Glenfield Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

At our last inspection, we rated this key question as 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 safe has remained as requires improvement. This meant some aspects of the service were not always safe. 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. They 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.

However, most staff reported incidents in line with trust policy and lessons were learnt to continually identify and embed good practice. Managers listened to local concerns about safety and investigated and reported safety events. Staff made sure there was continuity of care, including when people moved between different services. Staff were provided with safeguarding training specific to their role. Specialities we assessed worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Managers had systems in place to review staffing levels. They made sure that medicines and treatments were safe and met people’s needs, capacities, and preferences.

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

We have not awarded this service a score for Safe.

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

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.

The incident and accident reporting policy had expired in November 2024 and had not been updated at the time of our site assessment. The policy did not reflect the most up to date national guidance such as the Patient Safety Incident Response Framework (PSIRF). However, the service had an accessible and current patient safety incident reporting policy which reflected PSIRF. It provided details of individual responsibilities, investigation processes, method of dissemination of learning and timescales.

Staff had a good understanding about what incidents to report and how to report them. They knew how to access policies and how to escalate incidents and patient safety concerns. Incidents were reported using an electronic reporting system and escalated to a manager for review and investigation.

Most staff we spoke to across wards and theatres we visited reported incidents in line with trust policy. Staff described patient safety incidents they had reported. For example, skin damage and patient fall incidents were commonly reported by staff. From June 2024 and May 2025, a total of 1,317 incidents were reported of which 440 were categorised as fairly concerned, 173 as not at all concerned, 288 as not very concerned and 215 as very concerned. However, staff working in 1 surgical speciality told us they did not always report incidents in relation to the condition of the theatre environment or poor conduct as they did not consider it would improve. Furthermore, during our site assessment staff told us about incidents in relation to staff behaviour and conduct that could impact patient safety. However, we could not see these incidents had been reported through the electronic reporting system.

Staff reported patient safety events and never events clearly and in line with trust policy. Data showed there were 5 incidents of moderate harm and above reported from June 2024 to May 2025. The service reported 1 never event between June 2024 and June 2025. This occurred within vascular surgery and resulted in the surgery being abandoned. These were investigated as a patient safety incident and learning had been identified and implemented in these cases. A team training day was carried out to look at the themes leading to the never event, which included the impact of human factors.

Managers investigated incidents thoroughly and lessons were learned from safety events reported. Staff told us they received individual feedback from incidents they had reported. Learning was shared at an individual, as well as departmental level. Managers undertook in-depth reviews into specific areas where they had noted themes. For example, they had undertaken an in-depth review in relation to patient falls and pressure care management. Staff were generally included in the review process and learning was shared with the wider team. These reviews were shared with the team and immediate debriefs were carried out.

Feedback from incidents that occurred in different areas was shared during daily staffing huddles and monthly ward and theatre meetings. For example, we saw evidence learning had been shared from a recent serious incident in coronary care. The outcome of the investigation had been shared with staff, and we saw there were action plans in place to implement learning on relevant surgical wards, as well as bespoke training for staff.

Incidents were an agenda item on each clinical management group and speciality governance meeting. This meant service leaders had good oversight of incidents. Each speciality had mortality and morbidity meetings where they discussed specific incidents and learning. However, these meetings varied considerably in terms of content, approach and staff engagement across specialities.

Staff understood their responsibilities to meet the duty of candour and to be open and honest with patients when notifiable incidents occurred. Incident investigations we reviewed following our site assessment showed duty of candour had been applied.

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. Staff made sure there was continuity of care, including when people moved between different services.

Standard operating procedures including referral guidelines were in place for each surgical speciality. Following our site assessment, we were provided with referral procedures for hepatobiliary, thoracic and cardiac surgery. The procedures varied in content, however in general, outlined how referrals from other trusts or general practitioners were received, processed, reviewed, allocated for surgery and timeliness of admission. However, the procedures in 1 speciality did not reflect the surgical team complexities which meant there was a risk of a patient waiting longer than necessary. For example, in cardiac surgery, referrals were sent direct to individual consultants and patients were added to their waiting lists, regardless of whether there was capacity with other surgeons. However, referrals were also sent to the cardiac service where referrals were pooled and allocated by the clinical lead to the surgeon with the appropriate skills and availability to see them quickest. At the time of our assessment, 35 to 40% of referrals were pooled. Managers were aware of this risk and both clinical and operational managers were working together to streamline and continue to strengthen the process.

The World Health Organisations (WHO) ‘Safer Surgery’ checklist was used across all theatres we visited. The WHO checklist is a standardised tool to improve communication and teamwork in theatres to reduce errors and complications. The checklist had been fully completed at each stage in 11 out of 12 theatre records we reviewed across different specialities. However, we observed 4 surgical procedures and found, whilst the WHO checklist was carried out and verbalised, not all staff involved with the operation were fully engaged in the process in 3 procedures we observed. For example, in 2 cases, we observed the timeout was verbalised well, however, not all staff stopped what they were doing to fully engage in the process. We observed some staff carrying on with tasks and other team members holding other conversations. We observed 1 sign-out and found staff were not listening, instead we observed laughing and joking between staff and 1 staff member left the theatre. Staff shared an incident they reported which occurred the week prior to our site assessment where staff not listening led to a patient being anaesthetised before blood was ready. Furthermore, staff being distracted during time out was a factor which led to a recent never event that had been investigated. Learning from these incidents was shared with staff and incorporated into theatre training days.

