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Leicester General Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 5 February 2020

Our rating of this hospital stayed the same. We rated it as requires improvement because:

  • We rated safe, responsive and well-led as requires improvement and effective and caring as good.
  • In rating the hospital, we took into account the current ratings of the services not inspected this time.
  • Although services provided mandatory training in key skills to all staff, completion rates in surgery services for some modules were below the trusts target.
  • Outpatients services did not consistently manage records well.
  • Not all key services were available seven days a week.
  • People could not access services when they needed it. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were not always in line with national standards.
  • Services did not have an overarching leadership team, to oversee the service to deliver high quality sustainable care.
  • Not all leaders and teams in outpatient services used systems to manage performance effectively. They did not always identify and escalate relevant risks and issues and identify actions to reduce their impact.

However:

  • Services had enough staff to care for patients and keep them safe. Most staff had training in key skills, understood how to protect patients from abuse, and managed safety well. Services controlled infection risk well. Staff assessed risks to patients and acted on them. They managed medicines well.
  • Staff provided good care and treatment and gave them pain relief when they needed it. Managers monitored the effectiveness of services and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • Services planned care to meet the needs of local people and took account of patients’ individual needs.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. Services engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.
Inspection areas

Safe

Requires improvement

Updated 5 February 2020

Effective

Good

Updated 5 February 2020

Caring

Good

Updated 5 February 2020

Responsive

Good

Updated 5 February 2020

Well-led

Requires improvement

Updated 5 February 2020

Checks on specific services

Medical care (including older people’s care)

Good

Updated 26 January 2017

We rated medical care services as good overall.

Safety of medical services was rated as requires improvement. Patients were at risk of not receiving the correct treatment in a timely manner. Nursing staff were not consistently adhering to trust guidelines for the completion and escalation of early warning scores (EWS); frequencies of observations were not always appropriately recorded on the observations charts and medical staff had not always documented a clear plan of treatment if a patient’s condition had deteriorated. Where patients had met the trust criteria for sepsis screening, not all patients were screened appropriately.

Potential risks to medical care services were anticipated and planned for in advance. However, not all staff were aware of the arrangements in place to respond to emergencies and major incidents.

There were systems, processes and standard operating procedures in infection prevention control, records, medicines management and maintenance of equipment which were mostly reliable and appropriate to keep patients safe. Patients were protected from abuse and staff had an understanding of how to protect patients from abuse.

We rated medical care services in effective, caring and responsive as good.

Care and treatment was planned and delivered in line with current evidence based guidance, standards, best practice and legislation and patients received effective care and treatment. Where outcomes for patients were below expectations when compared with similar services action plans had been put in place.

Patient’s symptoms of pain were effectively managed in both ward and department areas with good comfort outcomes for patients in endoscopy. Staff were proactive in assessing the patient’s nutrition and hydration needs.

We observed staff positively interacting with patients and patients were treated with kindness, dignity, respect and compassion while they received care and treatment. Feedback from patients was consistently positive about the care and treatment they had received.

Medical care services were mostly responsive to patient’s needs; patients could access services in a way and at a time that suited them and there was a proactive approach to understanding and meeting the needs of individual patients and their families. However, referral to treatment times (RTT) for the cancer standards and access to diagnostic tests were worse than the England average.

We rated well led as good.There was a vision and strategy for this service and whilst it was very strategic staff were able to describe this to us during our inspection.Staff were consistent in delivering care and demonstrating behaviours in line with the trust vision and strategy.Staff reported good nursing leadership from their line managers and matrons of the service. Nursing staff felt ward sisters, matrons and heads of nursing were visible and provided a good level of support.

Critical care

Good

Updated 26 January 2017

We rated critical care services as good overall.

Safety thermometer data showed there was a high incidence of harm free care delivered to patients. We saw that evidence based best practice guidance was being used to determine care.

We saw patients, their relatives and friends being treated with dignity and respect. Staff demonstrated that they understood the impact of critical care on people and their families both socially and emotionally.

There was a vision and strategy for the reconfiguration of critical care service at Leicester General Hospital despite the current hold on progress being made as a consequence of financial pressures.

There was an effective governance structure in place which ensured that risks were recognised and discussed including mitigating actions, timescales and ownership.

There had been a delay in the timely reporting of a recent never event. Not all the staff on duty on the day of the inspection were aware of the never event and the subsequent changes to practice.

The environment fell short of the current Health Building Notes (HBN 04-02) for critical care.

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There was a delay in patients being transferred out of critical care when their condition improved. The critical care outreach service was not provided 24 hours a day, seven days a week.

End of life care

Requires improvement

Updated 26 January 2017

We rated end of life care services at the Leicester General Hospital as requires improvement. We rated responsive and caring as good with safe,effective and well led as requires improvement because.

