We carried out a focused inspection on 20 December 2017, to follow up on concerns we identified during routine engagement, regarding the safe use of additional beds in non-designated areas during times of increased demand.

Intelligence data showed that at times of increased demand, staff placed additional beds/trolleys in non-designated areas. The use of non-designated areas included placing patients in ward corridors, using additional areas to nurse patients (such as treatment rooms, day rooms, and sensory rooms) and increasing the capacity of ward bays by placing patients in beds in the middle of the bay.

We raised the use of non-designated areas with the trust in May 2016, during a follow-up to a comprehensive inspection. At that time risk assessments of the use of non-designated areas were not consistently undertaken or applied, and there was a lack of robust assurance of the oversight of patients waiting on trolleys. A requirement notice was served to the trust, to ensure there were appropriate arrangements in place for assessing the suitability of patients to wait on trolleys on the assessment ward. Since the 2016 inspection, the trust had reviewed documentation, including risk assessment and standard operating procedures, for placing patients in non-designated areas; and they had commenced weekly and quarterly audits of the results.

In September 2017, through routine reviews of the National Reporting and Learning System (NRLS) data, we observed a number of reports that showed patients were still being placed in non-designated areas. Staff raised concerns that on some occasions, risk assessments of these patients had not been carried out appropriately; and some patients were being nursed in non-designated areas (including corridors) for a number of days. We discussed this with the trust. The trust explained that at times of increased demand for beds, capacity was increased by placing additional beds/trolleys in (what the trust termed) “non-designated areas”; such as ward corridors and in the middle of bays, and using treatment rooms, day rooms, and sensory rooms as escalation areas. The trust had identified two different occasions when non-designated areas could be used; and classified in there full capacity plans.

Information provided by the trust showed that between October 2017 and December 2017, non-designated areas within the trust were in use on the majority of days. The number of patients per day in non-designated areas ranged between six to 40 patients. During this inspection, we saw five patients nursed in non-designated beds in the areas we visited; three on the corridor, one located in the middle of a bay, and one located in a treatment room. At the time of the inspection, the trust was not able to provide length of stay data for patients in non-designated areas. However, during the inspection, we saw two patients that had been nursed in non-designated beds for a period of four days.

Information we reviewed showed that between March to December 2017, the trust had received seven formal complaints and eighteen patient advice and liaison service (PALS) concerns relating to the use of non-designated areas.

We asked the trust how they received assurance that patients in non-designated areas were receiving safe care and treatment. We reviewed the information provided by the trust, and discussed this at management review meetings. We concluded that a focused inspection was required to identify if a breach of the regulations had occurred.

To get to the heart of patients’ experiences of care and treatment we always ask the same five questions of all services: are they safe, effective, caring, responsive to people’s needs, and well-led? Where we have a legal duty to do so, we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

At this inspection we inspected the core service of medicine only and the safe, responsive and well-led domains; we did not rate the services.

During the inspection we identified the following concerns:

• There was a lack of robust assessment and documentation of decision making for patients being nursed in non-designated areas.

• There was a lack of suitably qualified staff; when taking into account best practice, national guidelines and patients’ dependency levels. In addition, staffing levels were not altered to reflect the use of non-designated areas.

• There was a lack of robust documentation in relation to the requirements of the Mental Capacity Act (2015) and consent to being nursed in non-designated areas.

• The non-designated areas being used to nurse patients were not always suitable and did not meet all patients’ needs.

• At the time of the inspection, the trust was not able to always meet patient’s privacy and dignity in relation to the environment they were nursed in. The single sex accommodation annual declaration 2017, outlined that when patients were allocated to corridors, the trust required they were always allocated on same gender wards. However during the inspection, we did not see that the trust always achieved this. On ward J14 a mixed male and female ward we saw a male and a female patient located on the same ward corridor

• The use of non-designated areas reduced the privacy of patients and compromised their dignity.

• A number of incident forms we reviewed indicated a theme of nursing staff being overruled in decision making processes about placing patients on corridors. A number of reports also highlighted patients (or their relatives and representatives) who were unhappy or upset about being nursed in non-designated areas.

However, we also saw several areas of good practice including:

• We observed that during the inspection, staff treated patients with compassion and respect.

• Patients we spoke with said they felt listened to, they felt safe, and that they were treated with kindness.

• The service had systems in place for reporting, monitoring, and learning from incidents. Staff we spoke with knew the procedure for reporting incidents, and described completing an incident form each time a non-designated bed space was used.

• We also found effective communication between teams to ensure patients in non-designated areas were medically reviewed, as appropriate.

• The trust had developed a number of initiatives to improve patient flow, and relieve capacity and demand pressures.

• We found that all members of staff approached were happy to speak with us and share concerns, discuss challenges faced, and highlight good practice to us.