Safe handover processes were observed across the specialities we assessed. We attended 3 team briefs in theatres and observed they were conducted using a standardised template. All patients were discussed which included a review of the procedure, medicines, consent and any risks. Patients underwent a pre-assessment, and risks were reviewed throughout their treatment journey. Recovery records we reviewed showed there was a handover from theatre staff and ward staff told us they generally received a good handover from theatres, recovery and enhanced care. Ward co-ordinators attended daily meetings with enhanced care and theatre staff to plan for admissions following surgery.

Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge. Prior to discharge, staff made referrals to district nurses for wound management where appropriate. Staff referred for specialist input, for example, patients with a learning disability were assessed by the learning disability team. Furthermore, patients on a cancer pathway receive specialist support before and after surgery and plans were put in place for post discharge support with specialist nurses.

Staff were provided with safeguarding training specific to their role. They worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. 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. They shared concerns quickly and appropriately.

Staff were provided with training specific to their role in recognising and reporting abuse. The 95% trust target for all staff in the completion of adult and children safeguarding level 2 modules had been exceeded. The trust had a designated safeguarding lead trained to level 4 in adults and children’s safeguarding and could be contacted by staff for additional support if required. The trust provided additional safeguarding training information following their factual accuracy review of this report. Level 3 safeguarding training was only provided to safeguarding specialist nurses, matrons, heads of nursing and duty managers, as they did not expect general clinical staff to assess and manage the safeguarding elements of care, as this was led by their specialist teams.

Staff had a good understanding of safeguarding and how to take appropriate action. Staff we spoke with understood how to protect patients at risk of or suffering significant harm. Staff worked with other agencies to safeguard patients, and staff knew how to escalate safeguarding concerns to their manager.

Accessible safeguarding policies and procedures were in place and reflected national guidance. Most staff we spoke to felt confident to act where they had concerns of abuse or neglect. Staff knew how to make a safeguarding referral and who to contact with concerns. For example, where staff identified potential safeguarding risks at home, they consulted with the safeguarding team and other multidisciplinary colleagues to ensure patients were protected.

During our site visit, we reviewed the record of a patient with a learning disability. The records were completed comprehensively, included a hospital passport, with clear preferences, likes and dislikes recorded. We saw personalised actions to safeguard the patient had been implemented. Staff were able to access these records and knew about the patients’ individual needs.

There was a clear understanding of the requirements of the Mental Capacity Act and staff described how they put these into practice. Staff understood the Deprivation of Liberty Safeguards (DoLS) and how these were applied. At the time of our site visit, there were no patients who reportedly lacked capacity or who were subject to DoLS.

Specialities we assessed did not always work collaboratively to understand and manage risks. Although staff managed most risks well, there was a lack of review of those associated with potential blood clots and systems monitoring waiting lists were not fully safe or effective.

Staff assessed patients’ suitability and fitness for surgery using a standardised tool. It included an assessment of the patient’s fitness for surgery, medical history, medicine review, vital signs, blood tests, infectious disease screens and any other related clinical checks. These were undertaken by a nurse in conjunction with the surgical team prior to surgery. All pre-operative clinical tests were completed in line with National Institute for Health and Care Excellence (NICE) guidelines.

The condition of patients was optimised before surgery, where possible. Pathways were in place for escalating complications such as anaemia, diabetes, and situations where patients had not stopped specific medication prior to surgery. We saw some surgery list cancellations were in relation to the health or risks to the patient.

Nurse led risk assessments and care plans were completed on admission and where required reviewed for each patient. These included assessing risks such as falls, pressure care management, mobility, wound care, catheter care, cannula care, communication needs, nutrition and hydration. We reviewed 16 patient records and found the risk assessments and care plans were generally completed and reviewed for each patient. We observed measures were in place to prevent harms. For example, we saw evidence of falls prevention in place for patients at risk of falling and pressure relieving equipment in place for those at risk of developing skin damage.

Venous Thrombosis Embolism (VTE) assessments had been completed for all patients on admission but not reviewed thereafter. Only 2 out of 16 records we reviewed had been reassessed within 24 hours of the initial assessment, post-operatively or when there had been a change in condition. Specialities we assessed undertook regular audits of VTE assessments. Audits from November 2024 to April 2025 showed 98% compliance with VTE risk assessments against trust standards. However, this did not include VTE reviews. This meant the most up to date risk was not documented or audited, which could impact the safety of medicines prescribed. The trust told us they intended to audit compliance with this, implement staff training and incorporate reminder alerts to improve compliance.

