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Provider: Leeds Teaching Hospitals NHS Trust Good

We are carrying out checks on locations registered by this provider using our new way of inspecting services. We will publish the reports when our checks are complete.

Reports


Inspection carried out on 10 – 13 & 23 May 2016

During an inspection to make sure that the improvements required had been made

Leeds Teaching Hospitals NHS Trust is one of the largest trusts in the United Kingdom and serves a population of around 780,000 in Leeds and up to 5.4 million in 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 outpatient services are provided at Wharfedale Hospital and outpatients services are also provided at Seacroft Hospital. The Leeds Dental Institute, although part of the trust, was not inspected at this inspection.

We carried out a follow up inspection of the trust from 10 to 13 May 2016 in response to the previous inspection as part of our comprehensive inspection programme in March 2014. We also undertook an unannounced inspection on 23 May 2016 to follow up on concerns identified during the announced visit.

Focussed inspections do not look across a whole service; they focus on the areas defined by information that triggers the need for an inspection. Therefore, we did not inspect all the five domains: safe, effective, caring, responsive and well led for each core service at each hospital site. We inspected core services where they were rated requires improvement. We also checked progress against requirement notices set at the previous inspection due to identified breaches in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. As a result of the March 2014 inspection, we issued a number of notices, which required the trust to develop an action plan on how they would become compliant with regulations. We reviewed the trust’s progress against the action plan as part of the inspection.

We inspected the following locations:

At Leeds General Infirmary (LGI), we inspected the following domains:

  • Urgent and emergency care (A&E) - safe and effective
  • Medicine - safe, effective, responsive and well-led
  • Surgery - safe, responsive and well-led
  • Critical care - safe, responsive and well-led
  • Maternity and gynaecology - safe
  • End of life care - safe

We inspected the following domains for children’s and young people’s services at the Children’s Hospital, which is reported in the LGI location report – safe, responsive and well-led.

At St James’s University Hospital (SJUH), we inspected the following domains:

  • Urgent and emergency care (A&E) – effective
  • Medicine – safe, responsive and well-led
  • Surgery - safe, responsive and well-led
  • Critical care - safe, responsive and well-led
  • Maternity and gynaecology - safe
  • End of life care - safe

At Chapel Allerton and Wharfedale Hospitals, we inspected the safety domain within surgery.

We did not inspect the Leeds Dental Institute and we did not inspect the outpatients’ services across the trust as these had previously been rated as good.

We did not inspect the caring domain across the trust as this was rated as good across all trust services at the previous inspection.

Overall, we rated the trust as good. We rated safe as requires improvement, effective, responsive and well-led as good. We rated Leeds General Infirmary and St James’s University Hospital as requires improvement, Chapel Allerton Hospital as good and Wharfedale Hospital as good.

Our key findings were as follows:

  • Since the last inspection, the trust had invested time, effort and finances into developing a culture that was open, transparent and supported the involvement of staff, and reflected the needs of the people who used the services.
  • Changes such as the development of clinical service units and governance arrangements that were in their infancy at the last inspection had been further embedded and embraced by staff in the organisation.
  • Each clinical service unit had clear direction and goals with steps identified in order to achieve them.
  • The leadership team had remained stable. Staff across the organisation were positive about the access and visibility of executives and non-executives, particularly the Chief Executive. There had been improvements to services since the last inspection.
  • The leadership team were aware of and addressing challenges faced with providing services within an environment that had increasing demand, issues over patient flow into, through and particularly out of the organisation, including the impact this had on service provision; and the recruitment of appropriately skilled and experienced staff.
  • The trust values of, ‘The Leeds Way’ were embedded amongst staff and each clinical service unit had a clear clinical business strategy, which was designed to align with the trust’s ‘Leeds Way’ vision, values and goals. This framework encouraged ownership from individual CSUs.
  • We saw strong leadership of services and wards from clinicians and ward managers. Staff spoke positively about the culture within the organisation.
  • Staff reported across the trust that they were proud to work for the organisation and felt that they worked well as a team across the different sites.
  • The trust invited all 15,000 staff to participate in the national staff survey, with a response rate of over 8,000 staff across the organisation. The survey showed that there was continuous improvement. The response rate for the NHS Staff Survey 2015 was 50%, this was better than the England average of 41%.
  • At service level there were governance processes and systems in place to ensure performance, quality and risk was monitored. Each CSU met weekly and used the ward health check to audit a range of quality indicators including the number of falls, complaints, pressure ulcers, staffing vacancies and staff sickness. This information was then escalated to senior staff and through the trust’s governance structure.
  • There was a positive culture around safety and learning from incidents with appropriate incident reporting and shared learning processes in place. However, learning from Never Events was not consistent amongst all staff within theatres. All steps of the World Health Organisation (WHO) safety checklist were not consistently taking place: audit data and our observations supported this. The audit data provided by the trust did not assure us that national early warning score (NEWS) and escalation was always done correctly.
  • There were occasions when nurse and care support worker staffing levels were below the planned number. Despite having a clear escalation process, non- qualified staffing levels did not always mitigate for the reduction in qualified nursing levels. Nursing, midwifery and medical staffing levels did not meet national guidelines in some areas, particularly surgery, theatres, critical care, maternity and children and young peoples’ services. The trust was actively recruiting to posts and supporting a range of role development programmes to diversify the staff group, including supporting advance roles and role specific training for non-qualified staff.
  • Arrangements and systems in place were not sufficiently robust to assure staff that the maintenance of equipment complied with national guidance and legislation.
  • There were arrangements in place for assessing the suitability of patients who were appropriate to wait on trolleys on the assessment ward. However, these were not consistently applied, or risk assessments undertaken. There was a lack of robust assurance over the oversight of patients waiting on trolleys.
  • Adherence to General Medical Council (GMC) guidance and the trust consent policy was not consistently demonstrated in patient records. In accordance with trust policy, a two stage consent process including two patient signatures was not consistently evidenced in patient records. However, we were assured that patients were well informed about their surgical procedure and had time to reflect on information presented to them at the pre-assessment clinic.
  • There was a much improved mandatory training programme. However, there were still low completion levels in some training, particularly resuscitation and role relevant safeguarding.
  • The Summary Hospital-level Mortality Indicator (SHMI) and the Hospital Standardised Mortality Ratio (HSMR) indicated there was no evidence of risk compared to the England average.
  • There were suitable arrangements in place for the prevention and control of infections, including policies, procedures and a dedicated infection prevention control team. Areas visited were clean and staff generally adhered to good infection control practices.
  • The trust responded to complaints and concerns in a timely manner. Improvements were made to the quality of care as a result of complaints and concerns.
  • The trust took into consideration the needs of different people when planning its services and made reasonable adjustments for vulnerable patient groups.
  • There was clear guidance for staff to follow within the care of the dying person’s individual care plan when prescribing medicines at the end of their life. Patients’ individual needs and wishes at the end of their life were represented clearly in the documentation.
  • Policies and guidelines were based on the latest national and international guidelines such as from the National Institute for Health and Care Excellence (NICE) and Royal College of Emergency Medicine.
  • On the whole, patients received pain relief in a timely manner and were able to access food and drinks as required.
  • Arrangements were in place to alert staff when patients were in receipt of treatment or admitted with special needs or were vulnerable, including living with dementia and learning disabilities. Staff had received training on how to support patients and individualise care to meet specific needs.
  • Staff understood their responsibilities in relation to the Mental Capacity Act (2005), restraint of patients and the treatment of detained patients, although there was some inconsistent practice over care of patients receiving rapid tranquilisation treatment.

