Letter from the Chief Inspector of Hospitals
Leeds Teaching Hospitals NHS Trust is one of the largest trusts in the United Kingdom and serves a population of about 752, 000 in Leeds and surrounding areas treating around 2 million patients a year. In total, the trust employs around 15,000 staff and provides 1785 inpatient beds across Leeds General Infirmary, St James’s University Hospital, Leeds Children’s Hospital and Chapel Allerton Hospital. Day surgery and outpatients’ services are provided at Wharfedale Hospital and outpatients’ services at Seacroft Hospital.
We carried out this comprehensive inspection because the Leeds Teaching Hospitals NHS Trust was initially placed in a high risk band 1 in CQC’s Intelligent Monitoring System. Immediately prior to the inspection the intelligent monitoring bandings were updated and the trust was then placed in a low risk band 4, this was in the main due to an improved staff survey result.
We did not inspect Leeds Dental Institute as part of this review as this is a specialist service and outside the scope of the inspection. In addition, Leeds Teaching Hospital NHS Trust provides children’s cardiac surgery services, which are also specialist services and therefore not included in this inspection.
We undertook an announced inspection of the trust on 17, 18, 19 and 20 March 2014. We also inspected Leeds General Infirmary and St James’s University Hospital unannounced on the evening of 30 March 2014.
Our key findings were as follows:
Accident and Emergency services
Leeds General Infirmary and St James’s University Hospital provided accident and emergency services for adults. Children’s accident and emergency services were provided at Leeds General Infirmary.
At department level, the service was well led, staff felt engaged and involved in service improvement and redesign work. Staff worked well as a team.
The accident and emergency departments at both hospitals were clean and well maintained.
Nursing and medical staffing levels were safe as the trust was proactively managing the shortage of doctors by increased consultant cover and by developing advanced practioners and overseas emergency medicine training programmes.
Nursing handovers were comprehensive and thorough covering elements of general safety as well as patient specific information.
There was good ownership of risk and learning from incidents within the departments.
Not all staff had completed mandatory training particularly safeguarding children Levels 2 and 3 where appropriate.
Care and treatment was in accordance with nationally recognised best practice guidelines.
There was an effective Clinical Decisions Unit with access to a range of specialists 24 hours a day, including good access to mental health services, through the acute liaison psychiatry (ALP) service.
Patients were treated with dignity and respect and kept informed by staff about what was happening during the course of their stay in the department. The implementation of dignity rounds helped ensure that patients were as comfortable as possible, including ensuring that drinks and food was available.
The trust had been performing better than the national targets since June 2013 for 95% of patients waiting less than four hours to be admitted, transferred or discharged. Patient flow was maintained through the departments and was better than the national average.
The children’s accident and emergency department was staffed by paediatric consultants and nurses, and the trust had recently recruited more staff. The service improvement team was reviewing staffing within the children’s accident and emergency department as part of a wider piece of work looking at the effectiveness of the department. On most day shifts there was a nursery nurse on duty with one or two care support workers.
Both Leeds General Infirmary and St James’s University Hospital provided medical services. Leeds General Infirmary provided specialist cardiology, neurology and stroke services for the region. It did not accept general medical patients (who were transferred to the St James’s University Hospital).
Patients were admitted promptly to the appropriate ward, although some patients then had to be transferred to an ‘outlying’ ward once their acute phase of treatment was finished as there were some delays in transferring them back into the community.
There had been a concentration on improving the acute care pathway, which meant that the elderly care service had not developed as it should, particularly the care of patients living with dementia.
Medical wards at both hospitals were clean and well maintained.
Low numbers of nursing and medical staff in some areas, particularly out of hour’s medical cover and anaesthetists meant that there was a risk that patients were not always protected from avoidable harm.
There was a good culture of reporting incidents among the nursing staff, but this was not seen as a priority for all clinical staff. The recent introduction of the ‘safety board’ on wards had been embraced by the staff and all spoke positively about it.
Not all staff had completed their mandatory training.
There was inconsistency with the quality and recording of the nursing and medical handovers, which meant important information may not always be passed on appropriately to the next shift.
Care was provided in line with national best practice guidelines and the trust performed well in comparison to other hospitals providing the same type of treatment. Although there was an annual clinical audit programme and a central Clinical Audit Database on which clinical audits should be recorded, this was still in its relative infancy and thus although audits were undertaken there lacked clarity over what was being audited, the outcomes and how this information was captured.
Multidisciplinary working was widespread and the trust had made significant progress towards seven-day working.
Patients were treated with kindness and respect and patients were complimentary and full of praise for the staff looking after them.