A nationally recognised tool was used to identify and escalate deteriorating patients. The National Early Warning Score (NEWS2) was used to monitor patients for signs of deterioration. Staff had completed training to recognise the deteriorating patient and knew how to manage deteriorating patients. Electronic systems alerted the Deteriorating Adult Response Team (DART) of any patient with a high NEWS score. They proactively contacted the ward to ensure staff had taken all appropriate actions and offer support. We reviewed 16 patient records and found NEWS were generally recorded in a timely manner and were acted upon when the clinical signs of deterioration were identified. Audits undertaken from 1 December 2024 to 31 May 2025 demonstrated 96.8% of observations were completed in line with NEWS frequency rules and 92% of NEWS scores were escalated when required. There was a folder in theatres with ‘crisis cards’ which provided staff with evidence-based algorithms for dealing with possible emergencies in theatres.

Processes were in place for staff to assess patients at risk of sepsis. However, sepsis treatment was not always timely in line with best practice. Audits undertaken from 1 December 2024 to 31 May 2025 demonstrated 79% of patients with confirmed sepsis were treated, including administering intravenous antibiotics within an hour. However, 18% were treated within 1 to 3 hours and 3% over 3 hours. During our site assessment we reviewed the record of a patient with a high NEWS score and suspected sepsis. Sepsis screens were completed and reviewed by a doctor within an hour. Appropriate actions were taken in line with the sepsis care bundle, including timely administration of antibiotics. Feedback from audits was shared with staff to improve practice and compliance.

Systems to monitor the risks of patients on waiting lists for treatment did not always provide staff with up-to-date information about the patient’s condition whilst waiting. For example, at the time of our site assessment, the service was undertaking a review of patients waiting for cardiac treatment and those who were lost to follow up. This was an action from an external review undertaken in November 2024. Following our site visit, the review had not been fully completed but initial findings showed there were 352 patients recorded as lost to follow up. Of these, 180 had been reviewed and 53 required further investigation to understand why there had been a delay and the clinical impact of these long waits. We saw limited evidence patients waiting were reviewed to reassess their priority status and to consider any changes. This meant at the time of our assessment, managers and clinicians did not have a robust oversight of the impacts of long waits or any changes in the clinical conditions of all patients waiting. However, the trust advised us further validation of the waiting list carried out after our assessment, showed over 50% of the 352 patients recorded as lost to follow up were due to the outcome not being correctly coded. They provided assurance they were working to strengthen their digital validation process to ensure they had an accurate picture of their waiting list.

Staff quickly recognised when people needed urgent help or support and used appropriate tools and technology to assist. Staff were aware of any post-operative risks including the risks associated with anaesthetic. They closely monitored patients post-operatively for deterioration and post-operative delirium. Staff used high visibility beds to keep a closer eye on patients where required. Where patients were at risk of falling, staff used equipment to prevent this from happening.

Critical care and enhanced care services were provided on-site to support the management of deteriorating patients. Glenfield hospital carried out mostly specialist surgery which involved complex and high-risk procedures. We found there were clear processes to transfer patients to critical care from surgery, and this was planned prior to surgery in most cases. For example, cardiac cases went to critical care straight from surgery and thoracic cases went to a purpose build surgical enhanced care unit. This unit was also used as a step down from critical care for post-operative cardiac patients. Surgeons worked closely with the critical care team and maintained oversight of their patients during their critical care admission.

In theatres we observed scrub nurses carrying out counts of equipment. Most nurses we spoke to said they felt comfortable to stop if they were missing any equipment during an operation. However, some nurses did not always feel comfortable to do this due to the behaviour of senior colleagues.

Processes were in place to review patients’ post-surgery. Daily medical reviews were undertaken. Patients had a medical review daily led by a consultant or registrar. We found there were clear processes to transfer patients to critical care from surgery, and this was planned prior to surgery in most cases. Surgeons worked closely with the critical care team and maintained oversight of their patients during their critical care admission.

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.

The environment within theatres varied considerably and some operating theatres were not well maintained. There were 10 theatres at Glenfield Hospital which included a hybrid theatre and specialist theatres for breast, vascular, cardiac, thoracic, hepatobiliary and emergencies. The hybrid theatre had imaging equipment within the theatre such as X-ray to reduce the need for further surgeries. We visited theatres 2, 3, 6, 7 and 8. We found theatres 2, 3 and 6 to be poorly maintained. The theatres looked visibly run down which posed a risk of effective infection prevention management, accidental injury and poor working conditions for staff. In general, we found wear and tear to the flooring, such as visibly marked stains, defects to the skirting and damage to doors. This was of significant concern as the operations undertaken in these theatres were often high risk and complex, requiring a safe environment. Equipment including mattresses, surgeon arm supports and chairs were damaged with temporary fixes including tape used to cover up rips.

In theatre 2, there was plastic edging from the scrub sink panel on the floor which had fallen off. There was damage and staining to the floor. There were defects to laminate covering on work surfaces with wood exposed.