Importantly, the trust must:

• Ensure there are suitably skilled staff available to care for patients being nursed in non-designated areas; taking into account best practice, national guidelines, and patients’ dependency levels.

• Ensure that when non-designated areas are in use, the privacy and dignity of patients being nursed in bays or corridors are respected and not compromised, and that the areas are suitable to meet patients’ needs.

• Ensure there is robust assessment and documentation of decision making for patients being nursed in non-designated areas,; including assessment of patients’ mental capacity, reasons for deviation from the operating procedure, patient preferences, and patients’ right to consent.

• Ensure data is collated on the numbers, location, and length of stay of patients in non-designated beds.
• Ensure that staff reporting concerns about the use of non-designated areas are supported and receive feedback.

Ellen Armistead

​Deputy Chief Inspector of Hospitals

The last times we visited the service in August 2011 and December 2011, we found that the delivery of care was not always safe and effective and there were often times when there were insufficient staff. We therefore issued compliance actions and said the service needed to improve.

The purpose of this review was to see what action the care provider has taken in order to comply with Outcome 1 (Respecting and involving people who use services), Regulation 17, Outcome 4, (Care and welfare of people who use services) Regulation 9 and Outcome 13, (Staffing) Regulation 22.

We visited four wards in the hospital during this inspection. Two were acute medical wards for older people, one was a stroke re-habilitation ward and the other was an acute medical admissions ward for older people.

On all four wards visited most of the patients we spoke with were very complimentary about the care and treatment they were receiving. Comments included:

“They explain what is happening.”

“Staff are all very kind and make you feel very relaxed.”

“Staff are friendly and explain what they are doing.”

“Physiotherapists come often.”

“Staff are prompt and give assurance.”

“The doctors explain everything.”

“Staff come and chat to you.”

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:

“At weekends there are not always enough staff and staff do not have enough time.”

“Staff are good but could do with more staff.”

“They were short of staff this morning.”

Staff told us during this visit, they felt good care was given to patients. The majority of staff said they now felt that for most of the time they had enough staff to make sure people’s needs were properly met. Staff described times when they worked short staffed but said it was always manageable and safe.

A small number of patients told us they didn’t think there was enough to do on the ward. Comments included:

“There is nothing to do on the ward. There is no television or radio.”

“It is difficult to know what day it is – everyday is the same.”

“There is very little to do.”

“There is little to do apart from watch the world going by.

“I just sleep and sleep some more.”

“There is not much to do. I’m just waiting to go home.”

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

We spoke with people who use the service and their relatives and visitors.

People told us that the wards were very busy and there were not always enough staff. Some of the comments included:

“Staff don’t have time to talk.”

“Staff wouldn’t be able to cope without the students.”

“Sometimes not enough staff.”

“Not enough staff to deal with wandering /shouting patients.”

“Staffing levels vary.”

“Relative does personal hygiene needs because not enough staff.”

“Ward is understaffed.”

However, some people said there were enough staff. Their comments included:

“Staff answer the buzzer quickly.”

“Staff are approachable.”

“Staff brilliant.”

Staff explain everything and are friendly.”

“Enough staff on the ward.”

“Staff look after you well.”

“Staff talk to you about your care.”

Most people we spoke with were happy with the care they received. They said:

“Staff explain care and treatment”

“Staff explain what is happening and will deal with concerns.”

“Staff explain what is happening and do not talk across you.”

“Staff explain everything and are friendly.”

“Kept well informed about care and what is happening with discharge.”

“Doctors explain what is going on.”

The majority of people we spoke with said they enjoyed the food at the hospital. However, one person said, “On a moist diet but by the time food is served it is dry and difficult to eat.”

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 stayed the same. We rated it them as requires improvement because:

• We found that nurse staffing did not always meet the minimum levels to ensure patients received safe care and treatment and there was a high turnover of nursing staff. This was observed in multiple services at the hospital
• We found that mandatory training compliance in multiple services was below the trust target of 80%
• We observed that effective infection prevention and control protocols were not consistently followed on all wards and theatres and we had concerns about the number of healthcare acquired infections in surgical services at the hospital
• We observed that substances hazardous to health such as cleaning solutions and alcohol gels were not always stored securely and in some cases were accessible to patients
• We observed that the mental health assessment room did not meet recommended standards and that staff understanding of mental capacity and consent was variable
• We had concerns about patient privacy and dignity in some areas of the urgent and emergency care service

However:

• Patients we spoke to told us that staff were polite and professional and treated them with care and compassion. This was observed on all services we inspected.
• Appropriate escalation policies were in place at the hospital and National Early Warning Scores were calculated and escalated in line with these polices
• We observed safe medicines management, resuscitation trolleys were regularly checked with tamper proof seals in place and all medicines and items were found to be in date