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Provider: South Warwickshire NHS Foundation Trust Requires improvement

A review of one or more of the ratings contained within the inspection report has been carried out at the request of the provider. Further to the review the ratings within this report have changed.

Reports


Inspection carried out on 15,16,17,18 and 29 March 2016

During a routine inspection

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.

.

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


CQC inspections of services

Service reports published 19 August 2016
Inspection carried out on 15 – 18 March 2016 During an inspection of End of life care Download report PDF | 316.45 KB (opens in a new tab)
Inspection carried out on 15 – 18 March 2016 During an inspection of Community health services for adults Download report PDF | 385.27 KB (opens in a new tab)
Inspection carried out on 15-18 March 2016 During an inspection of Community health services for children, young people and families Download report PDF | 377.41 KB (opens in a new tab)
Inspection carried out on 15 – 18 March 2016 During an inspection of Community health inpatient services Download report PDF | 298.38 KB (opens in a new tab)
See more service reports published 19 August 2016

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