A staff member raised concerns that a few weeks before our site visit, plugs fell off the wall in a cardiac theatre and fused the sockets in the theatre and anaesthetic room during an operation. Extension leads had to be used to continue the operation and plug in equipment. This had not been fixed at the time of our site visit. In theatre 3 we found similar concerns. For example, there was staining on the walls and rusted equipment.

The environment within theatres was on the service risk register. There were 3 risks associated with the environment including lack of an effective refurbishment programme, insufficient downtime for planned preventative maintenance and lack of capital funding. All were rated 20 which was very high risk. The risks cited had the potential to lead to surgery delays and cancellations, and patient harm if not acted on. Service leaders were fully cited on the risks and told us an extensive refurbishment plan was needed but the capital funds available to them would not meet the level of work required. They were in the process of completing a business case to the trust board with a plan to decant and refurbish theatres in need of refurbishment, but this had not been progressed at the time of our site assessment. There was a planned preventative maintenance programme in place for theatres and staff escalated issues to the estates team to fix any issues and respond to incidents. However, service leaders recognised estates had not always responded to these incidents in a timely manner and they had escalated these concerns to the trust estates department. Risks were monitored in monthly business and governance meetings and reported to the board. Following our site assessment, managers told us they had undertook a review of the environment and were prioritising maintenance in relation to the condition of the environment.

Equipment in theatres was not always received in a timely manner or not up to expected standards. Surgeons and theatre staff shared their concerns with the quality and efficiency of sterile services. Sterile services were offsite and were responsible for the cleaning and restocking of equipment required for operations. Staff described multiple issues with equipment, such as missing instruments and holes in wrappers which meant equipment was no longer sterile and could not be used. Furthermore, surgeons also expressed concerns that specialist equipment required for surgery was not received on time, impacting scheduling of operations. From July 2024 to June 2025, 116 incidents were reported in relation to equipment or products being lost or damaged. This impacted the efficiency of surgical services being delivered, which meant there were sometimes delays in equipment being obtained before they could commence an operation.

Managers told us they had set up regular meetings with suppliers and sterile services to improve the equipment they received. Staff raised concerns about the medical resourcing team which included challenges related to capacity and leadership which affected operational efficiency. Managers were aware of the challenges with medical resourcing and were working to address the issues to improve access to equipment.

Theatre leaders were often restricted in dealing with issues as the budgets for equipment were the responsibility of the speciality at the time of our site visit. Leaders were aware this often led to delays with equipment being ordered. However, managers were working with surgeons and theatre staff to ensure they were ordering equipment within appropriate timescales and checking they had what they needed as part of team briefs and before commencing an operation. They intended to centralise their budgets to improve efficiency and timeliness of ordering equipment. This was in the process of being implemented at the time of our site assessment.

Most areas had secured access. However, we visited wards 23, 29 and 31 which did not have secure access in and out. During our last inspection in 2022, we found ward 31 had multiple entrances and was often used as a thoroughfare between other wards. This was referenced as a security risk on the divisional risk register at the time with plans to introduce door controls. During this site visit we found there were multiple entrance/exit points on ward 31 which were unsecure with no evidence of door controls in place. This meant potentially vulnerable patients were not always safe and unauthorised persons could get into the wards. However, in theatres and on the surgical enhanced care unit, access was restricted by key card.

The surgical wards we visited were well maintained and generally followed national guidance. Wards we visited were suitable for their purpose and contained sufficient equipment to meet patient needs and keep patients safe. Electrical equipment underwent regular checks across. There were sufficient beds to manage new admissions, including emergencies. For patients with higher support needs, there were high visibility beds or bays.

There was access to specialist equipment required in an emergency which was in good condition and regularly checked by staff. This included resuscitation and difficult airway trolleys. Anaesthetic equipment checks were regularly completed which included daily checks of anaesthetic machines.

Sepsis grab boxes were not always routinely checked. We checked 4 sepsis boxes located in the bottom drawer of emergency trolleys on wards 23, 26, 31 and the recovery area in theatres. We found 2 of these boxes had not been checked for some time and there were out of date consumables and fluids in the boxes. These were escalated and equipment was immediately removed. Managers told us they were not used anymore and were not included in the online checking process. However, as the equipment was readily available, there was a risk a staff member could use out of date equipment or infusions.

Clinical waste was stored and disposed of in line with national guidance.

Fire safety equipment was available, serviced and in safe condition. This included fire exits marked and free from obstruction.

Specialities we assessed did not always have enough qualified, skilled and experienced staff. However, managers had systems to review staffing levels. 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.

During our inspection in 2022, we found the service did not have enough medical, nursing and support staff in theatres which led to reduced theatre lists and cancellations. During this assessment, we found improvements had been and continued to be made. However, there were still areas where staffing levels impacted the day-to-day running of the service, including theatre cancellations and management of ward-based clinics.

