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Leicester General Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 26 January 2017

University Hospitals of Leicester NHS Trust is a teaching trust that was formed in April 2000 following the merger of Leicester General Hospital, the Glenfield Hospital and Leicester General Hospital. The trust has 1,959 general and acute beds. 147 of these beds are maternity beds and 49 are critical care beds. 394 inpatient beds and 86 day-case beds are located at Leicester General Hospital.

University Hospitals of Leicester NHS Trust provide specialist and acute services to a population of one million residents throughout Leicester, Leicestershire and Rutland. The trust’s nationally and internationally-renowned specialist treatment and services in cardio-respiratory diseases, cancer and renal disorders reach a further two to three million patients from the rest of the country. The trust provides services from four hospital sites, Leicester Royal Infirmary, Leicester General Hospital, the Glenfield Hospital and the St. Mary's Maternity Hospital.

Leicester Royal Infirmary is close to Leicester city centre and provides Leicestershire’s only emergency department. The hospital has approximately 975 inpatient beds and 66 day-case beds. There were 149,806 inpatient admissions, 993,617 outpatient attendances and 135,111 emergency department attendances between April 2015 and March 2016.

Leicester General Hospital has 394 beds and provides services which include a centre for renal and urology patients. As a teaching hospital it works in partnership with several universities including the University of Leicester, Loughborough University and De Montfort University, to provide teaching, research and innovation programmes for doctors, nurses and other healthcare professionals.

During this inspection we followed up on the identified areas that required improvement from the 2014 inspection. We looked at a wide range of data, including patient and staff surveys, hospital performance information and the views of local partner organisations. The announced part of the inspection, taking place between the 20 and 23 June 2016, and critical care being inspected between the 25 and 27 July 2016. We also carried out unannounced inspections to Leicester Royal Infirmary, the Glenfield Hospital and Leicester General Hospital on 27 June, 1 July and 7 July 2016.

Overall, we found the Leicester General Hospital was performing at a level that led to the judgement of requires improvement. We inspected six core services at this hospital; two were rated as good and four were rated as requires improvement.

Our key findings were as follows:

  • There were systems in place to report incidents. However, staff did not always recognise concerns, incidents or near misses which meant that opportunities to learn from incidents may be lost. Never events had been reported but a delay in reporting and poor systems to embed learning did not ensure that the vent would reoccur.
  • We were concerned about the trust’s management of deteriorating patients and those who presented with sepsis. This is a severe infection which spreads in the bloodstream and if left untreated can lead to death. Where patients had met the trust’s criteria for sepsis screening, they were not all screened in accordance with national guidance. This put patients at risk of not receiving the correct treatment in a timely manner.
  • Infection control was not always given sufficient priority. Standards of cleanliness and hygiene were not consistently maintained across all areas of the trust. Audits showed variable performance.
  • Staffing were mostly being met, supplemented by the use of bank and agency staff.
  • Care and treatment was mostly 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.
  • Staff were mostly aware of the correct use of the Mental Capacity Act (MCA) 2005 and the Deprivation of Liberty Safeguards (DoLs) when caring for patients in vulnerable circumstances. However, in surgical services staff were not knowledgeable about the application of MCA processes.
  • Staff were caring. We observed staff positively interacting with patients and patients were treated with kindness, dignity, respect and compassion while they received care and treatment. Relatives and carers told us they felt involved and informed. The environment and availability of gowns did not always ensure that patient’s dignity was protected.
  • There were significant and ongoing typing backlogs in the gynaecology administration department, this could pose a risk to patient safety.
  • Patients experienced unacceptable waits for some outpatient services trust wide. There were backlogs in some outpatient specialities, which clinicians had not fully prioritised, and for some diagnostic scans.
  • There was a clear vison and strategy for the service, which was shared by most staff and most of the leadership team were visible and well respected.

