Agenda item

The Deputy Chief Nurse at University Hospitals Leicester has submitted a report providing an overview of current care standards. The report highlights the actions being taken to drive improvements and outlines the tools in place to support and assure quality of care.

UHL Quality Care Standards submitted a report to highlight the current position of actions being taken to continuously improve the position. It was noted that:

·       A new quality assurance framework was being rolled out across the whole organisation to understand the areas requiring support where the standards fell below the expected target. New tools were developed to ensure recording and visibility foe patients cared for in temporary escalation spaces (TES), during times of escalation across the system. This includes care for patients receiving care on ambulances, awaiting transfer into the Emergency Department.

·       It was explained that rising pressures in emergency care formed the context for understanding the challenges in maintaining quality standards.

·       Data showed that emergency department (ED) attendances continued to increase, with no signs of reduction. As a result, performance against the national four-hour standard had been impacted.

·       UHL was operating at approximately 60% compliance with the four-hour standard, compared to a national average of around 100 trusts, placing the trust below expected performance levels.

·       The ED was becoming increasingly busy, with delays in patient transfers contributing to ambulance handover challenges. Approximately 30% of ambulance arrivals were experiencing extended waiting times outside the department.

·       In response, the Trust had expanded urgent treatment capacity, increased alternative pathways, and made changes to the ED footprint.

·       It was noted that a requirement to respond to ambulance releases within 45 minutes had added pressure to maintain rapid patient flow, further compounding complexity.

·       Hospital-acquired pressure ulcers had previously placed UHL as an outlier nationally. While new equipment and beds had been introduced, early rollout lacked sufficient staff training. Improvements had since been made, although further work remained.

·       Specialist services, which had been paused during the COVID-19 pandemic, had now returned to ward settings to support care. It was also highlighted that some patients arrived with pre-existing pressure ulcers, which were not always recorded in time due to early system constraints.

·       85% of patients were now being seen within the agreed timeframe, which had positively impacted pressure rates.

·       Falls in hospital remained a key challenge, particularly among patients with dementia or delirium. The unfamiliar hospital environment increased risk, and additional specialist care was being introduced.

·       A business case had been approved for sensor mats that alert staff when patients attempt to move, aiming to reduce the incidence of falls.

·       The Trust was using a quality platform called MEG to monitor nursing metrics, including screening and care planning. Some red and amber ratings were noted, indicating areas for improvement. Nursing assessments were expected to be completed within six hours.

·       A quality improvement framework known as the LEAF (Leicestershire Excellence Assurance Framework) had been introduced in the previous year. This tool assessed ward performance based on 12 standards covering quality, safety, efficiency, patient and staff experience, with measurable metrics.

LEAF is structured around 5 key pillars:

­   Quality & Safety

­   Efficiency

­   Patient Experience

­   Staff Experience

­   Improving

·       These pillars are further defined by 12 standards and underpinned by 69 measurable metrics

·       LEAF had been rolled out across all adult inpatient areas and was due to be extended to specialist areas in the coming months.

·       Early findings from LEAF indicated that efficiency was the category requiring the most improvement.

·       A new metric was being used to monitor care in Temporary Escalation Spaces (TES), such as ‘corridor care’, to evaluate how these settings affected patient experience and quality.

·       While the majority of indicators in TES settings were rated green, suggesting patients continued to receive appropriate medical and nursing care, red indicators remained around dignity due to the nature of the environment. It was acknowledged that dignity screens were used, but the patient experience was not equivalent to a ward setting.

·       The Trust confirmed this work formed part of a continuous improvement plan, with a forward focus in LEAF Phase 2.

LEAF - Phase 2:

Phase 2 of LEAF implementation will focus on specialist areas

Scoping sessions will be set up with representatives from the Emergency Department and Critical Care to agree on the specific metrics to be included in their LEAF dashboards

Quality Improvement:

Continued focus on embedding LEAF principles and driving quality improvement across all areas.

Harm Reduction:

Ongoing work to address key areas identified in the Temporary Escalations Audits and other harm reduction initiatives.