There were variable vacancy rates for nursing staff in theatres and on surgical wards. Data provided to us by the trust showed from June 2024 to May 2025, the average vacancy rate for both registered nursing staff and non-registered support staff combined was 14.1%. The highest average vacancy rates were seen in cardiac theatres (21.8%) and emergency and renal theatres (22.7%). In both areas, we found the vacancy rates were reducing following recruitment into posts. For example, in January 2025, the average vacancy rate was 32.7% in cardiac theatres which had significantly reduced and at the time of our site assessment all posts had been recruited into. However, not all new staff had started, and some were supernumerary and being inducted. Renal remained high but was reducing and at the time of our site assessment had reduced to 15.5% with 4.2 Whole Time Equivalent (WTE) vacancies. Theatre staffing was on the risk register as a high risk (16) and was being mitigated through recruitment, use of agency forward planning of rotas and theatre lists.

Data provided to us by the trust showed overall registered nurse WTE vacancy rates on surgical wards at Glenfield Hospital from May 2024 to May 2025 averaged 4.8%. Higher than average rates were seen on the surgical enhanced care unit (7.9%), ward 37 (7.3%) and ward 36 (11.6%). Vacancy rates for non-trained nursing staff were high and averaged 10.1% over the same period. An active recruitment plan to fill vacant posts was in place.

Staff turnover rates for nursing staff were variable across theatres. Overall staffing turnover in theatres, including the recovery area was 4.2% from May 2024 to May 2025. However, data sent to us following our site visit showed the turnover was high in specific areas such as cardiac theatres (22.6%), hepatobiliary and vascular theatres (12.5%). By comparison the recovery team and emergency and renal theatres had a 0% turnover over the same period. Staff of all levels told us the high turnover was impacted by the culture, reported uncivil behaviours between some staff and the intensity of long working hours. This impacted more junior nurses’ ability to develop surgical skills. Managers and trust leaders were aware of this. An improvement plan to address culture in cardiac theatres was in place, yet improvements were perceived by staff to be inconsistent. However, following our site assessment, the trust further action to address these cultural concerns within the service.

Theatre lists were cancelled due to staffing levels and not always being able to meet the Associations for Perioperative Practice (AFPP) recommendations for theatre staffing. Data provided to us following our site assessment showed 10 sessions in May 2025 were cancelled due to staff availability and 13 sessions in June 2025. Staff worked within specialities and at the time of our site assessment, did not rotate which impacted their ability to cover different specialities in the event of staff absence or shortage.

The number of registered nurses and healthcare assistants did not always match the planned numbers on surgical wards. During our site visit we observed 2 out of 4 wards we visited where the planned numbers did not match the actual numbers of staff. For example, we found ward 23 were down 1 registered nurse during the day and night and 2 HCAs during the day and 1 at night. On ward 31, they were down 1 HCA in the day. Ward leaders and co-ordinators supported where the actual staffing levels did not meet the planned.

Ward staff told us they were regularly moved to other wards to cover where they were short staffed. This meant there could be insufficient staff to undertake patient care. Ward staff told us when clinic attendance was busy, it was very difficult for them to manage this along with ensuring patients on the ward were safe. On some occasions, patients were readmitted from the clinic which led to increased pressure to manage these patients. Matrons were aware of this and told us they intended to look at skill mix on these wards moving forward to ensure they had the correct staff on shift to manage the clinics.

Data provided to us following our site visit showed from June 2024 to May 2025, the average shift fill rate across surgical wards in the day was 88% and 91% at night. All wards were generally above 80%. Average fill rates across theatres from June 2024 to May 2025 was 86% for registered theatre staff and 63% for non-registered theatre staff. Recovery was generally above 90% over this time. However cardiac fill rate was consistently low ranging between 60-77%. This reflected the high vacancy rates overtime and theatre cancellations.

There were reducing rates of bank and agency nurses. Agency was used in theatres but not on wards. We saw there was a reliance on bank and agency in theatres. Bank use on wards has been steadily reducing from June 2024 to May 2025. Where temporary staffing was used, managers told us they used staff familiar with the wards and specialities. Temporary staff had an induction to the ward and theatres.

Staffing levels were calculated using a nationally recognised staffing tool; however, 2 areas managed post operative outpatient clinics on the wards, and staff reported that at times staffing was not optimised to meet the needs of the outpatient clinic and the complexity of patients on the ward. Matrons told us they intended to look at skill mix on these wards moving forward to ensure they had the correct staff on shift to manage the clinics.

There were processes to review staffing levels daily. Registered nurse and non-registered nurse staffing levels on surgical wards were planned and reviewed against the actual numbers. A safe staffing tool was used to analyse the staffing levels based on the acuity of patients on the ward. This indicated where more staff were required to ensure safe staffing. A matron was allocated daily to review and have oversight of staffing across surgical wards. Where areas were short staffed, staff were moved. Managers attended daily bed meetings to present staffing levels and acuity concerns and seek support from the trust to mitigate staffing risks.

In theatres, there were 5 WTE band 7 theatre team leaders who each managed a smaller group of theatres based on specialities within the overall group of 10 theatres. The team leaders were supported by a band 6 deputy. A team leader was designated to oversee theatres which involved trouble shooting and dealing with staffing issues.

