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Warwick Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 8 March 2018

Our overall rating of services stayed the same. We rated them as requires improvement because:

  • Risks to patients were not consistently monitored and completed. The hospital did not always complete patient risk assessments. Also fresh eye’ cardiotocography trace reviews, safer surgery checklists and swab counts were not always completed in line with national recommendations and trust policies.

  • Systems and processes did not ensure that medicines were stored, prescribed and administered correctly. However, the hospital took action to rectify issues during our inspection.
  • Patient’s information including electronic records was not always stored securely in all departments, increasing the risk of breaches of confidentiality.
  • The hospital did not always adhere to infection prevention and control practices, such as hand hygiene. Systems were not always effective to ensure that equipment was maintained appropriately.
  • The hospital did not always have enough staff in all departments, to meet the demands on the service and there was variable compliance with mandatory training. There was no specialist palliative care consultant based at the hospital, which did not meet national guidelines. However, a specialist consultant was being recruited to the post.

However:

  • Staff received training and appraisals of their development to support safe care and treatment. There was good culture of incident reporting and track record on safety. For example, no never events reported since 2016.
  • Patients’ feedback was positive about the care and services. Staff were proud to work at the hospital and this was demonstrated in consistently good performance in the NHS staff survey results.
  • Patients could access care and treatment at the hospital in a timely way. The emergency department performance was above the England average for the time taken for patients to be seen in the department and the percentage of patients waiting between four and 12 hours from the decision to admit until being admitted. However, data showed that the trusts performance was declining against these targets.
  • Patients care was planned and delivered in line with evidence-based guidance, standards and best practice. Individual patients’ requirements including, physical and mental health needs were met.
Inspection areas

Safe

Requires improvement

Updated 8 March 2018

Effective

Good

Updated 8 March 2018

Caring

Good

Updated 8 March 2018

Responsive

Good

Updated 8 March 2018

Well-led

Requires improvement

Updated 8 March 2018

Checks on specific services

Critical care

Good

Updated 28 March 2017

The service demonstrated a good track record on safety with low rates of infection and avoidable harm to patients.

Patient outcomes reported within ICNARC showed the service performed as expected, or better than expected for most outcomes when compared to other similar critical care services.

Staff understood and spoke positively about the safety reporting system in place, and felt that openness and transparency about safety was encouraged.

Staffing levels were compliant with Guidelines for the provision of intensive care services, 2015 ( (the core standards) with staffing levels and skill mix planned, implemented and reviewed to keep people safe at all times.

There were clear policies, procedures and training in place to enable staff to keep people safe and safeguarded from abuse.

The environment was clean and well organised, and we saw good compliance with infection prevention and control practices.

Risks to people who used the service were assessed, monitored and managed on a day-to day basis.

Care and treatment was delivered in accordance with best practice and recognised guidance and standards.

There was collaborative working amongst the multi-disciplinary team, and with other services and providers.

Staff had the right qualifications, skills, knowledge and experience to do their job and were supported through appraisal, supervision, training and revalidation.

Patients and those close to them spoke positively about their care and treatment, and felt supported and cared for by staff.

There were clear processes in place for people to raise concerns or complain; these were low in number and managed in a timely manner.

The nursing leadership team were knowledgeable about quality issues and priorities, and took action to address the challenges; there was alignment between the recorded risks and concerns raised by staff.

Staff satisfaction was high and staff felt engaged with the service leaders.

Outpatients and diagnostic imaging

Good

Updated 28 March 2017

Performance data showed a good track record in safety.

Clinical areas were generally clean and well-organised. Medical records were maintained accurately and securely, and there was an effective records tracking and location system.

Infection control procedures were followed and the service conducted regular audits.

There were robust systems in place to ensure that patients and staff were protected by adherence to national guidelines relating to ionising radiation and diagnostic imaging.

The service had a system in place to recognise and respond to changes in patient’s health.

There was evidence that patients were told when things went wrong and offered an apology.

There were systems in place to ensure the right patient received the correct diagnostic procedure.

Staff were recognising, resolving and discussing incidents but not always recording them in line with trust policy, this meant that learning from incidents was not always shared.

Not all staff had the appropriate level of training for safeguarding children.