We saw several areas of outstanding practice including:

  • A new automated closed-loop unit dose medicine administration system was in operation on the renal wards.
  • New starters who were nurses recruited from EU countries had a 12-week supernumerary period within the ward area and a bespoke Professional Development Programme. Included within the development programme was; trust behaviours, early warning score (EWS), infection prevention control, planning / evaluating care, managing pain, care of the dying patient and equipment training. Templates were also included to assist registered nurses in their revalidation process.
  • An MDT meeting took place weekly on ward two; this included all members of staff included in an individual patient’s care. For example, allied health professionals (physiotherapy, occupational therapy and speech and language therapy), medical and nursing staff and a neurological psychologist. The patient and relevant family member would also be present at this meeting where a patient’s individual rehabilitation goals would be discussed and reviewed.
  • The trust recognised that families, friends and neighbours had an important role in meeting the care needs of many patients, both before admission to hospital and following discharge. This also included children and young people with caring responsibilities. As a result, the ‘UHL Carers Charter’ was developed in 2015.
  • On ward 1, a flexible appointment service was offered for patients. In order to help patients who had other personal commitments, for example work commitments, staff would work flexibly sometimes starting an hour earlier in the day to enable the patient to receive their care at a time and place to meet their needs.
  • The development of a pancreatic cancer application to support patients at home with diagnosis and treatment. This will potentially assist patients and family members face the diagnosis and treatment once they have left the hospital.
  • Midwifery staff used an innovative paper based maternity inpatient risk assessment booklet which included an early warning assessment tool known as the modified obstetric early warning score (MEOWS) to assess the health and wellbeing of all inpatients. This assessment tool enabled staff to identify and respond with additional medical support if required. The clinical service risk assessment booklet also included a range of risk assessments. This meant that all assessment records were bound together.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

Medicine

  • The trust must take action to ensure nursing staff adhere to trust guidelines for the completion and escalation of the early warning scores (EWS) which may indicate a patient is deteriorating.
  • The trust must ensure that where patients met the trust’s criteria for sepsis screening, they were screened in accordance with national guidance.

Surgery

  • The trust must ensure venous thromboembolism (VTE) assessments are  re-assessed after 24 hours.
  • The trust must ensure hazardous substances are stored in locked cabinets.
  • The trust must ensure staff know what a reportable incident is and ensure that reporting is consistent throughout the trust.
  • The trust must ensure staff learning is embedded after a never event and are trained in the use of the delirium tool.
  • The provider must ensure that staff complete consent forms appropriately for patients who lack capacity and were made in line with the Mental Capacity Act 2005.

Critical Care

  • The trust must ensure 50% of nursing staff within critical care have completed the post registration critical care module. This is a minimum requirement as stated within the Core Standards for Intensive Care Units.

Maternity and gynaecology

  • The trust must ensure there are sufficient numbers of suitably qualified, competent, skilled and experienced persons to meet the requirements of the maternity and gynaecology service. We found:
  • Midwifery staffing ratios did not meet current recommendations.
  • One to one care in labour was not always provided.
  • Consultant obstetric cover in the delivery suite was 82 hours a week which did not meet the Royal College of Obstetrics and Gynaecology recommendation of 168 hours a week for a unit of this size.
  • The trust must ensure that midwives have the necessary training in the care of the critically ill woman, anaesthetic recovery and instrument/scrub practitioner line with current recommendations.
  • The trust must address the backlog in the gynaecology administration department so that it does not impact patient safety.

End of life

  • The trust must ensure 'do not attempt cardio-pulmonary resuscitation' (DNACPR) forms are completed appropriately in accordance with national guidance, best practice and in line with trust policy.
  • The trust must ensure there are sufficient numbers of suitable syringe drivers with accepted safety features available to ensure patients would receive safe care and treatment.

Outpatients & diagnostic imaging

  • The trust must ensure that all equipment, especially safety related equipment is regularly checked and maintained.
  • The trust must ensure building maintenance work is carried out in a timely manner to prevent roof leaks
  • The trust must ensure patient notes are securely stored in clinics.
  • The trust must ensure action is taken to comply with single sex accommodation guidance in diagnostic imaging changing areas and provide sufficient gowns to ensure patient dignity.

