The last time we visited the service in February/March 2012 we found the delivery of care was not always safe and effective and there were often times on wards 53 and 55 when there were insufficient staff. We therefore issued warning notices. The purpose of this review was to see what action the care provider has taken in order to comply with Regulations 9 and 22.

We visited three wards in the hospital during this inspection. Two were orthopaedic wards and one was a cardiology, medical admissions ward. On all three wards visited most of the patients we spoke with were very complimentary about the care and treatment they were receiving. Comments included:

“The doctors are excellent and they explain everything.”

“Nurses look after us.”

“They make sure you get your medication.”

“I have had excellent treatment and I have no concerns.”

“You are made to feel important because they tell you are you are doing really well.”

“Only wait a minute for staff to come if you call them.”

“Staff lovely I would give them 10/10.”

“Staff are prompt and give assurance.”

“When I use my call buzzer I am seen more or less immediately.”

“When I get home I will defend the hospital (had seen recent bad publicity and doesn’t agree with it.) I have had excellent treatment and I have no concerns.”

“The staff are discreet and my dignity and privacy is respected all the time.”

A small number of patients told us they didn’t think there were enough staff on the wards, however they said they were being properly cared for and their needs met. Their comments included:

“Staff are doing their very best, they are young and efficient but there is not enough staff.”

“Pleased with staff but sometimes can take a while to get to me. “Maybe three or four times it has taken 30 minutes to get to me but generally it is within five minutes.”

“Think would benefit from one or two more staff.”

“Ward very busy and sometimes not enough staff but the nurses still check on you.”

“Had no wash this morning could do with one.”

We also looked at survey information on the wards and saw the positive comments patients had made about their care and support. These included:

“All the staff have been fantastic – I can’t thank you enough.”

“I was very impressed by the thorough method used by a cleaner on the ward when cleaning the bed. My confidence and opinion of the ward staff increase as a result.”

“My treatment has been wonderful, efficient and friendly but I still want to go home.”

“All staff were thoughtful and attentive. This experience re-affirms my beliefs in the NHS. The LGI is a great hospital.”

Staff told us during this visit, they felt good care was given to patients. All of the staff we spoke with said they were using new care planning documentation and had been trained to do so. They said that care plans were now more about the ‘individual’ and focussed on how people wanted their care delivered, including the identification of people’s likes and dislikes. Staff also said they were now meeting people’s needs better due to ward re-organisations, better staffing levels and good direction and leadership. Comments from staff included:

“Things are much better recently, the change is great, feel I am fulfilling being a nurse properly.”

“Go home feeling I have done a good job.”

“Enough time now to meet people’s needs properly, better communication with patients, getting to them quicker.”

We visited ward 22, which specialises in ear nose and throat surgery, maxillofacial surgery and has six orthopaedic beds, ward 53 (orthopaedics) and ward 55 (orthopaedics) for this visit over a two day period. We spent time observing how care was delivered to people who use the service on these wards. We spoke with a number of people who use the service and staff and we looked at medical and nursing records for some people using the service.

The majority of people we spoke with were, in the main dissatisfied with their care and support, saying this was mainly due to shortage of staffing. Comments we received from people on ward 53 included:

“Staff are slow to answer the call bell. One day I had to wait between 30 minutes and 45 minutes for a nurse to answer the bell.”

“Some staff can be a bit sharp but I think this is because they are so busy.”

“Nurses don’t always have time to explain what is happening.”

“Staff are good but they are very busy and can not spend time with you.”

“Unless you ask they do not tell you what is going on.”

“Staff give good care but they are very busy and always rushed.”

There were a number of times when we observed care that was not appropriate or given in a timely manner on ward 53. People did not receive the assistance they needed at meal times. People’s requests for assistance or reassurance were at times ignored. We saw that people were laid in their beds in undignified or uncomfortable positions and we had to intervene to get staff to attend to people. We saw a person spoken to quite sharply by a staff member.