Urgent and emergency services

Requires improvement

Updated 8 March 2018

Our rating of this service went down. We rated it as requires improvement because:

  • The service had suitable premises and equipment, however, equipment was not always looked after well. We found inconsistencies with equipment checks with gaps in the daily checking of the blood glucose monitor and resuscitation equipment. There were also gaps in the daily checks of equipment and stores in each cubicle.
  • The service did not appear to control infection risk well, although there was no evidence of this impacting patient care or causing harm. We saw varied compliance with the use of handwashing, hand sanitising, use of personal protective equipment and cleaning regimes.
  • There were periods of understaffing which were not always addressed quickly, resulting in frequent gaps in nursing staffing.
  • Systems to manage and share care records and access to patient identifiable information (on computers) were not always secure.
  • The service did not follow relevant national guidance around safe management of medicine prescriptions the storage of medicines. This was highlighted during inspection and subsequently the trust took steps to ensure that there were processes in place for the safe storage and recording of medicine prescription use.
  • It was unclear if nursing staff had the right skills, or knowledge to do their jobs as there was no formal nursing competencies to ensure that staff were trained to the same level and variable compliance with mandatory training.
  • There appeared to be limited participation in multidisciplinary working. Teams were not inclusive of doctors and nurses, although worked cohesively with staff from other departments or specialities. The team did not always work cohesively with gaps in team meetings and limited attendance at governance meetings.
  • There was inconsistent nurse management within the team, which impacted on staff morale. Leaders were not always aware of the issues and challenges in the service.
  • Some staff told us that they felt they were not listened to when they raised concerns about staffing levels or competence.
  • Doctors told us that there was poor communication between U&EC and speciality doctors.
  • The sustainable delivery of quality care was not always monitored, with confusion over responsibilities in ensuring daily tasks were completed.
  • When activity was high, patients remained in corridors whilst waiting for cubicles or beds to become available. This meant that they did not always have privacy.
  • Ambulances on site waiting time to handover the patient and return to their ambulance was on average 40 minutes, which was higher than the 30 minutes recommended by the Royal College of Emergency Medicine.
  • Patients and relatives were confused as to whom they were speaking to or being treated by as there was no consistency with uniforms.

However:

  • Patients care and treatment was planned in line with current evidence based guidelines, standards and best practice.
  • Information about peoples care and treatment and their outcomes were monitored and the information used to improve care. The service performed similar to or better than the national average in most national audits.
  • Consent to treatment was in line with legislation and guidance, including the Mental Health Act 2005. Patients were supported to make decisions.
  • Feedback from patients and their loved ones was positive about how they were treated. People were treated with dignity, respect and kindness, supported patients and their loved ones to manage their emotional needs, taking into consideration their personal, cultural and social needs.
  • Patients were reviewed by a consultant within 14 hours of admission, which was in line with recommendations.
  • Patients could access the right care at the right time. Patients were prioritised according to their clinical condition and care and treatment was coordinated with other providers.
  • The trust performed similar to or better than other trusts nationally in all national targets.
  • The service performance was above the England average for the time taken for patients to be seen in the department and the percentage of patients waiting between four and 12 hours from the decision to admit until being admitted. However, data showed that the trusts performance was declining against these targets.
  • Staff knew their responsibilities for escalating concerns and reporting incidents.
  • Although there was limited evidence that there was any shared learning.
  • Patient’s nutritional needs were met, with oral diet provided to patients who were in the department for long periods.
  • Patients were generally positive about the service and the care they received.
  • People could access the service when they needed it. Waiting times from treatment and arrangements to admit, treat and discharge patients were in line with good practice.

Maternity and gynaecology

Good

Updated 8 March 2018

We previously inspected maternity jointly with gynaecology so we cannot compare our new ratings directly with previous ratings.

We rated it as good because:

  • Women were overwhelmingly positive about their care and treatment. They were treated with kindness, compassion, dignity and respect. Women felt involved in their care and were given an informed choice of where to give birth. Actions were taken to improve service provision in response to complaints and feedback received.
  • Staff had real-time access to women’s electronic maternity records, and could make informed decisions on patient care, management and treatment. The service received national recognition for their implementation and use of electronic maternity records. We found records were stored securely and patient confidentiality was protected.
  • All staff understood their responsibilities to safeguard patients from abuse and neglect, and had appropriate training and support. The service worked well with other healthcare professionals and agencies to ensure the needs of vulnerable women were met.
  • Staff understood their responsibilities to raise concerns and report patient safety incidents. There was a robust governance and risk management framework in place to ensure incidents were investigated and reviewed in a timely way. Learning from incidents was shared with staff and changes were made to the delivery of care because of lessons learned.
  • Women’s care and treatment was planned and delivered in line with current evidence-based guidance. There was an effective system in place to ensure staff were aware of updated guidelines. National and local audits were carried out and actions were taken to improve care and treatment when needed. The service performed better than the national average for perinatal mortality rates and neonatal audit standards.
  • The service managed medicines and women’s pain well. They met the national standards for obstetric anaesthesia. Women were encouraged to self-administer medicines where appropriate, and were empowered and supported to manage their own health, care and wellbeing.
  • Managers appraised staff’s work performance and held supervision meetings with them to provide support and encourage improvement. The service received national recognition for its partnership model of midwifery supervision.
  • Service provision met the needs of local people. They worked closely with commissioners, clinical networks and service users to plan and improve the delivery of care and treatment for the local population.
  • Leadership was strong, supportive and visible. The leadership team understood the challenges to service provision and actions needed to address them. There was a positive culture, which was focused on improving patient outcomes and experience. Staff were committed and proud to work at the trust.
  • The service had a vision of what it wanted to achieve and clear objectives to ensure it was met. The vision and strategy was developed with involvement from staff and patients and reflected national recommendations for maternity care provision.

However:

  • We found ‘fresh eye’ cardiotocography trace reviews, safer surgery checklists and swab counts were not always completed in line with national recommendations and trust policies.
  • Midwifery specific training compliance was generally below the trust target, particularly for medical staff and blood transfusion training.
  • Midwifery staffing levels generally did not meet patient acuity levels within the service. The midwifery to birth ratio was worse than the trust threshold and national recommendations. Women did not always receive one-to-one care in established labour. We reported these concerns following our previous inspection in March 2016. We also found the labour ward coordinator was generally not supernumerary. The trust was taking action to address midwifery staffing levels.
  • There were inconsistencies in the monitoring of emergency equipment to ensure it was safe and effective for patient use.
  • Women who attended the maternity assessment suite were not always reviewed in a timely manner.

Medical care (including older people’s care)

Good

Updated 8 March 2018

Our rating of this service improved. We rated it as good because:

  • Staff knew their responsibilities for escalating concerns and reporting incidents. The service planned for emergencies and staff understood their roles if one should happen.
  • 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.
  • The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment. Bank and agency staff were used to fill gaps in rotas.
  • Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
  • Most complaints were responded to within the timeframe specified in the trust guidelines.
  • Staff involved patients and those close to them in decisions about their care and treatment.
  • Staff provided emotional support to patients to minimise their distress.

However:

  • Medical records were not always stored securely. Records were not locked away and could be accessed by members of the public.
  • Safety systems were in place but were not monitored. Leaders did not ensure effective action was taken to improve compliance.
  • Care rounds and risk assessments were not always formally documented in patient records.
  • The service did not always control infection risk well. Staff did not always keep themselves, equipment and the premises clean. Control measures to prevent the spread of infection were not always followed.
  • The average length of stay for all medical patients at Warwick Hospital was higher than the England average.
  • The trust strategy and the medicine service strategies were not well known by staff in the medical division. Progress against the strategies was not monitored.

Surgery

Good

Updated 28 March 2017

There was a culture of incident reporting and staff said they received feedback and learning from serious incidents. However, some staff did not always receive feedback on all clinical incidents. Staff were able to speak openly about issues and serious incidents.

The environment was visibly clean and generally staff followed the trust policy on infection control, although, we saw no evidence of domestic staff using cleaning checklists.

Medical staffing was appropriate and there were good emergency cover arrangements. Consultant-led, seven-day services had been developed and were embedded into the service.

Staffing levels were planned and reviewed to ensure that patients received safe care and treatment. Agency and bank staff were used and sometimes staff worked additional hours to cover shifts but this was well managed and patients’ needs were met at the time of the inspection.

Treatment and care were provided in accordance with evidence-based national guidelines. There was good practice, for example, assessments of patient needs, monitoring of nutrition and falls risk assessments. Multidisciplinary working was effective.

Patients outcomes were generally good but not all staff were aware of patients’ outcomes relating to national audits or performance measures.

Most staff had received annual appraisals and support systems for staff development were effective, however there were areas of poor compliance with mandatory training.

Staff had awareness of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) procedures to keep people safe.

The consent process commenced in outpatients, there were specific consent clinics and consent was reconfirmed at the time of admission.

Patients told us that staff treated them in a caring way, and they were kept informed and involved in the treatment received. We saw patients being treated with dignity and respect.

Patient care records were appropriately completed with sufficient detail and kept securely.

The service had an effective complaints system in place and learning was evident.