There were not always enough medical staff to keep patients safe. At the time of our site visit, there were 4.4 WTE consultant vacancies across cardiac, thoracic, renal transplant and vascular surgery. The shortage of vascular consultants was on the risk register as very high risk due to the possible impact in delays in diagnosis and treatment. This was mitigated with cover from other sites and locums to support emergency provision.

Furthermore, there were 5.2 speciality trainee vacancies, 7 trust registrar (ST3) vacancies and 3 foundation year doctor vacancies. There was a good skill mix of medical staff on each shift, and the medical staff matched the planned number. Rotas for thoracic, vascular, cardiac and hepatobiliary specialities we reviewed from April to June 2025, demonstrated shifts were generally filled. Where there were gaps, we saw cover was arranged. We saw there was always a consultant surgeon, registrar and doctors in training on call always with on-site presence. There were 2 cardiac consultants on call for general cardiac and the regional aortic service. Managers could access locums when they needed additional medical staff. However, locum usage at the time our site visit was minimal. Where they were used, managers made sure they had a full induction before they started work.

Consultants were on-site for the cardiac, thoracic, renal transplant and vascular specialities from 8am to 6pm Monday to Friday. They were also present to review patients on weekend mornings from 9am to 12pm. Outside of these times there was a non-resident consultant on call for these specialities.

Resident doctors in cardiac surgery worked on call every 1 in 7 weeks. Following a coroner’s inquest where resident doctor availability was a concern, the rota was changed to 1 in 9 weeks on call. Due to structural changes in the rota, the rotation had returned to a 1:7 ratio. However, the service had subsequently recruited to resident doctor posts to enable a rotation of 1 week in 9 on call.

Medical staff raised concerns about the on-call rota. Some medical staff considered the rota to be stressful and restrictive to developing skills. Doctors in training were on call for 2 in every 4 weeks. At night they had to cover all specialities (4 wards) as well as their own area. They described it as stressful and exhausting. Some specialities did not complete day tasks which put pressure on the on-call team to complete these. Most doctors in training were complimentary about the time they had in theatres to learn and build skills. However, staff working in cardiac surgery did not consider they were given sufficient opportunity to be present in theatres as they were required on the wards.

Ward staff told us the medical staff were always present on the ward. Daily ward rounds took place where all patients were reviewed across all wards and specialities. Registrars were accessible to review patients ward staff were concerned about and were responsive to request for support. We observed positive relationships between the medical and nursing teams on wards we visited. Registrar and doctors in training told us their workload was very high which restricted their ability to spend time in theatres and get good exposure to operations as they were required on wards.

Theatres were staffed according to the Associations for Perioperative Practice (AFPP), Association of Anaesthetists of Great Britain and Ireland (AAGBI) recommendations. There was always a consultant anaesthetist on call and onsite out of hours. However, there were significant vacancies with anaesthetists which restricted their availability at times. Staff told us anaesthetists were not always available to support theatre lists which resulted in cancellations. Data we reviewed following our site visit showed there were 33 cancelled theatre session in May 2025 and 41 in June because of lack of anaesthetist availability. Anaesthetist availability sometimes impacted the timeliness of high-risk surgery planning. There was limited capacity for them to attend meetings to plan for high-risk cases which delayed operations taking place. This was a known risk and discussed at quality and safety board meetings. It was noted there were significant numbers of patients to be seen by the anaesthetist team and the risk was rated a 20 on the risk register for very high risk. This risk is in the context of a national shortage of anaesthetists.

There were not enough perfusionists to safely support specialist surgical procedures. Perfusionists are healthcare professionals who manage the heart and lung machines during open-heart surgery to make sure blood, and oxygen circulates through the body. A demand and capacity study undertaken between August 2024 and January 2025 demonstrated they were significantly under resourced to manage the requirements of theatres. At the time of the study there were 9 WTE and a trainee. The study showed the team required 16 WTE to realistically deliver an uninterrupted service. It restricted their ability to plan for theatre lists and there had been cancellations as a result. The service was also impacted by recent staff long term leave and staff leaving the department. From July 2024 to June 2025, 16 incidents were reported in relation to there not being enough on call perfusionists to cover theatres. For example, there were often only 2 on call to cover 3 clinical areas and newly qualified perfusionists on-call with limited support. This meant there was a risk there would not be a perfusionist available to attend in an emergency or to assist with patient transfers. There were plans to increase training opportunities to recruit and train more to ensure cardiac procedures were not impacted. However, there was a national shortage of perfusionists.

Mandatory training in key skills was provided to all staff and managers made sure everyone completed it. The mandatory training was comprehensive and met the needs of patients and staff. Data received in June 2025 showed the overall compliance with mandatory training for staff working in all surgical services was 93%. Identification of sepsis training compliance was 99% and falls prevention was 99%. Basic life support training was 94% and resuscitation training was 100%. Not all staff were required to undertake Immediate Life Support (ILS), except for theatre recovery staff where 88% of registered nurses had been trained to this level. This enabled there to always be at least 1 staff member with ILS level skills on duty. We requested Advanced Life Support (ALS) compliance data; however, this was not provided. Managers advised they had enough suitably qualified staff to ensure they complied with trust standards in delivering safe life support. Anaesthetists were trained to ALS level, and they were always present in theatres. On surgical wards consultants were trained to ALS level and the trust DART team always had an ALS trained staff member present for emergency support. Compliance with learning disability and autism training was 99%.

