Glenfield Hospital

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

At our last assessment we rated this key question requires improvement. 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 responsive has remained as requires improvement. This meant 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.

However, they 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. Specialities we assessed 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.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to safe care and treatment.

We have not awarded this service a score for Responsive.

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

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.

Staff respected patients’ personal, cultural, social, and religious needs. Services were generally planned and delivered in a way that took the needs of different patients into account.

Patients and those close to them were regularly involved in planning and making shared decisions about patients care and treatment, so it was centred on them and their needs. Multidisciplinary team meeting minutes we reviewed demonstrated the patient voice and choice was heard during discussions about the treatment plan. For example, we saw a cardiac surgery case considered the patient not wanting to have surgery and the team provided alternative options for the patient.

Patients’ records reflected their physical, mental, emotional and social needs, including those related to protected characteristics under the Equality Act. A ‘this is me’ booklet was available for all patients and their relatives to complete upon admission. This helped staff personalise care provided to certain patients with different needs. It gave patients and carers the opportunity to let staff know what they or their family member would like to be called, their hobbies, previous employment, sleep pattern, information about eating and drinking, and activities of daily living.

The learning disability team reviewed patients quickly following admission. They assessed patients and made sure their individual needs were met, and patients felt safe and supported.

Managers made sure staff, patients and carers could access interpreters when needed. Information on interpreting services was readily available. Information leaflets could be translated upon request.

Specialities we assessed understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

Patients received care and treatment from services that understood the diverse health and social care needs of their local communities. It also worked with others in the wider system and local organisations to plan care.

The surgical specialties recognised the complexities and health inequalities of the community of Leicester. Staff working within surgical specialities we assessed recognised patients undergoing certain procedures such as cardiac surgery were often more high risk based on ethnicity. Research indicates that certain ethnic groups may experience differences in access to care, surgical procedures performed, and post-operative outcomes. Specialities we assessed were working towards improving the pathway for high-risk procedures and patients. They had a specific high risk multi-disciplinary meeting to discuss and plan for these operations in a joined-up way.

Services were co-ordinated and responsive. For example, surgeons’-maintained oversight of their patients who were transferred to critical care from surgery. They worked with the critical care teams to ensure their care needs were met and specific risk factors overseen by specialist teams. Satellite clinics were set up in neighbouring hospitals to assess and follow up patients closer to home.

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.

Patients received written information ahead of their appointment which included specific instructions and information about what to expect as part of their care and treatment. For patients having a surgical procedure, the information included guidance on staying nil by mouth, arrival time, the procedure and aftercare.

Patients were not always at the centre of their care and treatment choices. Patients who had waited a long time for elective surgery were not always updated when they would be booked in for surgery. Some patients we spoke to during our site visit shared this was frustrating as they were not informed or updated. However, patients we spoke to during our site visit in general told us once they had been admitted, staff communicated with them well about what to expect, timescales for surgery and updated them if there were any delays.

Patient’s individual needs to have information in an accessible way were identified and recorded. The trust had carried out a review of needs relating to the Accessible Information Standard, which it relaunched in September 2024. The information governance team (IGT) worked with staff to improve standards of information provided to patients, including non-clinical information, such as direction signs in the hospital and wards. Communication needs were recorded in most patient records.

However, staff understood but did not always apply the policy on meeting the communication needs of patients with a disability or sensory loss. In general, staff were not aware of tools available to them to help them communicate with non-verbal patients whilst in hospital. Staff told us they got round this by allowing carers and family to be present throughout their admission. Staff also implemented hospital passports which provided a detailed overview of the likes, dislikes, needs, including communication needs of patients who may be non-verbal.

Staff knew how to access interpreting and translation services to enable them to make reasonable adjustments for people who did not speak English as a first language and for Deaf people who use British Sign Language.

Information was available in relation to specific procedures and what to expect pre- and post-surgery. This was available in different languages, braille and easy read formats on the trust website. We observed on some wards, an accessibility statement outlining how patients could access information in another language or format. This was written in different languages.

Specialities we assessed made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They involved people in decisions about their care and told them what had changed as a result.

Patients, relatives and their carers knew how to give feedback about their experiences including how to raise complaints or concerns. The service clearly displayed information about how to raise a concern was clearly displayed in patient areas we visited. Patients told us they felt comfortable raising any issues with the staff caring for them at the time. No patient we spoke to felt it necessary to raise a formal complaint as they felt the staff dealt with any issues they had.

Staff understood the policy on complaints and knew how to handle them. Managers investigated complaints and identified themes. Staff knew how to acknowledge complaints and patients received feedback from managers after the investigation into their complaint. We reviewed the complaint outcomes for investigations which took place in 2024. All demonstrated a full investigation had taken place as well as an acknowledgement of the complaint and an apology for the concerns raised. We also saw complainants were provided with a summary of the intended actions and feedback given to staff.