Staff on wards 53 and 55 told us they were often short staffed and this affected their ability to give people adequate care. They said, they feel rushed, and have no time to interact with people who use the service when short staffed. They said people often have to wait over 30 minutes to go to the toilet and on occasions there is frequent bed wetting and poor personal care given as a result of being short staffed.

People we spoke with said the wards were very clean. Comments included:

“Seems clean, always see plenty of cleaning.”

“Very clean.”

“They clean like maniacs.”

“The ladies then come round and inspect the cleaning.”

“They are pretty thorough.”

“Washing of hands and wearing aprons is standard procedure, they all do it.”

We undertook a simultaneous review of three hospitals managed by the Leeds Teaching Hospital NHS Trust.

As part of our review we undertook an unannounced inspection on 4th and 5th August 2011 of St James’s University Hospital, Leeds General Infirmary and Wharfedale Hospital.

During our inspections we spoke to a number of patients. Most people were satisfied with, and were positive about the care they received. They said they were treated with respect and that their privacy was maintained and their dignity was upheld.

At St James’s University Hospital, people’s comments included, “They always pull the curtains round when dealing with you, “Nurses approach in a very nice way and explain what they are doing. A few don’t and just deal with the necessary care” and “Treated very well”.

At Leeds General Infirmary, people said, “Couldn’t fault the care”, “Staff are cheerful and seem to listen” and “Staff have been very good”.

At Wharfedale hospital we received comments that included, “Have been in a few hospitals, this is one of the best. Staff are polite and friendly. Would choose this hospital in the Leeds area” and “Hospital is first rate, come in regularly, have got to know nurses, they are all very nice.” One person stated that there are more staff than patients. During our visit, we observed staff tending to patients and did not see any issues relating to staffing levels on the ward.

Some staff at St James’s University Hospital and Leeds General Infirmary told us that they did not believe there were sufficient staff at all times and as a result some people do not receive care in a timely way. For other people it was sometimes difficult to ensure their dignity was maintained while receiving care.

At St James’s University Hospital, staff said that at times they could not always manage people’s continence needs and they sometimes had to feed two people at once.

At Leeds General Infirmary one staff member said they felt that patient care suffers due to staffing levels and that as a result beds aren’t made, patients aren’t helped with food and observations are not done. Another said they had worked many shifts where there were only two qualified nurses on the ward in the day time when they have been assessed as needing three for dependency levels. They stated that this affects patient care as the nurses will not get to review pressure areas for every patient on these days and will have limited time to spend with each patient.

Some staff said there were sufficient staffing levels on the ward and that attendance is quite good.

People said they were given good information about their treatment and care and were able to ask questions. They said they felt included in decisions made about their care and were given time to consider any treatment options and procedures.

In the main, people said that hospital staff communicated well with them and that they received their test results in a timely manner.

Some people said they were not always kept informed and were not told when tests such as x-rays or scans would be carried out and sometimes did not know they were going for a test until the porter arrived to take them. One person at Leeds General Infirmary said, “You don’t know from one day to the next when you are having your scan”. Another at St James’s University Hospital said that this lack of information was leading to worry and anxiety as to whether they could go home that day.

From our inspection of St James’s University Hospital, we received comments such as, “They explain everything with courtesy and understanding, from health care assistants to consultants”, “Communication has got better, they have started to communicate more”, “They make themselves available to ask you if you have any concerns or worries, they treat me like an adult” and “They keep you well informed on treatment and such things as medication”.

At Wharfedale hospital people said they had been given enough written information to take home. They said:

“Fantastic, one of the best hospitals I’ve been in”

“Polite, lovely staff – can’t do enough for you”.

People at St James’s University Hospital, and Wharfedale Hospital said they were satisfied with the food and choices available to them. We also saw that people were given the support they needed to eat and drink comfortably.

