Leicester General Hospital

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