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Leeds Dental Institute

Provider Leeds Teaching Hospitals NHS Trust Type NHS Healthcare Organisation Region Yorkshire & Humberside Last inspected 15 Feb 2019

Overall rating: Outstanding  View full CQC report

Domain ratings

Five CQC key questions
Safe
Good
Effective
Outstanding
Caring
Good
Responsive
Good
Well-led
Outstanding

Earlier inspection findings

pre-2024 framework · 21 must-do 39 should-do

Must-do actions (21)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 21
Must do
Responsive
The trust must continue to work to improve performance targets within the emergency department.
Regulation: Regulation 12(2)
⚠ The Department of Health’s standard for emergency departments is that 95% of patients should be admitted, transferred or discharged within four hours of arrival in the emergency department. From July 2017 to June 2018 the trust failed to meet the standard and performed generally worse than the England average. Arrival …
Must-do action 2 of 21
Must do
Safe
The trust must ensure that a safe environment is provided for patients with mental health needs.
Regulation: Regulation 12(2)
⚠ We found ligature points in the mental health room. The mental health assessment room did not meet recommended standards.
Must-do action 3 of 21
Must do
Safe
The trust must ensure there are sufficient numbers of suitably skilled, qualified and experienced staff at all times, in line with best practice and national guidance, and taking into account patients’ dependency levels.
Regulation: Regulation 18(1)
⚠ We were concerned that nurse staffing was not always safe: 38% of registered nurse shifts in the main ED were staffed at or below the minimum level.
Must-do action 4 of 21
Must do
Safe
The trust must ensure that mandatory training compliance, including safeguarding training, meets the trust standard.
Regulation: Regulation 18(2)
⚠ Mandatory training compliance for medical staff was below the trust target. Resuscitation training for all staff was below the trust target. Two of the seven safeguarding training modules for nursing staff had compliance rates below the trust target. Five of the seven safeguarding training modules for medical staff had compliance …
Must-do action 5 of 21
Must do
Safe
The trust must ensure that patients can safely access the minor injuries unit, and that there is clear signage to the department.
Regulation: Regulation 15(1)
⚠ We were concerned that some patients had difficulties accessing the MIU, and that those needing X-ray were required to return to the main department.
Must-do action 6 of 21
Must do
Caring
The trust must ensure that patients’ privacy and dignity is not compromised in any areas of the emergency department and minor injuries unit at St. James’s University Hospital.
Regulation: Regulation 10(2)
⚠ We were concerned that patients’ privacy and dignity was not always maintained, in both the main ED and MIU, due to the layout of the departments.
Must-do action 7 of 21
Must do
Safe
The provider must ensure that staff meet the trust target for compliance with mandatory training, safeguarding and mental capacity act training.
Regulation: Regulation 18(2)
⚠ Mandatory training figures for medical staff showed they were compliant with ten of the 18 courses. Five that did not meet the 80% compliance were between 70 and 79% compliance. The lowest mandatory courses were resuscitation at 46% and 65% compliance. Levels of safeguarding compliance varied, for registered nurses out …
Must-do action 8 of 21
Must do
Safe
The trust must ensure that 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 patient’s dependency levels. In particular the correct staffing levels provided to patients who have been identified as requiring enhanced care such as one to one or cohorted care.
Regulation: Regulation 1(1)
⚠ The service did not always have appropriate numbers of staff to ensure patients received safe care and treatment. There were registered nurse vacancies in most areas we visited, which resulted in staff managing higher volumes of patients. Patients who had been assessed as requiring one to one supervision were not …
Must-do action 9 of 21
Must do
Safe
The trust must ensure that hazardous substances are securely stored.
Regulation: Regulation 12(1)
⚠ Hazardous substances used for cleaning and alcohol gels were not always stored securely. Solutions continued to be stored in areas where they could be accessed by patients.
Must-do action 10 of 21
Must do
Safe
The trust must ensure that records are securely locked and stored including records stored on computers.
Regulation: Regulation 17(2)