In addition the trust should:

  • The trust should ensure infection prevention control is given sufficient priority on ward two.
  • The trust should ensure all staff are aware of the arrangements in place to respond to emergencies and major incidents.
  • The trust should consider the impact the uncertainty of the future of endoscopy services is having on staff within this area.
  • The trust should ensure the pre assessment pathway is streamlined to ensure all high-risk anaesthetic patients are pre assessed.
  • The trust should ensure they develop an action plan for managing cancelled operations due to a lack of high dependency beds.
  • The trust should ensure they develop an audit process for the World Health organisation (WHO) five steps to safer surgery checklist.
  • The trust should ensure medication storage in anaesthetic rooms is consistent across all areas.
  • The trust should ensure medical teams have sufficient time for handovers at the end of each shift.
  • The trust should consider the clinical management groups (CMGs) develop ways of sharing new ideas and best practice.
  • The trust should ensure that the actions initiated after the recent never event include re-enforcing the importance of the timely reporting of all incidents.
  • The trust should ensure it continues to work  to meet the existing areas of non-compliance with the D16 National Service Specification for Adult Intensive care. More specifically, the shortfall in allied health professional support and NICE guidance.
  • The trust should consider extending the critical care outreach team to cover each 24 period.
  • There should be constant use of patient diaries across the trust for patients in critical care units.
  • The trust should consider how it can reduce the number of delayed discharges in critical care.
  • The trust should consider how it is going to reduce the number of cancelled elective surgery cases due to the lack of availability of critical care beds.
  • The trust should consider how it is going to reduce the number of cancelled elective surgery cases.
  • Intravenous fluids should be securely stored to ensure the risk of tampering or contamination is minimised.
  • The trust should ensure that safeguarding pathways and procedures protect patients from avoidable harm.
  • The trust should ensure that all staff are aware of their responsibilities under the missing baby policy.
  • The trust should ensure that all staff are aware of their responsibilities under the major incident policy.
  • The trust should ensure that all maternity and gynaecology risks are added to the risk register to ensure mitigation and oversight.
  • The trust should ensure that in maternity and gynaecology the culture promotes supportive and respectful behaviour between all grades of staff.
  • The service should consider the reporting quality of the maternity and gynaecology dashboard data at a site level and set RAG targets for all outcomes to ensure greater oversight of outcomes and trends.
  • The trust should consider the investigation and coding of puerperal sepsis, wound infections and sepsis of unknown origin.
  • The trust should consider the appropriateness and robustness where incidents are down-graded.
  • The trust should ensure there are systems in place to ensure that staff demonstrate competence to operate different types of equipment.
  • Should locate, monitor and track the syringe drivers across the trust.
  • Review the leadership arrangements and focus on end of life care to ensure it is given sufficient priority at directorate and board level.
  • Consider how to reduce in-clinic wait time for patients.
  • Ensure clinic capacity is planned to meet patient demand.
  • Ensure that patients requiring following up appointments are seen in a timely manner.
  • Ensure where there are backlogs, patients have been assessed for clinical risk and prioritised accordingly.
  • Consider how to ensure leaflets and information available in outpatient clinics are translated where appropriate into languages used by the local community.
  • Address the reasons for hospital cancellations of outpatient clinics.
  • Ensure information about how to complain is available to patients in outpatient clinic areas.
  • Consider how to meet the needs of patients with a learning disability and reduce DNAs for these patients in outpatient clinics.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 26 January 2017

Effective

Requires improvement

Updated 26 January 2017

Caring

Good

Updated 26 January 2017

Responsive

Requires improvement

Updated 26 January 2017

Well-led

Requires improvement

Updated 26 January 2017

Checks on specific services

Maternity and gynaecology

Requires improvement

Updated 26 January 2017

We rated the maternity and gynaecology service as required improvement.

Midwifery staffing levels did not always meet minimum acceptable numbers for the unit and one-to-one care in labour was not always achieved.

There was a lack of junior doctors to cover the service out of hours. Whilst the service mitigated these risks wherever possible, lack of staff on occasions posed a risk to patient safety.

Women were at risk of not always receiving effective care and treatment as some midwifery staff did not have the competencies required when caring for women who were critically ill, following anaesthesia or when acting as theatre instrument practitioners.

Significant and ongoing typing backlogs in the gynaecology administration department could pose a risk to patient safety.

