University Hospitals of Leicester NHS Trust

This was the trust’s second inspection using our comprehensive inspection methodology. We had previously inspected this trust in January 2014 where we rated it as requiring improvement overall. This inspection was a focused inspection which was designed to look at the improvements the trust had made since the last inspection.

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 took place between the 20 and 23 June 2016 but we inspected critical care 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 provider was performing at a level which led to the judgement of requires improvement. We inspected 8 core services across three hospital locations. We rated the Leicester Royal Infirmary, Leicester General Hospital and the Glenfield Hospital all as requires improvement. Although the overall rating we gave the trust in this inspection was the same as they were awarded in their 2014 comprehensive inspection, we did find improvements had been made. These were particularly evident in staff engagement and confidence in the leadership team.

Our key findings were as follows:

• We found many staff commented on the positive culture change in this trust under the current Chief Executives leadership. There was recognition there were a lot of things that still needed focus and attention but they were in better position now than a few years ago. These comments reflected the changes to the staff survey results which showed an upward trend over the past three years.
• The trust was led by a respected board. Executive staff were much respected and staff had confidence in their leadership.
• The trusts vision and values were generally embedded into practice.
• The trust had an established governance process in place which was generally working well.
• The main committee responsible for quality was the Quality Assurance Committee (QAC). It was felt that the awareness of quality problems was high but more improvement was required to ensure the QAC was in a position to bring about rapid resolution.
• The non-executive directors were well sighted on the quality governance agenda.
• A series of quality indicators were used to identify wards or departments which required additional monitoring or support. We saw evidence of how these reports were used to identify areas of concern and how these areas were subsequently monitored. However, we found some areas during the inspection such as the concerns in the outpatients department at the Leicester Royal Infirmary which had not been identified by the quality monitoring process.
• Some of the executives and non-executives felt that there wasn’t enough pace in the organisation to address some of these areas.
• The trust had a Board Assurance Framework (BAF) which was a standing item on the Board's agenda. The BAF was described to us by several members of the executive team as being in development. For example there were some gaps in controls.
• The challenges that were faced in the A&E department were well known and were often spoken about during our inspection. All of the senior leaders whom we spoke with cited this as one of the trusts highest risks. In addition, we noted clinical staff who did not work in A&E were also aware of the significant challenges in A&E and the knock on effect this had one the rest of the trust. At our focus groups, some staff commented they felt the A&E department received too much attention by senior leaders and external agencies.
• There was no doubt the A&E department was causing significant problems for the trust. We observed how the patient experience was in some cases below the standard we would expect. It required a system wide approach to solving some of the problems being experienced. The trust saw a constant increase in the number of attendances at A&E and they could not always provide the level of care they wanted to. This was a problem that the trust alone could not address and it required action amongst the whole health and social care system across Leicester, Leicestershire and Rutland. Although there were plans in place and different initiatives to address the problems, we saw little evidence that these were making any impact on the numbers of attendances at A&E. The outpatient service had a backlog of patients who were waiting for follow-up appointments. The trust had a plan in place to address the backlogs and we could see they were reducing. Following the inspection the trust told us how this back log was being managed so that the risk to patients was as safe as possible.
• We found a number of problems with the outpatients clinics, particularly at the Leicester Royal Infirmary and the Leicester General Hospital. Patients told us they were not always satisfied with the outpatient service. This was also reflected in the number of trusts complaints as well as feedback from other organisations such as Healthwatch.
• The trust cancelled outpatient appointments more than the England average. Cancelling appointments created patient dissatisfaction, delays and complications with rebooking as well as a need to clinically re-assess the urgency and the patient in some cases.
• Clinics did not always run on time. The trust carried out its own analysis of wait times and the causes of delay and found the eye clinic was particularly prone to delays. The trust developed an action plan to improve waiting times, but when we inspected it was too early to assess its impact.
• Outpatient capacity did not meet demand. ENT, gastroenterology and orthopaedics did not have enough clinic slots to offer to patients. Some specialties did not have enough doctors to offer more clinics. For example, the eye and dermatology specialties were all trying to recruit doctors.
• The trust had already recognised they needed to make improvements to the management of deteriorating patients and the management of sepsis. Although we found poor performance during the inspection, evidence we have received since the inspection shows that the improvement plans are having some impact. Performance in relation to sepsis within the ED has particularly improved. We were confident the trust had effective plans and monitoring in place to make the necessary and important improvements.
• The trust’s ‘rolling 12 month’ Hospital Standardised Mortality Ratio (HSMR) had been below 100 for the past 3 years. Hospital standardised mortality ratios (HSMRs) are intended as an overall measure of deaths in hospital. High ratios of greater than 100 may suggest potential problems with quality of care.
• The latest published Summary Hospital-level Mortality Indicator (SHMI) for April 2015 to March 2016 was 99. The Summary Hospital-level Mortality Indicator (SHMI) is the ratio between the actual number of patients who die following hospitalisation at the trust and the number that would be expected to die based on average England figures, given the characteristics of the patients treated there. The trust rate was as expected.
• We saw patients were mostly being care with kindness and dignity and respect.
• The trust used recognised tools to assess the level of nursing staff and skill mix required. The chief nurse was sighted on nursing risks and wards which were flagging as requiring more support. There were some areas where staffing fell below the planned levels. Recruitment to vacancies’ was in process and staff were able to use bank or agency staff were available to fill staffing shortfalls. 
• Concerns were expressed to us about the trusts IT infrastructure. The Patient Administration System was old and was not supported by the service provider any more. At the time of the inspection the trust was waiting for funding from the Department of Health to implement a new IT system.