⚠ We saw that on various wards medical record trolleys were not always secure.
Must-do action 11 of 21
Must do
Responsive
The trust must ensure that the number of patients moved after 10pm is reduced.
Regulation: Regulation 12(1)
⚠ We saw large numbers of patients that moved wards after 10pm, the figures reflected the same levels when we inspected in May 2016, with no improvements. The numbers fluctuated and varied between 632 to 760 patients between March and August 2018.
Must-do action 12 of 21
Must do
Responsive
The trust must ensure that appropriate patients are moved to non-medical or different speciality areas.
Regulation: Regulation 12(1)
⚠ We found patients that were at risk of falls and patients living with dementia were inappropriately moved to non-medical areas.
Must-do action 13 of 21
Must do
Responsive
The trust must review the clinical decision unit to identify whether the unit is designed to meet the needs of patients waiting for long periods of time before an admission to medical wards.
Regulation: Regulation 12(2)
⚠ A high number of medical patients stayed in the clinical decision unit (CDU) based with the emergency department until a bed became available on a medical ward. At times patients remained on the CDU for between three and seven days. The CDU was not designed for this purpose.
Must-do action 14 of 21
Must do
Safe
The trust must ensure that at all times and across all services there are sufficient numbers of suitably skilled, qualified and experienced staff in line with best practice and national guidance taking into account patient’s dependency levels.
Regulation: Regulation 18(1)
⚠ We were not assured staffing levels and mix always supported the delivery of safe care and treatment; especially in high patient volume areas and wards with comparatively more outlier patients. There were registered nurse vacancies in most areas we visited, which resulted in staff managing higher volumes of patients.
Must-do action 15 of 21
Must do
Safe
The trust must ensure that mandatory training figures including advanced resuscitation and safeguarding training meet their required levels.
Regulation: Regulation 18(2)
⚠ Medical staff were not compliant with level two resuscitation training and advanced resuscitation training modules; data showed only 41.2% of medical staff had completed advanced resuscitation training and 41.2% had completed the advanced training update. Less than half of those eligible had completed safeguarding adult and safeguarding children training levels …
Must-do action 16 of 21
Must do
Safe
The trust must ensure all aspects of the WHO checklist are followed, in particular the team brief and de-brief components.
Regulation: Regulation 12(2)
⚠ Audit data for the location showed average team brief and de-brief compliance was low overall; and this was reflected in trust-wide audit data and reports.
Must-do action 17 of 21
Must do
Safe
The trust must ensure that hazardous substances are securely stored.
Regulation: Regulation 12(1)
⚠ We found a number of medicines fridges had been consistently out of temperature range, with no escalation or assessment regarding the likely cause recorded. We found patient records and substances hazardous to health were not always securely stored on wards.
Must-do action 18 of 21
Must do
Safe
The trust must ensure that records are securely locked and stored.
Regulation: Regulation 17(2)
⚠ We found patient records and substances hazardous to health were not always securely stored on wards.
Must-do action 19 of 21
Must do
Safe
The trust must ensure infection prevention and control (IPC) protocols are consistently followed on wards and in theatres.
Regulation: Regulation 17(2)
⚠ We found that infection prevention and control (IPC) protocols were not consistently followed on wards and in theatres. We also had concerns about the number of healthcare acquired infections (HCAI) in surgical services at the location.
Must-do action 20 of 21
Must do
Safe
The trust must continue to monitor the types and acuity of patients admitted to the David Beevers day unit, and clarify the maximum number of patients to be housed there, in line with IPC guidance.
Regulation: Regulation 12(1)
⚠ At inspection, we observed the David Beevers day unit (second phase recovery) was being used for surge capacity and housed both day case and inpatients. Data showed 357 non-elective outlier patient spells had taken place at the unit from April to August 2018.
Must-do action 21 of 21
Must do
Safe
The trust must ensure sharps disposal bins are not overfilled in line with best practice guidance.
Regulation: Regulation 15(1)

