South Warwickshire University NHS Foundation Trust

South Warwickshire Foundation NHS Trust provides a range of hospital and community health services to a community of approximately 270,000 in South Warwickshire and the surrounding areas. The trust provides a full range of district general hospital services at Warwick Hospital, community inpatient care at Stratford-Upon-Avon Hospital, Leamington Spa Hospital and Ellen Badger Hospital. The trust also provides neuro rehabilitation to young adults at the Central England Rehabilitation Unit (CERU), based at Leamington Spa Hospital. Community services for adult’s end of life care and children and young people are also provided by the trust.

There are 441 inpatient beds within Warwick Hospital and 50 inpatient beds throughout the community hospitals.

We carried out an announced comprehensive inspection of the trust from 15 to 18 March 2016. We undertook an unannounced inspection on 29 March 2016.

We held focus groups with a range of staff in the hospital and community, including union representatives, black and minority ethnic staff, governors, nurses, health visitors, trainee doctors, consultants, midwives, healthcare assistants, student nurses, administrative and clerical staff and allied health professionals. We also spoke with staff individually as requested.

Overall, we rated South Warwickshire Foundation NHS Trust as requires improvement with three of the five questions we ask with safe, effective and well-led being judged as requiring improvement.

We have judged the trust as good for caring and responsiveness. We found that services were provided by dedicated, caring staff. Patients were treated with kindness, dignity and respect and were provided the appropriate emotional support. The trust was planning and delivering services to meet the needs of patients. The emergency department and adult community services were rated as outstanding for responsiveness. Leadership for end of life care in the community was judged to be inadequate.

Our key findings were as follows:

Safety

• Nurse staffing levels and skill mix was planned and reviewed in line with national guidance. Most areas had adequate staff to ensure patients received safe care and treatment.
• Although the trust had taken a number of actions to promote the duty of candour to staff, some staff in the emergency, gynaecology and maternity departments did not have a thorough understanding of this and what this meant within their practice.
• The trust had reported one never event (a largely preventable patient safety incidents that should not occur if the available preventative measures had been implemented) in the 12 month period ending February 2016. Although still under investigation at the time of the inspection early lessons had been learnt and shared.
• The hospitals were seen to be clean and hygienic and most staff followed the trusts infection control policy, were ‘bare below the elbow’ and used personal protection equipment. There were some incidents of poor hand hygiene.
• All patients admitted to hospital were screened for methicillin resistant staphylococcus (MRSA) to assist with isolation and treatment. There was limited follow up of MRSA screening for patients admitted to the medical wards where we found results of this screening were not routinely recorded in nursing notes.
• Cases of MRSA were low with the trust reporting zero cases between August 2014 and August 2015, however there were 17 cases of C. difficile reported during the same period.
• Mandatory training was, across most areas below the trusts target of 85% and 95% for safeguarding adults and children and information governance.
• The level of safeguarding children’s training that staff in certain roles undertook was in line with trust policy, but was not compliant with intercollegiate document ‘Safeguarding Children and Young People: Roles and competencies for Health Care Staff (March 2014).. Therefore, we could not be sure that staff had the sufficient knowledge and skills to safeguard children.
• In many wards and departments we saw medicines in unlocked cupboards and drawers. Although some medicines were left unlocked to allow rapid access in an emergency in some areas all medicines were unsecured, not just ones that required emergency access therefore we were not assured that medicines were stored in a way that prevented misuse, tampering or theft.
• Processes and procedures had been developed for women on the postnatal ward to self-administer some medication if they opted to do so.
• In the emergency department (ED) and minor injury units, children with minor complaints were not seen in a secure paediatric area, they waited with adult patients which is not in line with national guidance. During our unannounced inspection; we observed changes to the ED had been made. A paediatric sub waiting room had been created within the main waiting area for paediatric see and treat patients, although there were no robust procedures in place for children to be observed for rapid deterioration while waiting in this area.
• Patient records were not always stored securely.
• Patient risk assessments were not fully completed on admission and generally not reviewed at regular intervals throughout the inpatient stay. This included incomplete risk bed rails risk assessments resulting in the use of bed rails without a completed risk assessment.
• Management of the deteriorating patient was in place in most areas of the trust through the use of early warning score (EWS) and paediatric early warning score were used (PEWS). However there was no such recognised tool in use in the special care baby unit.