We saw several areas of outstanding practice including:

Leicester Royal Infirmary

• Staff in the paediatric emergency department told us about the development of ‘greatix’, this was to enable staff to celebrate good things in the department. Staff likened it to ‘datix’, which enabled staff to raise concerns. Staff used greatix to ensure relevant people received positive feedback relating to something they had done. Many staff throughout the emergency department told us of times when they had received feedback though greatix and told us how this made them feel proud and valued.
• A range of medicines to manage Parkinson’s disease was available on the Clinical Decisions Unit (CDU) at the Glenfield Hospital. These medicines are time sensitive and delays in administering them may cause significant patient discomfort. These medicines were available to be ‘borrowed’ by other wards within the hospital and the nurses we spoke with were aware of this facility. The formulations of these medicines may sometimes cause confusion and pharmacy had produced a flowchart to ensure staff selected the correct formulation.
• On Ward 42, we attended a ‘posh tea round’. This took place monthly on the ward and provided an opportunity for staff and patients to engage in a social activity whilst enjoying a variety of cakes not provided during set meal times.
• During our visit to Ward 23, a patient was refusing to eat. The meaningful activities facilitator sat and had their dinner with the patient. They told us by making it a social event they hoped the patient would eat.
• Within oncology and chemotherapy, a 24-hour telephone service was available for direct patient advice and admission in addition to a follow up telephone service to patients following their chemotherapy at 48 hours, one week and two weeks post treatment.
• The trust had introduced a non-religious carer to provide pastoral support in times of crisis to those patients who do not hold a particular religious affiliation .Also to provide non-religious pastoral and spiritual care to family and staff.
• Midwifery staff used an innovative paper based maternity inpatient risk assessment booklet which included an early warning assessment tool known as the modified early obstetric 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 maternity inpatient risk assessment booklet also included a situation, background, assessment, recommendation (SBAR) tool, a sepsis screening tool, a venous thromboembolism (VTE) assessment tool which also had a body mass index chart, a peripheral intravenous cannula care bundle, a urinary catheter care pathway and assessment tools for nutrition, manual handling and a pressure ulcer risk score. This meant that all assessment records were bound together.
• On Ward 42, we attended a ‘posh tea round’. This took place monthly on the ward and provided an opportunity for staff and patients to engage in a social activity whilst enjoying a variety of cakes not provided during set meal times.
• During our visit to Ward 23, a patient was refusing to eat. The meaningful activities co-ordinator sat and had their dinner with the patient. They told us by making it a social event they hoped the patient would eat.
• Within oncology and chemotherapy, a 24 hour telephone service was available for direct patient advice and admission in addition to a follow up telephone service to patients following their chemotherapy at 48 hours, one week and two weeks post treatment. 

