All inspections: Warwick Hospital - Care Quality Commission

Pages 1 and 2 of this report relate to the hospital and the ratings of that location, from page 3 the ratings and information relate to maternity services based at Warwick Hospital.

We inspected the maternity service at Warwick Hospital as part of our national maternity inspection programme. The programme aims to give an up-to-date view of hospital maternity care across the country and help us understand what is working well to support learning and improvement at a local and national level.

We will publish a report of our overall findings when we have completed the national inspection programme.

We carried out an announced focused inspection of the maternity service, looking only at the safe and well-led key questions.

We did not review the rating of the location therefore our rating of this hospital stayed the same

Warwick Hospital is rated Good and South Warwickshire University NHS Trust is rated Outstanding .

How we carried out the inspection

During our inspection of maternity services at Warwick Hospital we spoke with 30 staff including leaders, obstetricians, midwives, and maternity support workers.

We visited all areas of the unit including the antenatal clinic, maternity triage, labour ward, birth centre, day assessment and postnatal ward We reviewed the environment, maternity policies while on site as well as reviewing 10 maternity records. Following the inspection, we reviewed data we had requested from the service to inform our judgements.

We ran a poster campaign during our inspection to encourage pregnant women and mothers who had used the service to give us feedback regarding care. We did not receive any feedback from the poster campaign. However, the trust shared with us some feedback they had received from their internal surveys completed recently. These reflected a kind and caring workforce who supported people during their stay in the maternity unit.

The trust provided maternity services at hospital and local community services and approximately 3,000 babies were born in the trust during 2022.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

We inspected two core services: urgent and emergency care and medical care. We rated both as outstanding overall.
Caring for medical care was rated as outstanding.
Responsive for urgent and emergency care was rated as outstanding.
Well led was rated as outstanding for both core services.
The hospital had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
Staff provided great care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
Staff treated patients with great compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers delivering care and support in a holistic, person centred way.
The hospital planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
Experienced and strong leaders at the hospital ran services well using reliable information systems and supported staff to develop their skills. Staff fully understood the service’s vision and values, and how to apply them in their work. All staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were very clear about their roles and accountabilities.

However,

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.

South Warwickshire Foundation NHS Trust provides a range of hospital care services 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 to its local population.

There are 441 inpatient beds within Warwick Hospital.

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

The trust obtained foundation trust status in 2010.

We inspected this hospital as part of our programme of comprehensive inspections of acute trusts.

We held focus groups with a range of staff in the hospital, 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.

The inspection team inspected the following eight core services at Warwick Hospital

• Urgent and emergency services

• Medical care (including older people’s care)

• Surgery

• Critical care

• Maternity and gynaecology

• Services for children’s and young people

• End of life care

• Outpatients and diagnostic imaging

Overall, we rated Warwick Hospital as requires improvement with three of the five questions we ask. Safe, effective and well led were judged as requiring improvement.

We have judged the hospital 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 was rated as outstanding for responsiveness.

Safety

Nurse staffing levels and skill mix were 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, not all staff had a thorough understanding of this and what this meant within their practice.

The trust had reported one never event (wholly preventable incidents, where guidance or safety recommendations that provide strong systemic protective barriers are available at a national level, and should have been implemented by all healthcare providers) 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 from 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 trust’s 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 national guidance. 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), 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 department 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.
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 patients’ 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 from 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 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. In addition there were not robust procedures in place to ensure that policies were reviewed in a timely way and reflected national guidance.
The executive team was stable and well established and was 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 a lack of oversight of the care for neonates, children and young people across the whole trust.
The directors identified to provide representation for end of life care services at board level, did not attended of life care meetings and the trust did not have a non-executive director who provided representation of end of life care at board level.
There was an extremely positive culture within the trust and staff felt respected and valued. The result sf the 2015 staff survey reflected this positive culture with the trust ranked in the top 20% of all trusts nationally.
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:

The use of reminiscence therapy within the emergency department (ED) for patients with a learning disability, 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 national guidance.
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.

