Warwick Myton Hospice

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We reviewed 9 quality statements for safe, learning culture, safe systems, pathways and transitions, safeguarding, involving people to manage risk, safe and effective staffing, safe environments, infection prevention and control, and medicines optimisation.

The service managed patient safety incidents well. Staff recognised and reported incidents and near misses and reported them appropriately.

Staff kept detailed records of patients’ care and treatment. There were processes for staff to follow to ensure patients records were sent to the appropriate team at the end of their treatment.

Staff received training specific for their role on how to recognise and report abuse.

Staff completed risk assessments for each patient, when there was a change in risks they updated the assessments.

The service had enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment.

The design, maintenance and use of facilities, premises and equipment kept people safe.

Staff controlled infection risk well. They used equipment and control measures to protect patients, themselves, and others from infection. They kept equipment and the premises visibly clean.

The service used systems and processes to safely prescribe, administer, record and store medicines.

This service scored 78 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service managed patient safety incidents well. Staff recognised and reported incidents and near misses in line with policy. For example, they reported when a clinical incident occurred and when a clinical incident was narrowly avoided, this was to ensure learning could be shared to prevent a future occurrence.

Managers investigated incidents and shared lessons learned with the whole team and the wider service which included staff at the providers 2 other locations. Patient safety incidents were also shared with partnership agencies working in end-of-life care so learning could be shared as widely as possible. When things went wrong, staff apologised and gave patients honest information and suitable support.

Staff described a culture of continuous learning, and they were provided with a lot of different opportunities to develop their knowledge and skills. For example, attendance at national conferences, formal and informal learning sessions, and through participation in research. However, some nursing assistants said they would have liked to have developed their clinical skills further but there was not always a provision for this.

Staff attended multidisciplinary team meetings to ensure patients were receiving evidence-based care and also to develop their knowledge and understanding about end-of-life care, including to gain an understanding of different treatment options. Nursing assistants who would not typically attend multidisciplinary team meetings were encouraged to attend on a rota basis for their learning and development.

Staff attended end of life learning events, weekly check-ins, and formal meetings hosted by partnership agencies to share learning and best practice.

The mandatory training was comprehensive and met the needs of patients and staff. Compliance with training for substantive staff was typically above or just below the providers expected compliance level of 80%. Bank staff substantively employed by the NHS could complete the provider’s training and/or demonstrate they had completed equivalent training with their primary employer.

The clinical governance team were responsible for collating clinical incident reports and looking at themes, as well as investigating incidents or overseeing incident investigations, and ensuring learning from incidents was shared. A monthly clinical adverse event and governance report was presented at the clinical practise forum. The report contained information about all of the clinical incidents reported in the previous month including falls, pressure sores another tissue damage, and all medicines related incidents, so learning could be shared across the staff group.

A root cause analysis approach was used to investigate incidents so people could be given an explanation of an incident and an apology when things went wrong, and an action plan could be developed to improve processes, included any learning requirements.

The electronic system for reporting incidents had recently been changed. However, an audit of incidents reported since the new system had been installed showed it was fully embedded as staff continued to report the same type and volume of incidents.

The provider shared their serious clinical incident reports with local organisations working within end-of-life care. This was so learning could be shared with external providers to ensure it was shared as widely as possible.

People, their relatives and friends, could refer themselves to outpatient services, or the hospice at home service. Referrals to the inpatient unit needed to be completed by a health care professional. Some referrals could be completed online others could be made by telephone . For example, urgent referrals for end-of-life care could be made by telephone to reduce delays in admission.

Patients referred for palliative end of life care had two pathways, 1 for medical led beds and 1 for nurse led beds. Medical led beds meant doctors managed the complex palliative care needs of patients. Nurse led beds were suitable for patients in the last six weeks of life, where their specialist nursing needs could not be met in their usual place of care. Nurse led beds were managed by nurses who had qualified as non-medical prescribers (NMPs), this meant they could prescribe the drugs needed to manage patient’s symptoms including pain. NMPs were also involved in supporting other nurses and family members as patients approached the last days of their life. They also played a role in the education of other nurses within the service.

Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date, stored securely and easily available to all staff providing care.

Staff told us they relied on staff from other agencies to make appropriate referrals to them so people’s clinical priority for care could be assessed. Senior leaders told us there was a workplan underway looking at the referral process to see if a change to the process could improve the quality of referrals. For example, the work plan explored a review of the processes with internal teams and external referrers to ensure referrers provided all the information necessary for a decision to admit a patient based on the hospice criteria. The work plan included providing any updates to referring teams if changes were introduced.