The medical staffing levels were not in line with the recommendations from the National Council for Palliative Care who recommend there should be one whole time equivalent (WTE) consultant for every 250 beds. The service had 3.5 WTE consultants and would require 7.0 WTE to provide cover to the three sites. The staffing was 50% lower than recommended.

The trust had 82 syringe drivers that were in line with best practice guidelines. However, only ten were ready for use. This meant the trust was reliant on using syringe drivers, which did not meet the NHS patient safety guidance.

We looked at 12 ‘Do Not Attempt Cardio Pulmonary Resuscitation’ orders (DNACPR) across the trust and found there were inconsistencies in how these were completed. We found that out of 12 DNACPR orders, six were completed correctly (50%). We found staff had not always followed trust policy when they completed DNACPR orders.

The trust had taken part in the National Care of the Dying Audit 2016 and had achieved three of the eight organisational Key Performance Indicators (KPIs). The trust scored lower than the England average for all five Clinical KPIs. The trust had undertaken an audit in April 2016 in response to the National Care of the Dying Audit 2016, and an action plan had been developed to address the KPI’s that had not been achieved.

The service did not have its own risk register and risks were not recorded on the trust wide risk register.

There was no strategic plan for end of life care throughout the trust.

The service did not have a non-executive director representing end of life care at board level.

However, we also found that care records were mostly maintained in line with trust policy.

Staff understood their responsibilities in following safeguarding procedures and care and treatment was delivered in line with recognised guidance and evidence based practice. The last days of life care plan was in use throughout the trust.

The trust had effective multidisciplinary working in place and staff were seen to be compassionate and we observed them treating patients and their families with dignity and respect.

A bereavement service was available to support family members with practical and support issues after the death of a patient. The chaplaincy service provided a 24 hour, seven days a week on call service for patients in the hospital, as well as their relatives.

The specialist palliative care team were committed to ensuring that patients receiving end of life care services had a positive experience.

The trust had a rapid discharge home to die pathway. Discharge in these circumstances was arranged by the specialist discharge sister and could be facilitated within a few hours for patients wishing to return home.

Staff spoke positively about the service they provided for patients. High quality, compassionate patient care was seen as a priority. Staff within the specialist palliative care team spoke positively and passionately about the service and care, they provided for patients.

The trust had recruited a bereavement nurse specialist in July 2015 who worked across the three hospital sites and closely with the specialist palliative care team (SPCT).

Maternity and gynaecology

Good

Updated 14 March 2018

However:

  • The service did not always control infection risk well. In the obstetric theatre the premises and some equipment was not kept clean or monitored regularly.
  • The service did not always use safety monitoring results. Senior staff collected safety information, but sharing with staff, women and visitors was limited. The information collected was not rated for comparison to national data. However, the service used elements of the information to improve the service.
  • The service did not always store medicines well. Medicines were stored in areas accessible to members of the public, and although fridge temperatures were checked, staff did not act on out of range temperatures. However, staff prescribed, gave, and recorded medicines well. Women received the right medication at the right dose at the right time.

Surgery

Good

Updated 5 February 2020

Our rating of this service improved. We rated it as good because:

  • The service had enough staff to care for patients and keep them safe. Staff understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However:

  • Although the service provided mandatory training in key skills to all staff, completion rates for some modules were below the trusts target.
  • Not all key services were available seven days a week.
  • People could not access the service when they needed it. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were not always in line with national standards.

Outpatients

Good

Updated 5 February 2020

Our rating of this service improved. We rated it as good because:

  • The service had enough staff to care for patients and keep them safe. Most staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them. They managed medicines well.
  • Staff provided good care and treatment and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Services were available five days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service mostly engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However,

  • The service did not consistently manage records well, we found one outpatient area where records were held together with elastic bands. However, the content of the records was of no concern. The service did not always manage safety incidents well and learn lessons from them. Staff did not always report incidents that should be reported. However, staff were aware of how to report incidents.
  • People could not always access the service when they needed it and some clinics were lower than the national standard for referral to treatment rates. The service did not always make it easy for people to give feedback.
  • The service did not have an overarching leadership team, to oversee the service to deliver high quality sustainable care. Staff did not understand the service’s vision and values, and how to apply them in their work.
  • Not all leaders and teams used systems to manage performance effectively. They did not always identify and escalate relevant risks and issues and identify actions to reduce their impact.

Diagnostic imaging

Requires improvement

Updated 14 March 2018

  • There was a good reporting culture within the imaging departments. Radiation incidents were well managed and thoroughly investigated.
  • We saw excellent working relationships between the staffing groups within the imaging and medical physics departments.
  • All patients we spoke to spoke positively about the care they had received in the department and told us they had received reassurance and support whilst using the service
  • Image report turnaround times were good despite the numerous IT issues the trust had experienced. The imaging department had reduced its reporting backlog from over 12,000 waiting over eight weeks for a report to less than 2,000 in five months.