The majority of women, their partners and relatives were positive about the care they had received. Most of the women we spoke with told us staff were kind and caring and that they were treated with dignity and respect and were happy with the emotional support they received. Staff involved patients in their care and treatment.

The trust provided an extensive range of specialist maternity and gynaecology services which included specialist midwives, ‘consultant direct’ and ‘one-stop’ gynaecology clinics.

Care and treatment was mostly planned and delivered in line with current evidence-based guidance, standards, best practice and legislation; however, some midwifery staff did not have the competencies required when caring for women who were critically ill, following anaesthesia or when acting as theatre instrument practitioners.

The service provided a cohesive and sensitive bereavement service for women experiencing pregnancy loss, including the employment of a specialist midwife, dedicated bereavement rooms and postnatal records.

There was a clear vison and strategy for the service, which was shared by most staff, and most of the leadership team were visible and well respected.

The outcomes for women against trust targets were mixed; the normal birth rate was above the national average and rates of instrumental birth were better than trust targets but the rates for caesarean section and postpartum bleeding were worse.

We were also not assured that incidents were appropriately graded following discussions at clinical governance meetings. Clinical audits were undertaken but could be delayed because of staff availability to undertake them. We were not assured that results of audit were addressed in the action plans.

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.

Surgery

Requires improvement

Updated 26 January 2017

We rated surgery care services as requires improvement overall

Safety was not a sufficient priority, for example the delay in recognising and reporting a never event. Staff did not always recognise concerns, incidents or near misses for example not reporting missing medical notes, or the lack of computers in theatre.

Venous thromboembolism (VTE) assessments were not  reviewed after 24 hours for patients preparing for surgery.

Staff were unaware of the correct use of the Mental Capacity Act (MCA) 2005 and the Deprivation of Liberty Safeguards (DoLs) when caring for patients in vulnerable circumstances.

The pathway for pre-operative and high-risk anaesthesia patients was not consistently followed causing potentially avoidable delays and cancellations. Some patients were not having pre-operative assessment despite being identified as high risk for anaesthesia.

Governance and risk management arrangements were not robust and as such did not always protect patients from avoidable harm.

Nursing staff consistently followed trust guidelines for the completion and escalation of deteriorating physiological observations and early warning scores (EWS)

On all the wards and departments we visited, we saw staff acting in a kind and caring way towards patients and the public. Relatives and carers told us they felt involved and informed.

There was strong local leadership with staff respecting line managers and feeling supported in their roles.

Intensive/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.

.

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).

Outpatients

Requires improvement

Updated 26 January 2017

We rated outpatient and diagnostic imaging services as requires improvement because:

Patients experienced unacceptable waits for some outpatient services trust wide. There were backlogs in some outpatient specialities, which clinicians had not fully prioritised. In some clinics there were long wait times. Patients complained of multiple cancellations.

The risks associated with anticipated events were not fully recognised, assessed or managed. Leaders did not risk assess outpatient waiting list or backlogs in a timely manner. High risk patients and patients whose circumstances might make them vulnerable were not always identified before arrival in clinic. Some equipment checks at Leicester General Hospital were not up to date.

The trust was developing governance arrangements to better manage performance for outpatients however the impact on patient experience was not apparent when we inspected.

The dignity of patients was not always respected. For example, there were changing areas which male and female patients had to share.

Patients waiting for appointments were not routinely checked for pain, or offered refreshments if they had been waiting a long time.

Staff understood and fulfilled their responsibilities to raise safety concerns and report incidents and near misses; managers supported them when they did. If something went wrong, there was a thorough review or investigation involving all relevant staff and people who used services. Lessons were learned and communicated widely.

Feedback from patients who use the service, those who are close to them and stakeholders was positive about the way staff treated people. Patients told us they were happy with the standard of treatment and care and that nurses and clinicians were kind and compassionate.

Care and treatment was planned and delivered in line with current evidence-based guidance, standards, and legislation The services used local and national audit arrangements to maintain the effectiveness of treatment. Diagnostic imaging used diagnostic reference levels to check dosage. Services used multidisciplinary team arrangements to benefit patients.

Leaders had a vision for the future of outpatient services and this was understood by staff.