Effective

• Care was delivered in line with legislation, standards and evidence-based guidance, however some local and trust guidelines needed updating.
• The mortality rate as indicated by the Summary Hospital-level Mortality Indicator (SHMI) was “as expected” for January to December 2015, at 1.1 against the England figure of 1.0. The trust Hospital Standardised Mortality Ratio (HMSR) (for in hospital deaths only) for January to December 2015 was “within expected range”, at 108.0 against the England figure of 100
• Data was submitted for all national audits in 2013/2014, with the exception if the Acute Myocardial Infarction and other ACS (MINAP) audit which was not submitted due to staffing issues. Performance in national audits was generally the same or better than the national average. Actions plans were in place to address areas for improvement action.
• Staff and teams worked well together to deliver effective care and treatment.
• Overall, the trust appraisal target of 85% for all staff had been met with 100% of medical staff and 92% of non-clinical and clinical staff compliant.
• Not all staff had full understanding of the Mental Capacity Act 2005 and their responsibilities and role in the management of patients with capacity concerns. This includes appropriate formal assessment processes and escalation of concerns.
• The individualised care of the dying patient care plan, which was a replacement for the Liverpool Care Pathway, was designed to be used for patients in hospital and community settings. However, this was found not to be fully embedded in the care of the dying in the hospital and was not used by the community teams.

Caring

• Feedback we received from patients was consistently positive about the way nursing and therapy staff treated them. Patients felt safe and cared for and staff were respectful of their needs and preferences and took time to understand personal requirements or to explain the care being delivered.
• The need for emotional support was recognised and provided through a range of support mechanisms including a clinical psychology service.

Responsive

• The flow of patients into and through the hospital was well managed with all areas of the trust taking responsibility for this.
• The trust consistently exceeded the Department of Health target for emergency departments of 95% of all patients to be admitted, transferred or discharged within four hours of arrival to the emergency department every month. The percentage of emergency admissions via ED waiting four to 12 hours from the decision to admit until being admitted has been consistently lower than the England average. This meant that patients could access services in a timely way.
• The percentage of admitted surgical patients that started consultant-led treatment within 18 weeks of referral was consistently below the 90% standard between September 2014 and May 2015. In June 2015 this standard was abolished. Between September 2014 and August 2015 the trust’s performance for this measure was better than the England average in all but two months. However, the trust consistently met the 95% indicator for non-admitted patient’s referral to treatment within 18 weeks and met the incomplete pathways other than for one month February 2015. The percentage of patients waiting more than six weeks for a diagnostic appointment was also consistently better than the national average.
• The number of cancelled operations was better than the national average with no operation cancelled due to the lack of a critical care bed.
• There were specific waiting times for patients diagnosed with and suspected of having a cancer. 95% of all patients who receive an urgent referral for suspected cancer and breast symptoms should be seen by a specialist within two weeks. All patients should receive their first definitive treatment 31 days from diagnosis and, all patients should receive their first definitive treatment within 62 days from urgent referral. From October 2013 to March 2015 the service mostly performed the same as the England average which ranged between 93%-96% for patients waiting for two week referrals.
• Following some challenges in meeting the two week wait for patients referred with suspected cancer and breast symptoms from April to September 2015 this had improved in the three months October to December 2015 and the target was met. From April 2015 to September 2015 performance against the 31 day target was mostly the same as the England average and since July 2014 the performance against the 62 day target has been better than the England average.
• Services were planned, delivered and coordinated to take account of people with complex needs, for example those living with dementia or those with a learning disability, with some innovative practices in the emergency department with the use of computer assisted reminiscence therapy.
• Overall complaints were well managed with the trust using the issues raised as an opportunity to learn and improve services.