Surgical services were provided by Leeds General Infirmary, St James’s University Hospital, Chapel Allerton Hospital and Wharfedale Hospital. Wharfedale Hospital only provided day case surgery. Staff reported a significant shift in culture in the organisation and the new management arrangements were working well, although the analysis and use of performance data was ‘work in progress.
Wards and theatres were generally clean across all hospital sites and there was evidence of learning from incidents in most areas.
There were arrangements in place for the effective prevention and control of infection.
Not all staff had completed their mandatory training.
The operating theatres used the World Health Organisation safety checklist, although improvements were needed as not all aspects such as the debriefing were embedded in practice.
At Leeds General Infirmary and St James’s University Hospitals, we found that there were inadequate levels of staff, both nursing and medical in some areas, particularly out of hours’ medical cover and anaesthetist availability. In response to this the trust had increased the use of locums to minimise risk.
Trust policies were available, which incorporated best practice guidelines and quality standards to monitor performance. However, there was insufficient audit evidence and systematic monitoring to demonstrate these were implemented and effective.
Patients were positive about their care and treatment and were treated with dignity and respect.
There were systems in place to manage the flow of patients through the hospital and discharge dates and plans were discussed for most patients.
Staff were aware of how to support vulnerable patients. However, mental capacity assessments were not always documented in accordance with the Mental Capacity Act (2005).
There was good multidisciplinary working with coordination of care between different staff groups, such as physiotherapists, nurses and medical staff.
Critical care was provided at Leeds General Infirmary and St James’s University Hospital. Staff were positive about the new leadership team and felt that communication had improved. However, staff were concerned about the increasing critical care bed pressures and increasing demands on the service.
We had concerns about the apparent ‘us and them’ culture between the two main hospital sites, the lack of engagement between senior medical staff and the limited planned cross-site working.
The critical care units were found to be clean with appropriate arrangements in place to prevent and manage infection, although there was some confusion over the use of some personal protective equipment.
Substantive nurse staffing levels were consistently below those required levels, which placed a reliance on nursing staff to work additional hours and a high use of agency staff. This was considered a risk by the permanent nursing team.
Mental capacity assessments and the deprivation of liberty safeguards were not embedded as part of the critical care process. Mandatory training completion was low and the mechanism in place for ensuring staff were up-to-date with their training appeared ad-hoc despite being co-ordinated by the Organisational Learning Department.
The critical care units followed a variety of national guidelines to determine best practice and we observed commonly used care tools such as care bundles.
We had concerns about the medical cover, the quality of the handover and support on the high dependency unit on Ward L39 at Leeds General Infirmary, which was overseen by the surgical services unit rather than the critical care service in accordance with the Critical Care Core Standards (2013).
Staff were caring and respected patients’ privacy and dignity. Patient’s families and carers were kept informed and involved and felt able to discuss concerns with staff.
Maternity and family planning
Maternity and family planning services were provided at Leeds General Infirmary and St James’s University Hospital. There was consistency of leadership across the maternity services, regardless of the location.
Maternity service areas were clean and effective procedures were in place to monitor infection control.
Where incidents had been identified, staff had been made aware and action taken.
There was a shortfall in relation to midwifery and medical staffing; action had been taken to recruit midwifery staff and medical rotas were in place to cover the maternity services. Staff reported that despite the vacancies, systems were in operation to ensure safety at all times.
Women received care according to professional best practice clinical guidelines and audits were carried out to ensure that staff were following recognised national guidance.
Women were pleased with the quality and continuity of service and felt staff had treated them with dignity and respect. Women were involved in their care; this had included the development of their birth plan and aftercare.
The maternity service had several midwives who had specialist areas of expertise to meet the diverse needs of women in their care.
Children’s and young people’s services
The Children’s Hospital was located within the buildings and facilities of the main hospital site of Leeds General Infirmary and was not easily identifiable as a dedicated service. There was no formal executive lead and oversight of children’s services, which were provided across other clinical service units in addition to those in the Children’s Hospital.
Nurse staffing levels on the children’s wards were identified as a risk and regularly fell below expected minimum levels, which placed staff under increased stress and pressure. There were gaps at middle-grade and junior doctor level and some medical staff were covering paediatric specialties without any specific paediatric training.
Although Quality and Safety Matters briefings were issued to staff to encourage shared learning from serious incidents not all staff we spoke to were aware of recent serious incidents that had occurred within the trust.
Children’s services were utilising national guidance, peer reviews and care pathways.
Nursing, medical and other healthcare professionals were caring and parents were positive about their experiences. Patients and their relatives were treated with compassion and felt involved in decisions about their care and treatment.
