Source · CQC inspection
Leicester Royal Infirmary
Provider University Hospitals of Leicester NHS Trust
Type NHS Healthcare Organisation
Region East Midlands
Last inspected 14 Jun 2024
Overall rating: Requires Improvement View full CQC report
Domain ratings
Safe
Requires Improvement
Effective
Good
Caring
Good
Responsive
Requires Improvement
Well-led
Requires Improvement
Earlier inspection findings
Must-do actions (4)
Must-do action 1 of 4
Must do
Safe
Care and treatment must be provided for patients in a safe way. The trust must ensure staff are assessing the risks to the health and safety of patients of receiving the care or treatment. Staff must be doing all that is reasonably practicable to mitigate any such risks. To that end, the trust must ensure all patients receive timely assessment and treatment for conditions, such as sepsis. Furthermore, the trust must ensure it continues to use all resources available to reduce the pressure on the department caused by increasing demand and ineffective and inefficient movement of patients onwards in their pathway. This includes the significant improvement to the agreed professional standards which remain non-compliant in most specialties.
Must-do action 2 of 4
Must do
Safe
The trust must ensure that the use of MEOWS is consistently implemented across the service in line with the policy.
Must-do action 3 of 4
Must do
Safe
The trust must ensure there are always enough suitably qualified and skilled staff on duty.
Must-do action 4 of 4
Must do
Safe
The trust must ensure staff report all incidents in line with the incident reporting policy.
Should-do actions (9)
Should-do action 1 of 9
Should do
Safe
The trust should ensure staff in the emergency department are up to date with the latest mandatory training modules and staff, particularly medical staff, are given time to meet compliance.
Should-do action 2 of 9
Should do
Safe
The trust should ensure staff in the emergency department adhere to infection prevention and control policy specifically in relation to dress code and any temporary measures introduced to prevent the spread of infection.
Should-do action 3 of 9
Should do
Safe
The trust should ensure staff have the right tools to be able to open locked doors when patient safety is a concern.
Should-do action 4 of 9
Should do
Well-led
The trust should continue to build on the work on staff recruitment and retention and look for support from other departments, such as rotational work with children’s nurses, as an option to build stronger and more flexible teams in the department.
Should-do action 5 of 9
Should do
Responsive
Due to patients having to stay far longer than planned or anticipated at times, the trust should consider how to meet the dietary needs of patients to ensure they are provided with food and drink in line with their cultural or other requirements.
Should-do action 6 of 9
Should do
Well-led
The trust should ensure staff are given sufficient quality time to complete a programme of good and effective governance. This should follow a recognised system of governance routines, including analysis of all forms of evidence and engagement.
Should-do action 7 of 9
Should do
Well-led
The trust should consider how it describes staff from ethnic minorities to bring the language into line with current practice and keep this under review.
Should-do action 8 of 9
Should do
Safe
The service should ensure all areas are clean and free form clutter and obstruction across maternity during internal works.
Should-do action 9 of 9
Should do
Well-led
The service should consider further separation of its maternity data for all sites.