We saw several areas of outstanding practice including:

  • There were outstanding examples of record keeping in the care of the dying person care plan. We saw that staff recorded sensitive issues in a clear comprehensive way to enable safe care to be given.
  • The development of Leeds Children’s Hospital TV allowed families to explore the wards and meet the teams.
  • Organ transplantation which included a live liver donation and transplant programme had been undertaken, which was the largest in the UK. Other aspects of the transplantation programme included Neonatal organ retrieval and transplantation, Life Port Trial, Kidney Transplantation, QUOD Trial, Quality in Organ Donation National Tissue Bank, Revive Trial, Organ Care System and Normothermic perfusion, Support for Hand Transplantation.
  • Procedures such as minimally invasive oesophagectomies were being performed. The colorectal team were using sacral nerve stimulation for faecal incontinence.
  • There is a consultant led virtual fracture clinic. This allows patients to be assessed without attending the hospital and then have the most appropriate follow up. This reduces unnecessary hospital attendances.
  • Revolutionary hand transplant surgery had taken place within plastic surgery.
  • Nurse-led wards for patients who were medically fit for discharge had been introduced to allow the service to adapt their staffing model to meet the needs of patients.
  • In response to patient carer feedback the acute medicine Clinical Service Unit had introduced John's campaign. This allowed carers to stay in hospital with patients with dementia.

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

Importantly, the trust must:

  • The trust must ensure at all times there are sufficient numbers of suitably skilled, qualified and experienced staff in line with best practice and national guidance taking into account patients’ dependency levels.
  • The trust must ensure all staff have completed mandatory training and role specific training.
  • The trust must ensure staff have undertaken safeguarding training at the appropriate levels for their role.
  • The trust must review the admission of critical care patients to theatre recovery areas when critical care beds are not available to ensure staff are suitably skilled, qualified and experienced.
  • The trust must review how learning from Never Events is embedded within theatre practice.
  • The trust must review the appropriateness of out of hours’ operations taking place and take the necessary steps to ensure these are in compliance with national guidance.
  • The trust must review the storage arrangements for substances hazardous to health, including cleaning products and sharps disposal bins to ensure safety in line with current procedures.
  • The trust must review and address the implementation of the WHO Five Steps to Safer Surgery within theatres.
  • The trust must ensure that physiological observations and NEWS are calculated, monitored and that all patients at risk of deterioration are escalated in line with trust guidance.
  • The trust must review the function of the pre theatre waiting area in Geoffrey Giles theatres and ensure that the appropriate checks and documentation are in place prior to patients leaving ward areas.
  • The trust must ensure that all equipment used across core services is properly maintained and serviced.
  • The trust must ensure that staff maintain patient confidentiality at all times, including making sure that patient identifiable information is not left unattended.
  • The trust must ensure that infection prevention and control protocols are adhered to in theatres.

In addition the trust should:

  • The trust should review and improve the consent process to ensure trust policies and best practice is consistently followed.
  • The trust should review the availability of referral processes for formal patient psychological and emotional support following a critical illness.
  • The trust should review the provision of post-discharge rehabilitation support to patients discharged from critical care.
  • The trust should ensure that appropriate staff have access to safeguarding supervision in line with best practice guidance.
  • The trust should continue to monitor the safe and correct identification of deceased patients before they are taken to the mortuary and take necessary action to ensure this is embedded in practice.
  • The trust should continue to work towards improving the assessment to treatment times within the ED department. The trust should also continue to work towards improving ambulance handover times and reduce the number of handovers that take more than 30 minutes.
  • The trust should ensure that systems and processes are in place and followed for the safe storage, security, recording and administration of medicines including controlled drugs.

Professor Sir Mike Richards

Chief Inspector of Hospitals


CQC inspections of services

Inspection carried out on 17-20 and 30 March 2014

During a routine inspection

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.

Medical services

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

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

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.

Outpatients

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.

Medication

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.

Complaints management

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

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up.

Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.


Joint inspection reports with Ofsted

We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.