In discussions with Members, it was noted that:

·       It was confirmed that the LEAF framework would eventually be rolled out to paediatrics.

·       Significant variability in ambulance waits was highlighted. Trusts with better performance typically had improved patient flow due to stronger internal systems and greater capacity.

·       While UHL had previously increased NHS England had introduced new standards for ambulance handovers, prompting further work in this area. However, the underlying issue remained a lack of physical space, resulting in some patients being placed in corridors a situation no one supported. Capacity, this only led to short-term improvements, as it did not address flow through the wider hospital. Sustained improvements had not been achieved.

·       Corridor care was described as a compromise on patient dignity and staff wellbeing, though sometimes necessary to release ambulances and save lives. The system was acknowledged as fundamentally broken.

·       Concerns were raised about the UK’s performance compared to other European healthcare systems, where such issues were reportedly less severe.

·       The issue of hospital falls was discussed. Reduced movement was linked to a decline in postural stability, and deconditioning was recognised as a contributing factor. A direct correlation between falls and hospital-acquired pressure ulcers was noted.

·       Members expressed appreciation for the openness of the report and acknowledged the difficulty of the issues discussed.

·       Corridor care was recognised as harmful for both patients and staff, with questions raised about what plans were in place to reduce its occurrence. Staff morale and patient experience were understood to be closely connected.

·       It was reported that corridor boarding often took place during the day when patients were known to be awaiting discharge. At night, this practice was distressing for staff, despite the support put in place by senior nurses and matrons.

·       Trigger points for initiating corridor care were monitored to ensure it remained a temporary escalation measure and did not become routine practice.

·        Members emphasised the exceptional demand on Leicester’s ED, which served a highly deprived, elderly, and frail population. Demand in Leicester was noted as higher than in many other areas.

·       It was stressed that the fundamentals of care should not rest solely with nurses, and that a whole-system cultural approach was required to reduce corridor care and manage demand.

·       There was concern about how frequently corridor care occurred. It was acknowledged that medicine used it more than other specialties, particularly at weekends and during winter pressures. Although not a daily occurrence, it happened regularly more than was considered acceptable.

·       Patients were provided with letters informing them that corridor care might occur. However, there were concerns that vulnerable individuals had less choice and were more likely to be treated in such environments.

·       Historically, UHL had taken a strong stance against corridor care, including designing the new ED without corridors to avoid the practice. However, current pressures had resulted in its reintroduction, primarily on ward areas.

·       Surgical wards experienced less pressure, though demand remained high at peak times. Corridor care was described as a frequent, though not daily, occurrence.

·       A number of plans were underway to improve the situation. Some were long-term, including prevention strategies, while others were more immediate, such as opening a new facility for patients who no longer required medical therapy.

·       Alternative pathways were being explored to reduce ED demand, and plans were in place to expand urgent response capacity and build a larger facility at LRI by next winter.

·       There was an interest in improving care for older people and preventing unnecessary hospital admissions. While many projects were underway, their impact would take time to materialise.

·       It was clarified that patients were not simply placed in corridors at UHL. Instead, temporary boarding occurred in ward areas while waiting for space to become available, with clinical oversight in place.

·       Members expressed strong support for collaborative working and emphasised the need not to make assumptions based solely on data. It was noted that high ED attendance was not always linked to deprivation, and that children aged 0–5 had the highest attendance rates.

·       Deeper data analysis was being undertaken to understand which populations were attending ED and why. A report on this analysis was due to go to the Trust Board in August and could also be shared with the Commission.

·       It was noted that many patients attended ED without requiring any intervention, which distorted the picture and highlighted the need for better-targeted support and alternative services.

·       Members stressed that resolving this required joint working across acute, secondary, and community services. Many individuals presented to ED due to a lack of available alternatives.

·       The importance of community-level support was highlighted. Preventing ED attendance often involved addressing basic needs, which were not always health related.

·       It was also noted that while population health data was generally strong for adults, it was less reliable for children. High levels of attendance among young children were often linked to a lack of support for young parents, especially those without extended family.

AGREED:

1.    Members note the report.

2.    An item on deprivation to come to a future board meeting.