Each speciality had specific ward-based competency training to ensure staff had the skills to manage patients post-operatively. Theatre staff underwent regular training days which focused on key areas within theatres to keep patients safe and learning from incidents. Human factors was not a standalone training but was incorporated into training days.

Managers provided new staff with appropriate induction. Surgical areas were specialised at Glenfield Hospital and each area had specific competency booklets which staff had completed or were working through.

Managers provided staff with appraisal of their work performance. Nearly all staff (95%) had received an annual appraisal. They identified the learning needs of staff and provided them with opportunities to develop their skills and knowledge. Theatre staff were provided with regular training days covering learning from incidents, simulations and standard safe surgical care training. This included looking at human factors as part of this but not as a standalone training.

Specialities we assessed 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.

The trust had infection, prevention and control (IPC) policies and procedures to help control infection risk. These and other related policies covered the actions required by staff to minimise the risk of infection and cross infection in the hospital and the surgery service. They had been reviewed to ensure compliance with national guidance.

Cleanliness varied across the specialities we assessed. The environment within theatres created challenges for the prevention and control of infections. Deep cleans of theatres were undertaken every 3 months, however, not all theatres were visibly clean and did not always have suitable furnishings which were clean and well maintained. The environment in some theatres, including theatre 2, 3, 6, 8 and some anaesthetic rooms needed maintenance and presented an infection control risk. For example, we observed stained flooring and walls, rust on instrument trolleys, wood exposure on work surfaces due to defects in laminate covering, sticky residue on equipment such as surgeon arm supports and trolleys, and damage to mattress covers. Theatres did not routinely label equipment to show when it had last been cleaned. This meant the service could not be assured the environment and damaged equipment in these areas had been appropriately decontaminated to an acceptable standard or were visibly clean. However, we found theatre 7 and the recovery area to be visibly clean, tidy and well maintained. We saw the use of labels to indicate when equipment had last been cleaned in recovery. Furthermore, surgical wards we visited were generally visibly clean, tidy and well maintained. Labels were used on wards to demonstrate when equipment had last been cleaned.

Following our site visit we raised concerns about cleanliness to service leaders. They told us they were taking immediate action to review flooring, wall panels and equipment within theatres. They had arranged for an industrial clean of the theatre flooring and planned to replace flooring if it could not be effectively cleaned. They intended to prioritise repairs and replacements to maintain high standards of cleanliness and hygiene.

Infection, prevention and control principles such as compliance with hand hygiene procedures and use of personal protective equipment (PPE) were not fully embedded in practice within theatres in line with the provider’s policy. We observed poor compliance with hand hygiene practice in theatres by all staff including surgeons, anaesthetists, perfusionists, nurses and support staff. Gloves were not always removed after tasks. Staff did not routinely decontaminate their hands using the 5 moments to hand hygiene guidance before leaving the operating theatre. We observed 12 staff members not decontaminating their hands before removing PPE and leaving the theatre. A staff member in theatre used gloves to count in dirty swabs and then go on to answer the telephone without removing gloves and decontaminating their hands. A surgeon removed PPE and then left theatres without decontaminating their hands following patient contact.

However, we observed staff in recovery and on wards washing their hands and using de-sanitising hand gel to decontaminate their hands before and after patient contacts. Hand sanitising gel was available for staff to use across theatres, recovery and wards.

Managers checked staff compliance with hand hygiene practice. Data provided by the trust following our site visit showed they consistently did not meet the providers expected hand hygiene standards across all areas. For example, audits undertaken from October to December 2024 showed compliance with hand hygiene techniques over this time averaged 30%, ranging from 6% to 65%. Handwashing after contact ranged from 50% to 82%. This did not meet the trust expected standards.

Actions taken to improve hand hygiene practice did not always drive improvement. We observed there were actions to improve compliance, however, based on what we observed during our site assessment in theatres, we were not assured the actions were always effective. Furthermore, compliance audits undertaken from April to June 2024, showed the average compliance was 34% which meant performance had deteriorated following these audits.

Staff in theatres did not always ensure their hair was tied back or use hair nets. Theatre shoes in the female changing room were visibly dirty. Face mask use was not compliant with trust policy. For example, face mask use was mandatory in cardiac theatres, and we observed multiple staff wearing them below their nose or around their neck during operations which was not in line with the provider policy and instructions on the mask wearing guidance poster which was visible to staff. However, we observed most staff to be bare below the elbow across all areas we visited.

Staff had access to PPE such as aprons, gloves and face masks. Hand sanitising gel was readily available to staff and hand-washing sinks were readily available to support effective hand hygiene. Staff on wards and in recovery were observed in general to follow IPC principles including hand washing and use of PPE. However, we did observe a surgical team on ward 23 enter an isolation room without putting on appropriate PPE.