Well led

• The trust had a clear vision to provide high quality, clinically and cost effective NHS healthcare services that met the needs of patients and the population that they serve. However there was no service specific written strategy for individual core services and specialties did not appear to have a shared vision or aim.
• There was a governance framework in place which supported the delivery of care although there were some areas of weakness. Whilst the board assurance framework and corporate risk register identified most of the keys risks, there were risks at local level that had not been captured. For example, we identified risks to patients receiving care which had not been recognised by either the local of executive team.
• The trust had procedures in place to ensure that policies were reviewed in a timely way and reflected national guidance. However during our inspection we found that the review of 4 policies was overdue. This meant we could not be reassured that staff were always following the latest guidelines.
• There was a lack of oversight of the care for neonates, children and young people across the whole trust.
• The trust did not have a strategy for end of life care; however they had recently appointed a full time consultant with the remit of developing a strategy. The end of life care team did not have a direct reporting structure to the board and there was no named non-executive director representing end of life care. The governance processes for end of life care were not established and the care planning tool for replace the Liverpool Care Pathway was not embedded.
• The executive team was stable and well established and were visible and well regarded by both staff and people in the local community who attended an event to tell us about their care.
• There was an extremely positive culture within the trust and staff felt respected and valued. The results of the 2015 staff survey reflected this positive culture with the trust ranked as 'better than average' when compared with all combined acute and community trusts in 2015.
• In line with previous years in 2015/16 the trust had made a small surplus however they clearly recognised the challenges to maintaining such a position.

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We saw several areas of outstanding practice including:

• Central England Rehabilitation Unit (CERU) provided neuro rehabilitation to young adults. Staff on CERU had developed and published an assessment tool called Sensory Tool to Assess Responsiveness (STAR). STAR was a tool aimed at providing an accurate diagnosis of prolonged disordered consciousness and establishing any means of communication in the patient. The STAR was used to assess responses to stimulation in visual, auditory and motor modalities, and also records observations of communication and emotion.
• The work of the community nursing service reviewing patients who were insulin dependent diabetics was recognised by Diabetes UK at the Patient First conference in London. Diabetes UK asked if they could work alongside the group and share SWFT good practice. The project had been put forward for the Health Service Journal (HSJ) and Nursing Times Awards 2016.
• The integrated health teams (IHT) encompassed district nursing teams, long-term condition and intermediate care teams in the community. IHT had recognised the need to review the number of patients with pressure ulcers. They had introduced the Priority 123 Skin/Equipment Review, which required staff to conduct weekly face to face, one monthly, three monthly, six monthly or annual reviews dependent on the category of priority.
• Family nurse partnership (FNP) teams was a voluntary programme for young first time mothers (and their partners), aged 19 years or under. They were outstanding in their performance management and quality assurance processes. They had a clear vision and strategy for the FNP service that was monitored via comprehensive quality performance measures.
• The use of reminiscence therapy within the Emergency Department (ED) for patients with learning disabilities, dementia and mental health conditions.
• A smartphone application for medical staff containing relevant trust information, policies, clinical guidance and teaching availability.
• The ED staff worked with external agencies to provide services, including substance misuse liaison specialist support for patients.

However, there were also areas of practice where the trust needs to make improvements.

Importantly, the trust must:

• Ensure that regular risk assessments are completed appropriately on admission to medical wards and repeated regularly to identify any changes in patient’s risk of harm. This includes bed rail and mobility assessments and nutritional assessments for patients receiving end of life care.
• Ensure that all staff receive safeguarding children training in line with intercollegiate document ‘Safeguarding Children and Young People: Roles and competencies for Health Care Staff (March 2014).
• Ensure that staff have full understanding of the Mental Capacity Act 2005 and their responsibilities and role in the management of patients with capacity concerns. This includes appropriate formal assessment processes and escalation of concerns.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Overall we found adult community services to be good. However, we rated the responsiveness of community health services for adults as outstanding.

Staff across the service understood the importance of reporting incidents and did so appropriately. We saw lessons learnt from incidents were shared amongst teams. Whilst there were vacancies across the majority of teams, staff felt the current workload was manageable and teams supported each other when demand increased.

Multi-disciplinary team working was apparent with services using referral pathways as required and there were good links with the local GP practices.

Appraisals and peer to peer learning provided staff with time to develop and share knowledge. Staff felt well supported in continuing professional development and were provided with clinical and caseload supervision at regular intervals.