At the Leeds General Infirmary most people told us that the food was good and that they received plenty to eat and drink. However we did receive some negative comments about the quality of the food. These included, “The food is so so”, “Food could be better” and “There are only 2 decent meals on the menu in a whole week”. Others said, “You can choose what to eat” and “The food is exceptional and I am not easily pleased”.

People told us they felt safe at all three hospitals and security is well managed.

At the Leeds General Infirmary, all the people we spoke to told us that they felt the ward was clean and we received comments such as “The cleaners are always about making sure its clean” and “Staff are very good they are always washing their hands or using the hand gel”.

Similar comments were received at St James’s University Hospital. These included, “Very clean everywhere”, “Very good, very clean, my wife is very pernickety and she has also been impressed”, “Staff look clean and tidy, nice clean overalls, gives you confidence in them” and “The staff always wash their hands, they all do it. You see them rub, rub”.

At Wharfedale Hospital people we spoke with said that they felt the hospital was “very clean” and others said it was “spotless”.

People who use the service were generally very complimentary about the staff at all the hospitals we visited. Most people said there were enough staff to meet their needs. People who use the service at St James’s University Hospital said, “Overall the nurses and physios have been really good. At times they are short staffed. They are stretched and sometimes we’ve struggled to find nurses”, “Staff are polite, they’re nice and look after me well” and “Usually enough staff, can be short on a night”.

At St James’s University Hospital and the Leeds General Infirmary, most staff told us that they didn’t feel they had enough staff at times which could result in people not getting the care they needed. For example, at St James’s University Hospital, staff said, “The managers try their best but there is not enough staff. I do worry. You hear they have to do budget cuts but I fear there is not enough staff and you hope it doesn’t happen on your shift. They have to stop it before something happens. It is a risk. Elderly wards are generally not staffed well”, “We are so often short staffed, I have brought it up but it seems so difficult to get approval for staff cover, I feel budgets are controlling everything, shifts get cancelled, you get sent to cover at other wards” and “Generally there is enough staff. Everyone works really well as a team”. One person said they had been having trouble sleeping. They said they did not feel they could discuss this with nursing staff as they said “They are always too busy”.

At Leeds General Infirmary one staff member said staffing levels had been ‘terrible’ and that low staffing levels caused a lot of stress, that patients would not get washed and pain relief could take a long time to be administered, leading to frustration for patients. They said things were improving as more staff had been recruited recently. Another said they were often short staffed and they felt this is unsafe and means answering call bells takes a long time and nurses miss things or don’t do observations.

At Wharfedale Hospital we spoke with a number of the staff. They told us that there is enough staff “most of the time”. The staff told us that the staff group is stable and has worked together for a number of years. We were told that the staff are flexible and “cover” for each other.

Our rating of services improved. We rated it them as good because:

• The emergency department demonstrated effective patient flow with dedicated staff utilised for handover of patients
• Critical care services in particular were rated as outstanding overall with significant improvement since our last inspection.
• Mandatory training compliance for nursing staff was higher than the trust target of 80% in most modules across services
• We observed good practice of infection prevention and control (IPC) in most areas. On all wards we visited there were either low numbers or no reported infections of methicillin resistant staphylococcus aureus (MRSA), clostridium difficile (C.Diff) or methicillin susceptible staphylococcus aureus (MSSA)
• Although staffing levels in some services did not meet the optimal target set by the trust; staff skill mixes had been adjusted to mitigate this risk and ensure safe and effective care.
• We saw evidence of good collaborative working with external partners including local NHS ambulance services, local authority, the local NHS children’s hospital and Mental Health services
• Services were caring with support available for patients who became distressed and an understanding demonstrated of the emotional impact of care and treatment upon patients and relatives
• Services were responsive with processes in place at clinical service unit level to plan services to meet patient’s needs

However:

• Mandatory training compliance for medical staff in some services did not achieve the trust target of 80%
• Patient records and substances hazardous to health were not always securely stored in all services
• Ligature points were observed in the mental health room on the emergency department