Following our site visit we escalated concerns about hand hygiene compliance to service leaders. In response, they told us they were taking immediate action to reinforce hand hygiene and face mask protocols through targeted audits and refresher training, particularly in theatre settings.

Systems and process to ensure staff could respond effectively to IPC risks, such as transmittable infections were in place. Action was taken to prevent infection entering the theatre area. All patients were screened at the pre-assessment stage for transmittable infections. If a patient was admitted to a surgical ward as urgent, an emergency or from another hospital, they were nursed in side rooms until infection screens had been undertaken and results received. Patients with known infections were planned at the end of theatre lists with adequate time to deep clean post-surgery.

Data provided by the trust showed from June 2024 to May 2025 there were no reported hospital acquired MSSA or MRSA infections. Seven Clostridioides difficile were reported over this time. There were processes in place to minimise the risk of hospital acquired infections. All elective patients were screened for specific infections prior to admission and emergency, and hospital transfer admissions were isolated whilst screening was undertaken.

Processes were in place to monitor and reduce surgical site infection (SSI) rates. SSI is an infection related to surgery that occurs at or near the surgical incision within 3 days of the procedure, or within 9 days if prosthetic material is implanted. At the time of our previous inspection in 2022, the service did not undertake any SSI surveillance at Glenfield Hospital. Following this, they implemented an SSI programme in 2023. The initial focus was on gathering data.

Some SSI rates were higher than the national averages and varied across specialities. From December 2022 to June 2025, 3-month SSI surveillance was undertaken on 2635 cases across specialities. Data was reviewed following our site visit for cardiac, hepatobiliary and breast specialities. Data for cardiac and breast specialities were higher than the national rate. Hepatobiliary infection rates had been increasing in the period of April to September 2024 but were lower than the national rate.

The SSI team had increased resource to enable them to fully implement an improvement programme. However, staff told us they did not always receive co-operation from all surgical specialities at Glenfield Hospital. Managers recognised there was more work to be done to improve consistency of approach and overall governance of SSI improvements and had plans to do this.

Cardiac surgery had a detailed action plan to reduce their infection rates which had a positive impact. For example, it covered pre-assessment, intraoperative processes, equipment quality, post-operative process, dressings and aftercare. Managers told us they needed to look further at the environment within theatres as part of SSI programme improvements and consistency moving forward. This reflected what we observed during our site visit in relation to the environment within cardiac theatres. Furthermore, the hepatobiliary speciality had implemented improvements to reduce SSI rates. This included the introduction of absorbable sutures for major resections that were coated with an antiseptic agent to reduce the risk of SSI and support wound healing. They also implemented a new prophylactic antibiotic regime for pancreatic and liver resections and were trailing alternative dressings to reduce post operative infections.

Post-operative wound clinics were in place on wards 26 and 31 for patients to return for dressing changes. This was to help reduce SSI rates and ensure the correct dressings were being used and signs of infection could be dealt with early.

Specialities we assessed made sure that medicines and treatments were safe and met people’s needs, capacities, and preferences. They involved people in planning, including when changes happened.

People were supported to receive their prescribed medicines in a way that met their individual needs including self-medication. People told us they were included in discussions about their medicines, so they felt informed about what they were taking. There was a ‘medicines self-administration’ policy (November 2024) which provided details for staff to help support people to look after and administer their own medicines following risk assessments and consent in certain situations. People told us they were given information, advice and support about their medicines including when there were changes made to their medicines by doctors and members of the pharmacy team. One person told us ‘’I have had counselling on all my medicines. Staff have been brilliant, we don’t realise how lucky we are to have this hospital here’’

Staff told us they knew how to contact pharmacy for advice and processes were in place for the supply of medicines. Emergency medicines were available, and staff had access to medicines out of hours, and an on-call pharmacy service supported staff. We were told medicine management link nurses helped in raising the profile of medicine safety.

We observed medicines were locked and secure and stored safely. The pharmacy team checked the safe and secure handling of medicines for safe medicine storage. We found the systems for medicines storage were well managed. Medicines were stored and managed neatly, safely and securely with access only to authorised staff. However, we found free standing oxygen cylinders used when transporting patients were not always stored safely and posed as a trip hazard. This was observed in theatres and on some wards.

Controlled drugs (CDs are medicines requiring more control due to their potential for abuse) were stored safely and securely with access restricted to authorised staff.

Staff stored resuscitation medicines (medicines which are required in an emergency) in line with Resuscitation Council (UK) guidance

VTE assessments had been completed. We saw evidence pharmacists checked the VTE assessments to ensure medicines were prescribed at the correct dose where needed. However, VTE re-assessments were not always completed, therefore we could not be assured this was based on the most up correct VTE status.

There was a process for managing and reporting any errors or incidents involving medicines. Reported incidents and trends were reviewed and staff were able to talk through the process that would be followed if this occurred.