Leicester General Hospital

• A new computerised individualised dosing system was in operation on the renal wards.
• New Starters in nephrology 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 risk assessment booklet also included a range of risk assessments. This meant that all assessment records were bound together.
• The pain management service won the national Grünenthal award for pain relief in children in 2016. The Grünenthal awards recognised excellence in the field of pain management and those who were striving to improve patient care through programmes, which could include the commissioning of a successful pain management programme.

Glenfield Hospital

• Staff in the paediatric emergency department told us about the development of ‘greatix’, this was to enable staff to celebrate good things in the department. Staff likened it to ‘datix’, which enabled staff to raise concerns. Staff used greatix to ensure relevant people received positive feedback relating to something they had done. Many staff throughout the emergency department told us of times when they had received feedback though greatix and told us how this made them feel proud and valued.
• A range of medicines to manage Parkinson’s disease was available on the clinical decisions unit (CDU) at the Glenfield Hospital. These medicines are time sensitive and delays in administering them may cause significant patient discomfort. These medicines were available to be ‘borrowed’ by other wards within the hospital and the nurses we spoke with were aware of this facility. The formulations of these medicines may sometimes cause confusion and pharmacy had produced a flowchart to ensure staff selected the correct formulation.
• A ‘Pain aid tool’ was available for patients who could not verbalise and/or may have a cognitive disorder. This pain tool took into account breathing, vocalisation, facial expressions, and body language and physical changes to help determine level of patient comfort.
• 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.
• The development of ‘my lung surgery diary’ by the thoracic team, with the help of patients during the patient experience day 2015However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

Trust wide

• The trust must ensure all Directors and Non-executive Directors have a Disclosure and Barring check undertaken to ensure they are of good character for their role.

Urgent & emergency services

• The trust must take action to ensure nursing staff adhere to the trust’s guidelines for screening for sepsis in the ward areas and in the emergency department. This also applies to medical areas.
• The trust must take action to ensure standards of cleanliness and hygiene are maintained at all times to prevent and protect people from a healthcare-associated infection. This also applies to medical areas and outpatient and diagnostic areas.
• The trust must ensure patients requiring admission who wait in the ED for longer that 8 hours  have a VTE risk assessment and appropriate thromboprophlaxis prescribed.
• The trust must ensure the privacy and dignity of patients within the majors area and the assessment area of the emergency department.

Medicine

• The trust must ensure patient side rooms with balconies have been risk assessed in order to protect vulnerable patients from avoidable harm.

Surgery

• 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 patients preparing for surgery have venous thromboembolism (VTE) reviewed after 24 hours.
• The trust must take action to address the shortfalls in staff education in relation to mental capacity (MCA) assessments and deprivation of liberty safeguards (DOLs).

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.
• The trust must ensure staff report incidents in a timely way.

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.
• 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.

Services for children and young people

• The trust must ensure at least one nurse per shift in each clinical area is trained in APLS or EPLS as identified by the RCN (2013) staffing guidance.
• The trust must ensure paediatric medical staffing is compliant with the Royal College of Paediatrics and Child Health (RCPCH) standards for sufficient paediatric consultants.
• The trust must ensure Neonatal staffing at the Leicester Royal Infirmary (LRI) neonatal unit is compliant with the British Association of Perinatal Medicine Guidelines (BAPM) (2011).
• The trust must ensure children under the age of 18 years are not admitted to ward areas with patients who are 18 years and above unsupervised.
• The trust must ensure nursing staff have the appropriate competence and skills to provide the required care and treatment for children who require high dependency care.

End of life care

• 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 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 ensure building maintenance work is carried out in a timely manner to prevent roof leaks.
• The trust ensure patient notes are securely stored in clinics.
• The trust must ensure the privacy and dignity of service users is protected.
• The trust must take action to comply with single sex accommodation law in diagnostic imaging changing areas and provide sufficient gowns to ensure patient dignity.
• The trust must ensure it has oversight of planning, delivery and monitoring of all care and treatment so it can take timely action on treatment backlogs in the outpatient departments.
• The trust must ensure that it carries out patient tests in private surroundings which maintain patients privacy.

Professor Sir Mike Richards

Chief Inspector of Hospitals