Should-do actions (39)

Recommended improvements to enhance service quality.

Should-do action 1 of 39
Should do
Responsive
The trust should continue to work towards improving ambulance handover times.
Should-do action 2 of 39
Should do
Responsive
The trust should ensure that when patients enter the emergency department they are assessed as soon as possible by a clinician.
Should-do action 3 of 39
Should do
Responsive
The trust should ensure that patients receive treatment in a timely manner, in line with trust policy and national guidance.
Should-do action 4 of 39
Should do
Responsive
The trust should ensure that patients are admitted, transferred or discharged within four hours of arrival in the emergency department, in line with the emergency care standard.
Should-do action 5 of 39
Should do
Effective
The trust should improve RCEM audits and action plans, and aim to achieve the required standards.
Should-do action 6 of 39
Should do
Responsive
The trust should aim to reduce the numbers of unplanned re-attendances and patients leaving the department before being seen.
Should-do action 7 of 39
Should do
Responsive
The trust should ensure timely closure of complaints, in line with trust policy.
Should-do action 8 of 39
Should do
Safe
The trust should ensure that outstanding incident reports are responded to.
Should-do action 9 of 39
Should do
Responsive
The trust should ensure that patients are able to access information in different formats and languages.
Should-do action 10 of 39
Should do
Safe
The trust should continue to audit infection control and hand hygiene techniques.
Should-do action 11 of 39
Should do
Safe
The trust should continue to improve the compliance of whether patients at high risk of falls had an enhanced care risk assessment completed.
Should-do action 12 of 39
Should do
Effective
The trust should ensure that the compliance rates for nutrition and hydration improve to an appropriate level.
Should-do action 13 of 39
Should do
Effective
The trust should continue to improve national audits in particularly the National Inpatient Falls audit.
Should-do action 14 of 39
Should do
Effective
The trust should ensure that patient’s mental capacity and decision making around mental capacity is recorded.
Should-do action 15 of 39
Should do
Effective
The trust should ensure that the process for DoLS applications and information are stored in the same place across the wards.
Should-do action 16 of 39
Should do
Responsive
The trust should continue to reduce the length of stay.
Should-do action 17 of 39
Should do
Responsive
The trust should ensure that complaints are closed within the trusts allocated time frame.
Should-do action 18 of 39
Should do
Well-led
The trust should ensure that CSU governance meetings are reflected between all the CSU and contain the same information.
Should-do action 19 of 39
Should do
Safe
The trust should review VTE risk assessment within 24 hours of admission compliance, and ensure performance is robust across surgical service areas.
Should-do action 20 of 39
Should do
Safe
The trust should review and monitor surgical site infection (SSI) rates within spinal surgery services; and work to improve these.
Should-do action 21 of 39
Should do
Safe
The trust should work to reduce the number of healthcare acquired infections (HCAI) in surgical services.
Should-do action 22 of 39
Should do
Responsive
The trust should ensure complaints are investigated and closed in a timely manner, in line with their policy.
Should-do action 23 of 39
Should do
Responsive
The trust should review outliers in the surgical bed base, and ensure that appropriate patients are moved to surgical wards.
Should-do action 24 of 39
Should do
Safe
The trust should ensure that when medicine fridges are found to be out of range, staff adhere to guiding actions outlined in trust policy.
Should-do action 25 of 39
Should do
Well-led
The trust should consider developing risk management strategies for CSUs and/or surgical specialities.
Should-do action 26 of 39
Should do
Effective
The trust should continue to monitor risk of readmission rates, excess mortality outliers, and patient outcomes from national audits; and work to improve performance.
Should-do action 27 of 39
Should do
Responsive
The trust should continue to monitor the proportion of cancelled operations, 18-week referral to treatment times, and length of stays; and work to improve performance.
Should-do action 28 of 39
Should do
Caring
The trust should ensure that the (draft) mixed sex accommodation policy is implemented, and procedures to avoid mixed sex accommodation breaches are embedded in the service.
Should-do action 29 of 39
Should do
Responsive
The trust should monitor surgical assessment unit capacity, and ensure that patients do not wait for extended periods to be triaged, assessed by a doctor and be admitted to the unit, where appropriate.
Should-do action 30 of 39
Should do
Well-led
The trust should ensure that governance meetings are consistently recorded between CSUs.
Should-do action 31 of 39
Should do
Responsive
The trust should display information for relatives and patients that information leaflets are available in languages other than English.
Should-do action 32 of 39
Should do
Responsive
The trust should ensure plans to provide washing and toilet facilities for patients on L08 are progressed and consideration is given to mixed sex accommodation.
Should-do action 33 of 39
Should do
Effective
The trust should continue to work to increase the number of staff with a post registration award in critical care nursing to meet GPICS recommendations.
Should-do action 34 of 39
Should do
Effective
The service should work to increase the level of specialist pharmacy input in line with GPICS standards.
Should-do action 35 of 39
Should do
Safe
The trust should ensure monthly checks of the difficult airway trolley on ICU are undertaken in line with trust policy.
Should-do action 36 of 39
Should do
Safe
The trust should ensure resuscitation training for medical staff meets trust targets.
Should-do action 37 of 39
Should do
Safe
The trust should continue to work to reduce the number of unit acquired infections in blood.
Should-do action 38 of 39
Should do
Safe
Improvements could be made to the process for reducing the risk of Legionella developing in the dental unit water lines and for ensuring that water temperature testing is regularly carried out.
Should-do action 39 of 39
Should do
Safe
Review the process for ensuring staff are up to date with the mandatory training for resuscitation and safeguarding at the correct level.

Location details

CQC ID: RR802
Local authority: Leeds
Region: Yorkshire & Humberside

Inspection report

Type: Location
Date: 15 February 2019
Rating: Good
Actions: 21 must-do 39 should-do
AI-extracted 3 Jun 2026

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