Patients said that staff were “absolutely amazing” and showed compassionate and considerate care during their visits. Patients said that they could call staff with any problems and they would visit within a few hours. They said they felt that staff often went above and beyond the requirements of their role to ensure patients received high quality care. Staff were extremely passionate about their role in improving patient conditions not only clinically but also emotionally. Well-being was a strong focus in all contacts with patients and consistent positive feedback was given about services provided.

There was a clear vision and strategy for the future of the service. Senior staff attended governance meetings. Staff said the recent reconfiguration of the service had improved morale.

Training levels on subjects such as manual handling, health and safety varied across community services which meant that the knowledge level of all staff was not consistent.

We found community children, young people, and family services at South Warwickshire NHS Foundation Trust good because:

• Openness and transparency about safety was encouraged. Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses.
• Safety performance was monitored by an electronic dashboard widely used in the NHS. When something went wrong there was a process in place to review or investigate incidents involving all relevant staff, children, young people and their families. Lessons were learned and communicated widely to support improvement in other areas as well as services that were directly affected.
• Staff took a proactive approach to safeguarding and took steps to prevent abuse from occurring, and responded appropriately to any signs or allegations. However, some therapy staff told us they had not been trained to level 3.
• Staffing levels and skill mix were planned, implemented and reviewed to keep children and young people safe at all times. Any staff shortages were responded to quickly and adequately to ensure staff could manage risks to patients.
• Risks to patients were assessed, monitored and managed on a day-to-day basis. Risks to safety from service developments, anticipated changes in demand and disruption were assessed, planned for and managed effectively. Plans were in place to respond to emergencies and major situations.
• Policies and standard operating procedures were up to date and evidence-based.
• Children and young people’s care and treatment was planned and delivered in line with current evidence-based guidance, best practice and legislation, including the Healthy Child Programme (HCP). This was monitored to ensure consistency of practice.
• Children and young people had comprehensive assessments of their needs, including consideration of their mental health, physical health and wellbeing.
• Children were cared for by a multidisciplinary team of dedicated and skilled staff.
• Parents were involved in giving consent to examinations, as were children when they were at an age to have a sufficient level of understanding.
• The individual needs of patients were taken into account when planning and delivering services.
• Patients and their parents were supported, treated with dignity and respect.
• Feedback from patients and families was positive and they felt supported and said staff cared about them.
• Patients and families were involved and encouraged in making decisions about their care. Staff spent time talking to children, young people and parents. They were communicated with and received information in a way they could understand.
• Complaints handling policies and procedures were in place. All complaints about the service were recorded. Information on the trust’s complaints policy and procedures was available on the trust’s internet website.
• All staff we spoke with told us they liked working for SWFT and there was good morale within their teams.
• Staff and managers we spoke with told us there was clear leadership at executive level. Local team leadership was well established and effective and staff said their team managers were supportive.

However, we also found:

• There was no divisional level community children’s services quality dashboard or audit plan in place. Community children and young people’s services were responsible for monitoring their own activities and outcomes. We found that there was a lack of performance information and no standard approach to monitoring patient outcomes.
• Some staff had not received safeguarding training to an appropriate level and may not have the level of competence to respond appropriately to safeguarding concerns.
• Different information technology (IT) systems made it difficult for staff accessing information on performance in a timely way challenging. There were also challenges in accessing laboratory results due to problems with the electronic records system.
• Children and young people’s needs were met through the way services were organised and delivered.We were told about a number of initiatives that the service was intending to do. However, we found it was taking time for action plans to be implemented.
• There was a lack of care pathway guidance for staff to ensure care was standardised across community children and young people’s services. The service lacked a common pathway with a joint assessment, co-triage, by a doctor, specialist nurse or approved health professional. Referrals were reviewed by each doctor, but staff we spoke with were unaware of whether there was a SWFT protocol.
• A comprehensive service review was ongoing. However, medical staff had problems accessing performance data to assist with the redesign of services. Senior medical staff reported that this was due to not being able to access performance data, such as patients who did not attend appointments (DNA) and referral to treatment times (RTT) in a timely way. There were unclear quality measures for each service, which meant the service missed the opportunity to collate information that could assist them in reviewing services.
• There was a five year strategy to understand demand. However, there was not a standardised approach across SWFT and this had led to a lack of common dashboards and KPI’s. This had been recognised by the service.
• Not all risks were identified on the risk register and so not all mitigating actions were taken.
• Staff told us there was a lack of appropriate information sharing protocols with the provider of school nursing services, and this had an impact on staff having timely access to up to date information.
• Staff reported services as being disjointed at middle management level. Staff told us community children, young people, and families services senior middle managers were not visible, even though they knew who they were.