There was support for people with a learning disability and reasonable adjustments were made to the service. However information leaflets and consent forms were not available in other languages. An interpreting service was available and used.

Surgical services were well-led. Senior staff were visible on the wards and theatre areas and staff appreciated this support. There was generally a good awareness amongst staff of the trust’s values.

Services for children & young people

Good

Updated 28 March 2017

Children and young people were treated with dignity, respect and kindness. Feedback from parents and children were positive. Parents felt supported and told us staff cared about them and their children.

Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. We found evidence sharing learning and changing practice as a result of incidents.

Services were clean and staff adhered to infection control policies and protocols. Equipment was checked daily, cleaned and documented.

The service used a comprehensive prescription and medication administration record card which facilitated the safe administration of medicine.

Patient records we looked at were comprehensive.

Medical ward rounds and nursing handovers took place three times a day across the service and were well attended.

The risks associated with anticipated events and emergency situations were recognised, assessed and managed.

Staff received training on the duty of candour.

Staff understood their roles and responsibilities for safeguarding children. Although mandatory training was generally well attended, safeguarding children training at level three was not in accordance with the intercollegiate guidance 2014 document published by the Royal College of Paediatrics and Child Health (RCPCH), ‘safeguarding children and young people roles and competences for health care staff, 2014’. This meant there was a risk that staff may not have the level of competence to respond appropriately to safeguarding concerns.

Although nursing staffing levels did not always meet RCN and Toolkit for High Quality Neonatal Services 2009 recommendations; and the service did not comply with RCPCH standards for having 10 consultants to cover, we found mitigating actions were in place and there was no evidence of a negative impact on the care and treatment children and young children received.

Children and young people’s care and treatment was planned and delivered in line with current evidence-based guidance, standards, best practice and legislation. This was monitored to ensure consistency of practice.

Staff were proactively supported to acquire new skills and share best practice and staff were competent to carry out the care of children and young people.

Services were planned and delivered in a way that was meeting the needs of the local population. The individual needs of children and young people were generally met.

Waiting times, delays and cancellations were minimal and managed appropriately.

The service was part of the integrated paediatric strategy (2014-2019) that included both acute and community provision of services. The vision, values and strategy had been developed through a structured planning process with regular engagement from internal and external stakeholders, commissioners and others.

Staff in all areas knew and understood the vision and values. Staff felt well supported and felt they were well managed.

The arrangements for governance and performance management did not always operate effectively. Governance arrangements were fragmented with no one person responsible for children and young people’s services.

Not all risks we identified on the risk register.

It was unclear who had the overall oversight of care for neonates, children and young people. After the inspection the trust told us that the Head of Midwifery had oversight of the service in the hospital.

We found limited evidence of public engagement.

Mandatory training compliance levels did not always meet the trust target. This meant that there was a risk that staff did not have the necessary skills to carry out their role.

There was no recognised early warning score tool for babies on SCBU and no audit for the use of a local tracker and trigger system on Macgregor ward within the last 12 months. This meant that there was a risk that any deterioration of a child’s condition may not always be recognised. However, we saw no evidence of this in practice.

There were no formal pain tools used on SCBU.

End of life care

Good

Updated 8 March 2018

Our rating of this service improved. We rated it as good because:

  • There had been a focus on continuous improvement across the service since our last inspection. There was now improved governance in end of life care, with a clear structure of accountability and audits and outcome measures in place.
  • There was a new governance structure in place that was understood by staff. There was an end of life care steering group that had trust wide representation and received regular audits and updates from various ongoing work streams.
  • Appropriate measures were in place to keep patients safe from avoidable harm. Incidents and safety monitoring results were collated and shared to improve the service.
  • Risk assessments and care planning for patients at the end of life had improved since the last inspection.
  • Medicines were managed and prescribed appropriately and equipment was available to patients at the end of their life and equipment was well maintained.
  • There was good team working across the service. Local managers supported their staff in their roles, with chances for professional development offered. Staff received the right additional training and support to care for patients at the end of life.
  • Patients were provided with compassionate and person centred care, which took account of their individual differences and needs. Relatives and friends were involved in care planning wherever appropriate and recognised as part of the caring team.

However:

  • There was a variable approach on the wards to the criteria for making referrals to the specialist palliative care and end of life team. Not all patients referred to the team met the criteria for assessment by the specialist palliative care team.
  • There was no specialist palliative care consultant based at the hospital, which did not meet national guidelines. The trust was in the process of recruiting a specialist consultant to the post.