A member of therapy team explained how they shared information about people as they transitioned from the service into the community following a period of respite. “If someone gets discharged into the community, we may go on a home visit and assess equipment for their home. If they live in Warwickshire, we may keep them on or we would contact community therapy and hand over to them. If they were discharged to a nursing home, there is a discharge note and we would comment on there. We can see the community notes and the GP notes and that has really changed things”.

Administrative staff had a process to follow when patients were discharged or died, this ensured paperwork was completed, and patient notes were passed to the correct teams.

The service had a clear admittance criteria for patients referred for palliative end of life care, symptom management, or respite care. Most of these referrals came from health professionals in the community or local hospitals. There were online referral forms, but telephone referrals could be made for people requiring an urgent admission.

There were daily internal meetings and regular meetings with external staff to discuss the waiting list, bed availability, and patients awaiting discharge. The internal bed meeting was used to discuss patients on the waiting list and allocate an admission date. The external meeting was used to give information about bed availability, receive new clinical and social information about patients on the waiting list, and to determine each patient’s clinical priority level and to discuss new patients added to the waiting list.

There was a process for staff to follow to ensure risks to patients were regularly monitored, including assessments for, falls, tissue viability, fluid balance, and infection. These processes were regularly audited and improvements were made as a result. For example, the tissue viability audit showed patients in decline (in the last days of their life) and independently mobile patients were not consistently having their skin viability assessed. An action plan was developed to ensure registered nurses completed a minimum of 1 daily skin viability check for all patients.

Key staff could access the local NHS trust electronic patient record systems to review people’s medical history to use as part of the triage process.

Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it. There was an active education plan for key staff to be trained to level 4 in safeguarding adults and safeguarding children so they could develop their confidence and competencies on both operational and strategic levels.

Staff understood their responsibility to report any concerns that could place people at risk of harm or abuse. Comments from staff included: "If I heard anything, if I saw anything, I would just go straight to my nurse in charge" and “It happened before, I went straight to the nurse in charge and documented it. It was more a family issue. We are not here to be referees so I handed it over to the nurse in charge and then it was handed over what the outcome was.”

Staff and volunteers were provided with training in safeguarding adults and safeguarding children commensurate with their role. However, compliance with safeguarding training was low for bank staff, with only 33% of bank nurses having completed this training. However, bank nurses and bank doctors worked substantively in NHS roles and could demonstrate they had received safeguarding training through their primary employer. A new process was being developed to record when training for bank staff had been completed elsewhere and to what level, so that this information could be added to the main training oversight tool.

The service had a safeguarding policy that reflected national guidance, and a safeguarding lead.

People and their relatives described regular and open conversations about risks around their health. We saw evidence of this in peoples care plans.

One relative described how their family member was at risk of falling due to a decline in their health. They told us staff had discussed placing a sensor mat by the person’s chair to alert them when the person tried to stand when their family were not there. The relative told us, “Because [name] has had a few falls, when I am leaving, I go and tell them, and the mats go down on the floor”.

One person told us they felt safe because, “There is always somebody around.” A relative told us, “I can go home and relax knowing he is in good care here. I feel like I had a weight pulling me down and that weight has gone into the air because I know [name] is safe here".

Staff told us they were informed about changes in patients risk profile during regular handovers and meetings, and risks continued to be monitored throughout the day.

Staff told us, they had an electronic patient record (EPR) system that contained information about patient care, including their care plans which were used to manage risk. Staff said if anything changed the EPR was updated to ensure all staff were aware of the change.

Risk management was reviewed as people’s health declined. Staff told us during the last days and hours of life an individualised plan of care was tailored to specific needs, focusing on minimising pain and discomfort, promoting comfort and maintaining dignity for the person.

Patients were involved in their care planning, this included assessing and managing risks. If patients were too poorly to make new decisions, or they lacked the mental capacity to do this, people with responsibility for making decisions, including staff, made best interest decisions on their behalf . A best interest decision is a decision made for someone who lacks the mental capacity to understand information or make decisions about their life. The best interest decision must be made in the person’s best interest and by people who are authorised to make a decision on behalf of the person. This could be doctors, carers, relatives, or other people who were important to the person.

People benefited from a warm and welcoming environment. People had their own bedroom space and access to various communal areas. This included quiet areas where people could spend time with their family members, a faith room and an area for children and younger visitors. All bedrooms had direct access to the communal gardens.