We rated community in patient services as good because:

• We saw that community inpatient services were safe, effective, caring, responsive and well-led. All care provided revolved around patient rehabilitation and reablement. Feedback from patients and relatives was very positive and we observed staff were caring and compassionate in their approach.

• Admissions and discharges were well managed. Delayed transfers of care were mainly due to family choice, lack of nursing home places and waiting for packages of care.

• Staff were aware of specific needs individual patients had and were able to put in place appropriate arrangements, where possible. Staff were knowledgeable about the complaints process and what action they would take.

• Risks and issues described by staff corresponded to those reported and were understood by leaders.

• There was a clear vision and strategy for the future of the service. Leaders were clear of their roles and accountabilities. There was a strong focus on continuous learning and improvement at all staff levels. Staff shared innovations and improvement work that they were involved with.

• Staff on the Central England Rehabilitation Unit (CERU) had developed an assessment tool called Sensory Tool to Assess Responsiveness (STAR). STAR is a tool aimed at providing an accurate diagnosis of prolonged disordered consciousness and establishing any means of communication in the patient.

Overall, we rated the community end of life care service as requires improvement.

We rated safety and caring as good, effectiveness and responsiveness as requiring improvement and well-led as inadequate.

• There was not a strategy for community end of life care services. Staff were unsure of the trust wide direction for the future of the end of life services.
• The trust did not have a non-executive director who provided representation of end of life care at board level.
• There were no formal processes in place to gather feedback from patients or relatives.
• The individual plan of care for the dying person, which was a replacement for the Liverpool Care Pathway, was designed to be used for patients in hospital and community settings. However, this was found to be not used by the community teams.
• The trust did not monitor the number of end of life patients who were rapidly discharged from hospital to die. Following our inspection the trust held a ‘rapid home to die workshop’ in June 2016 to assess and identify difficulties with the capacity of the community based services and coordination of the services, including third sector providers, involved in delivering end of life care.
• For the period January 2015 to January 2016 there were 906 deaths, of which less than half 434, (48%) of patients died in their preferred place of care.
• The community specialist palliative care team (SPCT) did not have a local audit programme in place, which meant they were unable to measure the effectiveness and outcomes of the service.
• Advance care plans (a plan that documents patients’ views, preferences and wishes about their future care) were not always in place for patients receiving end of life care and those we found, had not been consistently completed.
• We did not see evidence of how the service planned and delivered care to people in vulnerable circumstances,
• The SPCT did not carry personal protective clothing. This meant that staff and patients could be at risk of infection.
• Nutritional risk assessments were not always found in place. This meant there was a risk that patients would not receive the appropriate nutritional support and advice.
• The community SPCT were below the trust target for completion of mandatory training in eight of the 10 training requirements, including safeguarding children level one and two training. This meant that staff were not keeping their skills up-to-date and the service could not be assured that staff had the necessary knowledge in these areas.

However we also found:

• Patients were very positive about the service they received.
• Staff were committed to providing compassionate end of life care.
• Medicines were appropriately prescribed, administered and checked thoroughly and there was guidance available for staff on prescribing and the use of anticipatory medicines at the end of life.
• Staff working across end of life care community services used the same syringe driver; this ensured continuity of care and reduced the risk of medicine errors.
• Patients had access to equipment or aids they required. Community staff were able to arrange delivery of the equipment for patients who were returning home for their end of life care, on the same or the following day.
• The community specialist palliative care team (SPCT) provided services seven days a week. There was an on call consultant in palliative medicine available to provide telephone advice, to patients and professionals in community and acute settings, across Coventry and Warwickshire 24-hours a day.
• Do not attempt cardiopulmonary resuscitation (DNACPR) forms, indicated staff had involved the patient, or (if appropriate) relatives, in the decision.