinely reviewed. Regular multidisciplinary meetings were held to discuss patients and improve care. Staff collaborated across healthcare disciplines and with external agencies. Teams worked closely together to meet patient needs. Patients’ care pathways were reviewed by relevant consultants.

Audits were undertaken by ward leaders and matrons to check the quality of the service being delivered. These were presented as part of a regular clinical dashboard.

Specialities we assessed planned and delivered people’s care and treatment with them, including what was important and mattered to them. Staff did this in line with legislation and current evidence-based good practice and standards.

Staff followed up-to-date policies and clinical guidelines to plan and deliver high quality care according to best practice and national guidance such as National Institute for Health and Care Excellence (NICE) guidance. Policies, procedures and guidelines were generally up to date and reflected best practice.

A pre-operative assessment policy was in place which underwent regular review and was designed to ensure patients were medically fit and well informed before undergoing anaesthesia and surgery. The policy was aligned to national standards and best practice. Patients’ suitability for surgery was assessed, and they were provided with evidenced based information and support to help them understand the procedure, risks and make decisions. Patients we spoke to felt informed about their care and treatment and had good contact with surgical and nursing staff before, during and after their procedure.

Where appropriate patients were given pre-operative physiotherapy and exercise programmes to ensure they were fit for surgery and able to carry out their post-operative rehabilitation.

Managers provided new staff with appropriate induction. Newly qualified nursing staff told us they had undergone a robust induction and supernumerary period. The surgical areas were specialised at Glenfield Hospital and each area had specific evidence-based competency booklets which staff had completed or were working through.

Managers provided staff with appraisal of their work performance. The percentage of staff working in theatres and on wards who had an in-date appraisal was 95%. Managers identified the learning needs of staff and provided them with opportunities to develop their skills and knowledge. Managers ensured staff received the necessary specialist training for their roles. Theatre staff were provided with regular training days covering learning from incidents, simulations and standard safer surgical care training. This included looking at human factors as part of this but not as a standalone training. Training was updated to reflect evidence-based practice and any changes to this.

Managers ensured staff had access to regular team meetings. Team meeting frequency was variable but in general ward meetings were held monthly. Managers shared key updates with staff, feedback from incidents and mandatory training requirements were discussed.

Specialities we assessed worked well across teams and services to support patients. Staff shared their assessment of people’s needs when people moved between different services.

Doctors, nurses and other healthcare professionals worked together as a team to benefit patients. They supported each other to provide good care. We observed positive working relationships between staff on wards, demonstrating a mutual respect for each other’s role to meet patient’s needs. Ward rounds we observed were multi-disciplinary and all staff contributed to the patient discussions across all wards we visited.

We observed staff including physiotherapists and occupational therapists working closely with ward and theatre staff to provide treatment and support to patients.

Staff shared information about patients at effective handover meetings within the team. We observed on-call doctors’ handover from night to days shifts. Communication was clear, interactive and they provided good oversight of patients including those showing signs of deterioration and those at risk. Ward rounds we observed were multi-disciplinary (MDT) and all staff contributed to the patient discussions across all wards we visited.

Specialities we assessed collaborated with community services and referring local hospitals to ensure patients were medically optimised prior to surgery. Specialist clinic appointments were offered at neighbouring NHS trusts for patients requiring specialist surgery at Glenfield. Processes were in place to transfer inpatients from other NHS trusts who required surgery.

MDT meetings were held regularly led by specialities. The purpose of these meetings was to discuss new referrals and complex cases as a team of professionals and agree next steps and a treatment pathway. We reviewed meeting minutes for breast, vascular, thoracic, hepatobiliary and cardiac surgery specialities. In general, the minutes demonstrated good attendance, discussions took place, and, in most cases, decisions were documented. Multiple staff working within cardiac surgery described recent improvements in the effectiveness of cardiac surgical MDTs in reviewing patients who had been waiting a long time and when planning for high-risk cases which required input from more than 1 surgeon.

Specialities we assessed supported people to manage their health and wellbeing to maximise their independence, choice and control. They supported people to live healthier lives and where possible, reduce their future needs for care and support.

Staff focused on identifying risks to people’s health and wellbeing early and to support people to prevent deterioration. Patients attended pre-operative assessment appointments where their suitability for surgery was checked. This included the completion of an online health questionnaire, and an opportunity for the nurse or therapy teams to provide advice or refer patients on to other appropriate services if they required. For example, referral to smoking cessation services, dietitians, or exercise programmes.