People had the equipment they needed to keep them safe, manage their pain and maintain their independence. One relative told us, “If they haven’t got it (a piece of equipment) I just say, and it will be there.”

Therapy staff told us they worked with people to ensure they had the right equipment to safely maximise their abilities and maintain their independence. They gave examples of how inpatients and outpatients had been able to gain independence through the provision of specialist equipment. For example, walking aids or toilet risers.

There was an estates department that oversaw the maintenance of the building and gardens. The estates department was responsible for the management of faulty equipment and oversaw service contracts and the assets register.

The design, maintenance, use of facilities, premises and equipment kept people safe. Equipment was clean and well maintained.

There were several quiet rooms that could be used by patients and their families. That was a family room equipped with a TV, games, and books so that patients, especially those with young relatives had somewhere to spend time with their family.

The portable electrical equipment we looked at had been safety tested.

Patients had call bells within easy reach. Call bells were answered straight away.

People and their relatives told us staff were available when they needed them. Comments included: “There are loads, there is no shortage of staff" and “As soon as that bell goes off, a few seconds they are in here straightaway.”

Staff were visible in all areas and did not appear to be rushed. Staff communicated well with each other to respond promptly to people's needs.

Staff told us they had formal monthly individual and group supervisions. Because they worked with patients who had individual responses to their illness and to their treatment staff said they sometimes felt the need to have extra learning from more senior staff so they could understand if a patient's treatment was being optimised or if there was something else they could do. They referred to this as “ad hoc” supervision as it took place whenever they requested it. A member of the therapy team said, “we also have learning de-brief meetings and bring a case study and discuss how we can bounce back from this if things don't always go perfectly”.

NMPs told us they had formal 6 monthly training and regular prescribing education. They also attended local and national meetings, had regular study days and received a minimum of a yearly supervisory session from the medical prescribers.

Volunteers told us they received an induction when they started, completed mandatory training modules, and received other ongoing training to support them to carry out their roles. Volunteers received regular supervision and had a clear understanding of how to get addition support if they required it. They said the volunteer coordinator was visible in the service and regularly checked in on them. They told us they had a clear understanding of their role and responsibilities within the service. One volunteer told us, “The induction covered what to expect and how to do our role. I think that is a good trick they have pulled off with the induction, because it means we have clear boundaries.”

The service sometimes used bank administrative staff. These staff told us they received a full induction into the service and supervision to enable them to understand and perform the tasks expected of them.

The service used safer staffing processes to ensure staff and volunteers were safe to work with vulnerable adults. There was a process to check nurses and other health and care professionals maintained their registration with their professional bodies.

Consultant doctors employed substantively by the provider were on site from 8.30am to 4.30pm Monday to Friday. At all other times there were 2 on-call doctors. At the weekend the on-call doctors visited the inpatient unit so they could review each patient’s care. Senior nurses also provided on call support 24 hours a day 365 days a year.

Bank staff were used to cover sickness or when 1:1 care was needed for people. Bank staff received a formal induction and completed mandatory training. If they could demonstrate they had already completed mandatory training modules with their substantive NHS employer, they did not need to complete this again.

The provider used a tool to calculate safe minimum staffing levels for each shift for the number of open beds available. During the early shift there was a minimum of two registered nurses and two nursing assistants. On the late shift there was a minimum of two registered nurses and two nursing assistants and on the night shift two registered nurses and two nursing assistants.

Staff were offered an annual appraisal, 82% of staff due an appraisal before the end of October 2024 had received one, this was against a target of 85%. The provider had recently introduced a system to improve monitoring of appraisals to increase compliance.

There was an in-house education and training team. The team provided basic and enhanced training for internal staff, as well as training for staff in nursing homes and other community-based workers. For example, they offered training in advance care planning, basic life support, essentials of end-of-life care, and a palliative and end of life care workshop.

People benefited from being cared for in a clean environment where good infection control practices were followed. For example, staff wore personal protective equipment (PPE) when required to protect people and themselves from cross infection. People and their relatives did not raise any concerns in relation to this quality statement.

A member of the housekeeping team demonstrated a good understanding of national guidance relating to the correct cleaning equipment to be used in different areas of the hospice. They described a system to ensure information was shared about any infections so they could follow the provider’s policies and procedures to minimise the risks of the infection spreading.

The inpatient unit was visibly clean and had suitable furnishings which were clean and well-maintained.

There were supplies of PPE outside patient rooms, so staff had easy access to protective equipment required prior to entering the room. There were handwashing sinks in each room with antibacterial handwash and hand gel. We saw staff correctly donning and doffing PPE and we observed staff washing their hands regularly using the appropriate handwashing technique. The storage areas were clean and tidy. Stock was stored neatly so it could be checked and did not hamper cleaning.