Most patients and their relatives were encouraged to feedback through the Friends and Family Test (FFT). We observed QR (Quick Response) codes were displayed for people to scan and feedback direct to the service. The trust provided us with outcomes of FFT data for surgical wards at Glenfield Hospital which showed 97.6% of people said they would recommend the service. This exceeded the 95% target. Feedback indicated ‘staff were amazing, friendly and nothing too much trouble’ and ‘cannot fault any part of the department and all of the care we have received’. FFT results including ‘you said we did’ was displayed on wards we visited. Theatres had not implemented FFT at the time of our onsite assessment.

Matrons undertook monthly quality audits which involved speaking to patients about their care and experience. This gave them an opportunity to feedback any concerns and address issues quickly should they arise.

Patients were provided with information at the pre-assessment stage prior to their surgery. Surgeons and their teams talked through the procedure and associated risks. Patients were also supported by specialist nurses, depending on the speciality who provided further advice and information about the procedure and how to prepare for it. Patients were invited to a pre-operative assessment appointment. Some of this was undertaken over the telephone and face to face. Patients were given an information booklet which provided detail about the pre-assessment process, what to expect at appointments and on the day of surgery, including key contacts. For example, there was advice about food and fluid intake for diabetic patients. Some patients were also seen by the anaesthetic team and other specialist staff depending on their condition. Patients we spoke to in general felt well informed and involved in the decision making about their care.

Specialities we assessed did not always make sure that people could access the care, support and treatment they needed when they needed it.

Patients could not always access care, treatment and support when they needed to and in a way that worked for them. Referral and booking processes were inconsistent and varied across the specialities we assessed. There were various ways specialities received referrals. For example, referrals went to individual surgeons or to a speciality. Surgeon waiting lists varied which meant there was an inequity in access to timely treatment depending on who the patient was referred to. The capacity of the surgeon was not always considered which meant some patients having long delays for surgery when they could have been seen sooner by a different surgeon. However, in hepatobiliary services they pooled their referrals and waiting times were consistent across each surgeon.

Referral to treatment performance for surgical specialities varied. Performance against the NHS standard to see 92% of patients referred to treatment within 18 weeks was generally not met. The worst performing speciality was cardiac surgery where 55.9% (out of 299 waiting) of patients had been waiting more than 18 weeks for treatment. The best performing speciality was breast surgery where 98% (out of 1,080 waiting) of patients had been seen within 18 weeks. The trust target was 62.3% which was achieved by hepatobiliary pancreatic (65.9%), general renal (62.5%), thoracic (84.5%), vascular (71.2%) and renal access (80%).

Specialities we assessed were generally not meeting the 31-day decision-to-treat to treatment standard of 96% set by the NHS for specialities at Glenfield. Data from April 2024 to March 2025 showed 80. 7% of patients were treated for breast cancer within 31 days, 86% with upper GI cancer within 31 days and 88.4% lung cancer within 31 days. The specialities at Glenfield Hospital were performing slightly better than the trust average over the same period of 79.8%.

Cancer services at Glenfield were not meeting the 62-day referral to treatment standard set at 85% from April 2024 to March 2025. Only 44% of breast cases were treated within 62 days, followed by upper GI hepatobiliary (54.6%) and lung (62.3%). These averages were slightly better, excluding breast, than the trust average of 57.6%. Managers told us a pathway peer review would be completed for breast services as well as creating additional capacity to improve timeliness of treatment. It was noted for breast treatment, surgery involved co-ordinating different specialities including plastics which impacted timeliness of treatment. This would be looked at as part of the review.

Cancer waiting times varied but were improving. Data showed there were 31 patients waiting for treatment more than 52 weeks in hepatobiliary (14), Cardiac (7) and vascular (9). In hepatobiliary, these were patients with low-grade cancers and not urgent or high-risk cases. There were no patients waiting for more than 78 and 104 weeks. This was an improvement since our previous inspection in 2022, where there were 13 admitted patients waiting over 100 weeks, 100 patients waiting over 70 weeks and 379 over 50 weeks (as of 26 September 2022).

Specialities we assessed regularly exceeded the NHS standard of 75% of patients having their cancer diagnosis within 28 days of urgent referral. Cancer specialities, including breast, lung and upper gastrointestinal (GI) exceeded the NHS 28-day faster cancer diagnosis standard of 75% from April 2024 to March 2025. Breast achieved 92%, lung 84.9% and upper GI 88.4% over this time. This meant for patients diagnosed with cancer their treatment could begin as soon as possible.

Long waits for treatment were reviewed at fortnightly access and performance meetings. Day to day oversight of performance was monitored through a dashboard for each speciality.