Apart from the teenage cancer unit, there were no dedicated areas for young people. Young people over the age of 16 were admitted to adult wards were not always assessed for their stage of development. Although there was work in place to look at the transition from children’s to adult services, there was no policy for such transitions within the trust.
End of life care
The trust had recently introduced new ‘care of the dying patient’ care plans to replace the Liverpool Care Pathway (LCP). We were told that a future audit of the use of these was planned to assess their effectiveness.
Staff involved people in their care and treated them with compassion, kindness, dignity and respect.
Staff were committed to ensuring a rapid discharge for people receiving end of life care who wanted to go home or go to a hospice as their preferred place of care.
All the wards and departments we visited were led by managers who were committed to ensuring patients and their families received a high quality service.
Staff were positive about the management and support given with end of life care.
We saw some inconsistencies when assessing a patient’s capacity when making decisions about whether a ‘do not attempt cardiopulmonary resuscitation’ was appropriate. The Mental Capacity Act 2005 was not being consistently applied or documented.
Outpatient services were provided by all the hospital sites inspected.
There was consistency in leadership and governance from the clinical service unit at all sites. Staff at all levels felt encouraged to raise concerns and problems.
Incidents were investigated appropriately and actions were taken following incidents to ensure that lessons were learned and improvements were shared across the departments and hospitals.
Clinics were generally clean and appropriately maintained. The infection control procedures were adhered to in clinical areas, which appeared clean and reviewed regularly.
Staffing levels were adequate to meet patients’ needs.
The trust completed audits and had implemented changes to improve the effectiveness and outcomes of care and treatment.
Patients felt involved in their care and treatment and that staff supported them in making difficult decisions. The hospitals provided interpretation services and patients’ privacy and dignity were respected.
A common theme from the analysis of patient feedback was that waiting times in clinics could be improved in terms of length of wait and patients being informed of why and how long they were expected to wait.
There were appropriate arrangements in place the safe storage, administration and disposal of medication.
Medication storage areas were well organised and administration appropriately recorded, including the handling and disposal of controlled medications.
There was inconsistent prescribing of oxygen, which did not adhere to trust policy.
When we carried out this inspection, colleagues from the Patients Association looked at how complaints were managed in the trust using the Patient’s Association Good Practice Standards for Complaints Handling. A separate report has been provided to the trust with the outcome to this inspection.
From April to November 2013, the top three themes of complaints were with regard to communication, medical care and attitude. The trust’s Patient Advice and Liaison Service received 2895 concerns during the period April to November 2013. The highest number concerned head and neck, neurosciences and trauma services, mainly relating to administration, appointment or waiting time issues.
In January 2014, a revised Complaints Policy was implemented across the trust with the strategic intention of improving the management of complaints, attitude to complainants and to provide all those involved in the complaint handling with training.
A new team had been established and this was impacting positively on the receipt and handling of complaints.
The executive team was found to be committed to a cultural change in the handling of complaints and an improved response to patients concerns.
Work was progressing, but further areas for improvement included the increased capacity of the Patient Advice and Liaison Service, embedding the monitoring and auditing of complaints including performance information and better sharing of lessons learnt.
We saw areas of outstanding practice including:
The Macular Degeneration Clinic at St James’s University Hospital and Seacroft Hospital had won a national patient award for exceptionally good practice in the care of people with macular degeneration.
The Disablement Service Centre at Seacroft Hospital had been voted the best centre for the third year by the Limbless Association Prosthetic and Orthotic Charity.
The geriatricians had worked with the community and the A&E department to try to help avoid unnecessary admissions in the elderly population. Elderly patients were seen early by a multidisciplinary team, which was led by a consultant geriatrician and had significantly reduced the number of admissions. They also provided telephone advice to GPs via the Primary Care Advice Line. This work had been acknowledged by the British Geriatric Society and the Health Service Journal.
Importantly, to improve quality and safety of care, the trust must:
Ensure there are sufficient qualified and experienced nursing and medical staff particularly on the medical elderly care wards children’s wards and surgical wards, including anaesthetist availability and medical cover out of hours and weekends.
Ensure that staff attend and complete mandatory training, particularly for safeguarding and maintaining their clinical skills.
Ensure the appraisal process is effective and staff have appropriate supervision and appraisal.
Review the skill base of ward staff regarding care of patients discharged from the critical care units to ensure that they are appropriately trained and competent.
Ensure that staff are clear about which procedures to follow with relation to assessing capacity and consent for patients who may not have mental capacity to ensure that staff are clear about the Mental Capacity Act and implement and record this appropriately.