The provider had a process for staff to follow if a patient had a communicable disease to help keep people safe.

Infection prevention and control (IPC) audits were routine, and immediate action was taken if IPC fell below expected standards.

An external agency completed an audit of the environment in April 2024. The audit demonstrated 98.5% compliance with the NHS National IPC manual. Actions required to bring compliance to 100% or completed by July 2024. Hand hygiene audits for September and October showed 100% compliance with 17 hand hygiene standards. The audit for November 2024 showed 94% compliance. This was because paper towels had not been restocked in the sluice room. This problem was resolved at the time of the audit.

People and their relatives told us staff were very careful to ensure people were on the right medicines and dosages to keep them pain free and control their symptoms. One person on respite care told us, “They have been keeping on top of the symptoms I have been having, the pain relief and just delivering really brilliant care for me. I have had so many medicine changes, but they are really good at explaining everything”. One relative told us staff were very responsive if they reported an increase in their family member’s experience of pain.

Staff used appropriate tools to support patients with difficulty communicating expressing their pain levels. This included tools for patients with dementia and people whose first language was not English.

Staff, including the complementary therapy team, told us they worked collaboratively to ensure patient’s pain was under control.

Nursing staff were involved in collating data to demonstrate if patients had received their medication on time, including pain relief. They said the results of these audits were discussed at the monthly clinical practice forum so themes and trends in medicines errors could be identified and learning could be shared.

Staff had introduced a lymphoedema prescribing audit to check prescribing by non-medical prescribers was in line with the service non-medical prescribing policy and the Nursing and Midwifery Council (NMC) standards for nurse compliance. The audit measured nurse competence, to see if the non medical prescribers were prescribing safely, prescribing professionally, improving their prescribing practice, and were prescribing as part of a team. The audit which was conducted in April and May 2024 showed 100% compliance with policy and NMC standards.

Staff completed an antimicrobial audit to ensure antibiotics, antifungals, antiprotozoals, and antivirals were being optimised for individual patients, not overused or misused, and not leading to the development of resistance at individual or community level. The audit for 2023 demonstrated since the previous audit there had been a reduced number of drug charts that documented the reason the antimicrobial had been commenced but improvements in relation to other documentation relating to prescribing. There was an action plan to improve documentation which included the medical team reviewing the principles of antimicrobial stewardship and safe prescribing.

Medicines were administered stored and disposed of securely with access only to authorised clinical staff. Accurate records were kept of medicines prescribed for and given to people. These showed how people were supported to take their medicines and at the times they needed these. Staff completed medicines records accurately and kept them up-to-date.

We observed staff in the hospice at home team using the medicines chart from the GP which showed what medications could be administered to the patient, in what dose and timeframe. The staff member completed the medicines chart with information to say what medicines they had given the patient.

Syringe drivers which were used to administer medicines had been checked to make sure they were in good order to use which included checking the date of the next service. We saw medicines prepared in a syringe driver for patients on the inpatient unit had been checked and records signed by two nurses to show the correct amount of medicine were given.

There was a process to check the stock levels of controlled drugs each day. A further stock check was carried out 3 times a week by a pharmacist. There was a process for the safe and appropriate disposal of controlled drugs and other medicines when they were no longer required.

Medicines charts were clearly written. There was a process for medicines charts to be checked, and signed, by the visiting pharmacist. Staff completed an incident report if medicines were not given as prescribed. Medicines errors were audited and reported on monthly at the clinical practice forum. Data for July 2024 showed that across both inpatient sites (Coventry and Warwick) there had been 6 medicines related incidents, 4 of which related to a controlled drug, (this represented 0.16% of all controlled drugs administered). In August there were 8 incidents, 7 were incidents relating to a controlled drug (0.29% of all controlled drugs administered). Finding from the audit showed there had been an increase in missed doses of medication. Further investigation showed nurses had not consistently followed the process for signing off administration of controlled drugs. Subsequently a request had been made to the clinical practice educators to provide further training to staff to improve compliance with policy. In September 2024 there were 8 prescribing errors 5 of which were related to a controlled drug (0.20% of all controlled drugs administered) but not related to missed medication.

An annual report was presented to the clinical governance committee by the controlled drug accountable officer. The report outlined themes of incidents and any other concerns that had occurred in the previous 12 months and action that was required to reduce incidents, including learning to be shared.