Clinic and theatre list cancellation rates were generally high. This meant cancelled patients had to wait even longer to access treatment. From December 2024 to May 2025, 5495 clinical appointments were cancelled with 83.3% of those cancelled within 6 weeks of the appointment. Managers working within the renal, respiratory and cardiovascular clinical management group told us they were in the process of streamlining clinic structures across all surgical specialities to make them easier to book, reduce the risk of cancellations and ensure there was adequate capacity for new referrals to be seen. This included transferring bookings to a new system. Capacity and demand had been reviewed to inform new clinic structures. Moving forward clinics would have 5 new referral appointments and 8 follow up appointments. Administrative teams and surgical specialities were working to embed this. However, in the hepatobiliary speciality, they had already embedded an improved clinic template to increase capacity and reduce cancellations. For example, consultant led clinics had been increased to improve the number of patients offered appointments. Four-hour clinics consisted of up to 13 appointments and virtual clinics were used to review results and reduce the need for follow up appointments.

Data showed there were 1,333 operations cancelled from December 2024 to May 2025 which averaged a 33.5% cancellation rate across all surgical specialities. The highest cancellation rates were seen in cardiac (45%), vascular (42.5%) and hepatobiliary (36.1%) specialities. Data showed 47.5% of cancelled operations were not rebooked within 28 days in accordance with guidance.

During our site visit staff told us theatre lists were cancelled for a variety of reasons including staff availability, equipment availability, patient choice and last-minute changes to lists due to emergencies. In terms of staffing, anaesthetists’ availability was cited as a common reason for cancellations and in cardiac surgery, lack of trained staff due to high turnover of nurses.

Theatre managers told us they had challenges with short notice cancellations within 48 hours of surgery. Vascular surgery and cardiac surgery were cited as specialities with higher than average 48-hour cancellation rates. This was impacted by the way they managed theatre lists. For example, vascular ran elective and non-elective theatre lists together which meant if there were emergencies, the electives were cancelled. Cardiac had a lot of emergency cases and admissions overnight which impacted the cases already booked in. Managers told us the 48-hour cancelation rate for May 2025 was 8% with a target to reduce to 5%. We were told this had gradually reduced from 11% in the 12-month period leading up to our site visit.

To mitigate risks of elective cancellations due to emergency operations, managers had incorporated capacity within the theatre timetable for urgent and emergency operations. This was reviewed in a weekly meeting. An active recruitment campaign was in place to recruit nurses within cardiac theatres, however, the issues with culture within the department continued to be an issue impacting on retention of staff. Anaesthetist availability was cited as a national issue impacting ability to recruit.

Theatre utilisation rates were improving at Glenfield Hospital. They had met the 85% target in April 2025 with 87.7% of theatre time utilised. Whilst theatre cancellations were high, some specialities overbooked and in other specialities such as cardiac, as operations took longer more theatre time was used. Managers told us they generally maintained 85%. Furthermore, there was a significant improvement in operations starting on time which had improved by 13.5% at the time of our site visit.

Physical premises and equipment were accessible. Toilets and shower rooms were accessible. Patients were given support to overcome barriers. There was equipment available to meet patient’s needs. For example, there were mobility aids for patients with a physical disability and timely access to specialist support. There was a learning disability team who supported staff to assess the needs of patients with a learning disability or those who were autistic. They considered the environment and considered patients’ needs when making decisions about where they would be cared for. Staff told us they made reasonable adjustments to help people, and their families access services. Side rooms and extended visiting were arranged for patients with a learning disability. We saw this was in place during our onsite assessment.

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.

Patient care, treatment and support promoted equity, removed barriers or delays and protects their rights. Patient needs were assessed prior to admission. Staff identified any reasonable adjustments required to support each patient. For example, for patients with language barriers, interpreters would be booked in for future appointments and admissions.

Leaders and staff were alert to discrimination and inequality that could disadvantage different groups of people using their services. They collected information about patients to ensure services were inclusive and fair. The provider had undertaken equality impact assessments of their policies and procedures to ensure they did not place vulnerable people or people with protected characteristics at a disadvantage. Staff were trained in equality, diversity and inclusion. Staff understood the Equality Act 2010 and knew what protected characteristics were and gave examples of reasonable adjustments they had made to support patients.

At the time of our site assessment the trust was in the process of implementing an electronic patient record. The new system enabled staff to proactively identify vulnerable patient groups and individuals and address health inequalities. For example, gender and gender reassignment, travellers, mental health, dementia, neurodiversity, spoken language, religion, and school. Staff were starting to record and flag any reasonable adjustments made electronically.

Staff within specialities we assessed, and the wider organisation promoted a culture in which patients using the service felt empowered to give their views. Patients told us staff listened to them and took account of their individual needs. Patients were encouraged to provide feedback. There were posters showing patients how to feedback. We saw you said we did boards in ward areas.

We did not look at Planning for the future during this assessment. The score for this quality statement is based on the previous rating for Responsive.