Ensure staff are aware of the Deprivation of Liberty Safeguards and apply them in practice where appropriate.
Ensure that there are effective systems in place to ensure that risk assessments are appropriately carried out on patients in relation to tissue viability and hydration, including the consistent use of protocols and appropriate recording practices.
Ensure that all staff report incidents and that learning including feedback from serious incident investigations is disseminated across all clinical areas, departments and hospitals.
Review the nursing and medical handover to ensure that the appropriate information is passed to the next shift of staff and recorded.
Review the practice of transferring patients to wards before the bed is ready for them, necessitating waits on trolleys in corridors.
Introduce a rolling programme to update and replace aging equipment particularly on the critical care units.
Review the arrangements over the oversight of L39 High Dependency Unit at Leeds General Infirmary to ensure there is appropriate critical care medical oversight in accordance with the Critical Care Core Standards (2013). Ensure handovers are robust and consider introducing performance data for the area to assess and drive improvement.
Review the access and supervision of trainee anaesthetists and ensure that these provide the appropriate support to ensure care and treatment is delivered safely.
Review the clinical audit and auditing of the implementation of best practice, trust and national guidelines to ensure a consistent delivery of a quality service.
Review the information available on the guidance utilised across clinical service units to ensure the consistent implementation of trust policy, procedure and guidance.
However, there were also areas of practice where the trust should make improvements.
Review the effectiveness of the recruitment of staff processes to ensure delays to recruitment are kept to a minimum.
Ensure that there is medical ownership of patients in the emergency department, regardless of which speciality they have been referred to and accepted on.
Ensure that confidential patient information stored on computers in the minor injuries area is not accessible to unauthorised personnel.
Ensure that information about the Patient Advice and Liaison Service (PALS) and how to make a complaint is visible in patient areas.
Review the information available for people who have English as a second language and make written information more accessible including clinical decisions and end of life care.
Ensure that the provision of oxygen is appropriately prescribed.
Ensure that all staff involved in patient care are aware of the needs of people living with dementia and that the documentation used reflects these needs.
Ensure that all early warning score documentation is fully completed on each occasion used.
Consider displaying trend data over a period of time as part of the ward dashboards and that information is disseminated to staff.
Ensure that the windows on L26 are repaired and that the ventilation of the ward is appropriate to need.
Review the use of the Family and Friends Test results to improve consistency across departments.
Review the implementation of the guidance for the use of locum medical staff to ensure the effective induction and support of doctors.
Review the recruitment processes to ensure that they are efficient and timely.
Review the support and provision of the medical elderly care services with consideration of providing a seven day service and contribution to the monthly clinical service unit governance meetings.
Review the use of the World Health Organisation safety checklist for theatres to ensure that it includes all elements such as the team debrief.
Review the performance outcomes to ward safety thermometer dashboard results to ensure effective action planning to drive improvement.
Review the arrangements for surgery on the Clarendon Wing regarding their suitability and how performance, oversight and reporting were effective.
Review the bathing arrangements on Wards L24 and L50 to ensure that they meet health and safety standards and that there is accessible facilities for people with mobility problems.
Review the sterile supplies provision for sterile instruments and equipment in theatres to be assured that they deliver good quality in a timely manner.
Review the security of the hospital in general, but specifically with regard to access to theatre departments.
Ensure that risk registers are of a consistent quality and contain the appropriate details regarding actions taken or in progress.
Review the use of personal protective equipment on the critical care units to ensure consistent practice.
Implement a seven day a week critical care outreach team.
Review the IT system to ensure that all necessary information such as that identifying if a social worker is involved when ‘Looked After Children’ arrive in the hospital.
Review the consent process to ensure that where appropriate the child or young person is involved in decisions and signatures are obtained.
Develop facilities and recreational activities for older children and young adolescents in children’s services.
Appoint an executive lead for children’s services to ensure that there is consistent oversight and shared learning across clinical areas.
Review the frequency and effectiveness of the surgical morbidity and mortality meetings so that there is a more effective use of lessons learnt to improve patient outcomes.
Introduce a robust patient tracking system for surgical patients so that there is continuity of care at all times.
Review the effectiveness and care of patients following surgery on Bexley Wing in relation to the transfer post operation to Geoffrey Giles Theatres in Lincoln Wing, and potential multiple moves to fit in with service operating times.
Consistently apply patient feedback processes across clinical support services.
Review the waiting times in the outpatient clinics and information given to patients to ensure these are kept to a minimum length and patients understand what to expect.
Review the condition of the facilities in the mortuary to ensure all areas are fit for purpose.
Professor Sir Mike Richards
Chief Inspector of Hospitals