Patients were referred on for specialist input where required. For example, where surgery effected mobility or breathing, patients were referred to physiotherapists and to dietitians where it impacted nutritional intake. This was provided as an inpatient post-surgery, and patients were also referred for community support before they were discharged.

Staff supported patients to live healthier lives. During our site visit we observed health promotion advice on ward boards. Therapies teams supported patients with advice in relation to activity and healthy eating. Patients could be referred for smoking cessation support. Patients were provided with advice and referral on to support their recovery post-surgery and post discharge.

The thoracis was introduced an improved process for discharging patients following feedback. The specialist nurses completed one to one and group discharge information sessions to explain to patients about how to recover well, wound management care and where to go for support.

Specialities we assessed routinely monitored people’s care and treatment to continuously improve it. They generally ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

Specialities we assessed participated in national audits to benchmark their performance, including but not exclusive to the UK transplant registry, the national vascular registry and the national cardiac audit programme. Data was collated, validated and submitted to the relevant audit bodies and we saw evidence each speciality reviewed the outcomes and had plans in place to improve where required.

Outcomes were generally positive. For example, data submitted to the national vascular registry from January to December 2024 showed they performed better than the national averages for the number of patients undergoing a carotid endarterectomy (a procedure to remove plaque build-up in the arteries which supply blood to the brain) within 14 days of symptoms. They also demonstrated good outcomes for index operations of aortic aneurysm repair, lower limb reconstruction and the ratio of below knee amputations in comparison with national averages. Mortality rates (a measure of the number of deaths) were lower than national averages.

The renal team had one of the best 1-year patient and kidney survival rates in the country (98%).

The most up to date national adult cardiac audit run by the National Institute for

Cardiovascular Outcomes Research (NICOR) showed the service generally performed within the expected range. However, Glenfield Hospital performed worse than average for the number of cases discussed in a multidisciplinary team meeting before surgery. Part of the problem related to issues with coding being inaccurate. A corrective documentation and coding improvement plan was being implemented. Peripheral Venous Access Device (PVAD) audits were undertaken to ensure staff managed these in line with trust policy to prevent the risk of infection. We reviewed audit data from April to June 2025 for theatres and surgical wards. Data showed they were consistently not meeting the trust expected standard of care. For example, the renal, thoracic, cardiac and vascular ward compliance was 86%. These were monitored by the clinical management group leadership teams and actions to improve were in place. However, the actions did not appear to be having an impact to improve staff compliance with care of PVADs as improvements were not always being made.

A programme of internal audits was in place to monitor the quality of care being provided in line with best practice. This involved matrons and ward leaders following a set audit criterion, speak to staff and patients and observing the environment. Areas checked included but was exclusive to infection prevention, documentation audits, falls prevention, skin integrity management and specific quality measures in relation to the speciality. Performance was variable and this was monitored by service leaders with actions to improve.

National Safety Standards for Invasive Procedures (NatSSIPS) were available in the theatre department. NatSSIPS provided a framework to produce Local Safety Standards for Invasive Procedures (LocSSIPS). However, not all theatre staff we spoke to were aware of these.

Glenfield Hospitals anaesthetic department were accredited under the Anaesthesia Clinical Services Accreditation (ACSA) scheme by the Royal College of Anaesthetists. The ACSA scheme is a quality improvement initiative to promote excellence in anaesthesia services.

Specialities we assessed told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff understood how and when to assess whether a patient had the capacity to make decisions about their care. Staff understood the importance of ensuring people fully understood what they were consenting to and the importance of obtaining consent before they delivered care or treatment.

Staff were aware of the provider consent policies and processes which they followed to gain patient consent. Patient records showed capacity to consent to care, and treatment were assessed on admission. Consent forms were on the electronic patient record and consent was obtained digitally. Consent forms we reviewed were clear and legible and outlined the risks and benefits of surgery. Where patients lacked the capacity to make decisions about their care and treatment themselves, the policy provided clear information for staff to follow which was in line with national guidance and legislation to ensure consent was gained lawfully. Specific consent forms were available electronically for staff to use if a patient lacked capacity.

Staff took all practical steps to enable patients to make their own decisions. Patients told us they were given sufficient information to be able to make informed choices about their care and treatment. This included information about the risks associated with surgery and having anaesthesia. Staff told us they provided patients with relevant condition-specific information.

Staff received Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) training. They understood relevant consent and decision-making requirements. Staff knew how to access policy and advice on these topics. Managers monitored compliance with the MCA. Patients who lacked capacity to consent to procedures were identified during the pre-operative assessment process and this was reassessed throughout their admission.