In addition the trust should:

Ensure that staff in the outpatients department record all incidents.
Review staff have a clear understanding of the Duty of Candour.
Ensure that defined cleaning schedules and standards are in place to comply with the Department of Health 2014 document ‘Specification for the planning application, measurement and review cleanliness services in hospitals’.
Ensure that infection control and prevention policies are embedded into practice, particularly on the medical wards.
Ensure medicine fridge temperatures are recorded accurately and any deviation from temperature controls acted upon.
Ensure all medicines are stored safely in locked cupboards.
Ensure that facilities in the emergency department are suitable for caring for patients with mental health needs.
Ensure that all mandatory training is completed in line with the trust target.
Ensure that all staff have completed the relevant safeguarding adult training to ensure staff are aware of their roles and responsibilities in the identification of safeguarding needs and how to escalate concerns.
Establish formal cover arrangements for acute palliative care consultant post when they were on leave.
Continue to implement and monitor use of the swipe card access of the corridor and clean utility room in critical care to ensure safe storage of medicines, records and equipment on critical care.
Investigate and share learning from the controlled drugs incident on critical care and ensure any corrective actions are completed.
Ensure that all staff working in critical care receive training and guidance regarding their responsibilities outlined in the major incident plan.
Ensure that staffing levels meet patient demand, enable adequate care of children by a qualified paediatric nurse and allow monitoring of all patients within the department at all times of day.
Ensure that patient records are stored securely and completed in line with legislation.
Review the high number of caesarean sections developing an action plan to reduce these.
Ensure that there is an early warning score tool for babies on SCBU to ensure that any deterioration of a patient’s condition is recognised.
Ensure all trust policies are up to date and relevant.
Ensure there are appropriate polices and operating procedures to support processes within the emergency department.
Monitor pain scores in a consistent manner in the emergency department and ensure that there are formal pain tools used across SCBU and Macgregor ward.
Ensure that advance care plans (a plan that documents patients’ views, preferences and wishes about their future care) are in place for patients receiving end of life care.
Ensure the annual audit plan for maternity is formally approved, that recommendations address the issues identified and action plans for improvement are developed.
Develop, approve and implement an annual audit plan for gynaecology.
Ensure that outcomes for gynaecology patients are clearly presented and reviewed.
Ensure that nurses on the gynaecology ward receive training relevant to the specialism and acuity of patients admitted to the Beaumont ward.
Ensure privacy of in patients attending radiology department is maintained.
Ensure that the use of the individual plan for the dying person is embedded.
Audit the effectiveness of the end of life care service, including collecting information on the number of patients who have been discharged to their preferred place of care, collecting information on those patients who died in their preferred place of death and audit the effectiveness of the rapid discharge process.
Ensure arrangements are in place to monitor how quickly women attending midwifery assessment unit are seen and treated.
Ensure specialist palliative care team referral guidelines are place, and circulated to all wards and departments.
Reduce the delays for patients being discharged from critical care to the wards.
Ensure that leaflets and interpreters are available and used for non- English speaking patients.
Ensure that all complaints are reported to ensure themes are identified and lessons learnt cascaded to staff.
Ensure that there is clear leadership and overall oversight of care for neonates, children and young people.
Ensure that the arrangements for governance and performance management operate effectively in the services for children and young people.
Ensure that all risks are identified on the risk register and appropriate mitigating actions taken.
Ensure there is a clear process for the documentation and review of risks within the gynaecology service.
Ensure that each service has a local vision and strategy which is disseminated and understood by all staff so that it is embedded within the service.

Professor Sir Mike Richards

Chief Inspector of Hospitals

We focused our inspection on the Maternity Unit within the South Warwickshire NHS Foundation Trust Hospital. We visited the antenatal clinic and antenatal assessment unit (AAU), the delivery ward, and the combined antenatal and postnatal ward called Swan Ward. We did not inspect the Special Care Baby Unit at this time.

We spoke with eight women in the antenatal clinic, five women on the postnatal ward and two relatives. We also spoke with two doctors, the Head of Midwifery, the clinical governance midwife, the practice development midwife, the manager of the Electro-Bio Medical Engineering (EBME) department, six midwives, three support workers and a receptionist.

We found that people were involved in their care and encouraged to express their wishes and were treated with respect. One woman we spoke with told us, 'I have had a lot of opportunity to ask about my surgery. Everything has been explained to me. I know exactly what is going to happen.' Another told us, 'I could ask any questions I wanted, I never feel rushed when I come here, even though it is sometimes very busy.'

People commented positively on the care they received and we found that care and treatment plans were completed appropriately. Comments included, 'You couldn't ask for a more caring hospital. They have arranged parking for me this week as I have to come in daily.' Another person told us, 'All the nurses are brilliant. It has been a wonderful experience. Everything had been explained to me beforehand as I was booked for surgery, so I knew what to expect.' We found evidence of good information and support provided to women throughout their pregnancy, delivery and postnatal period.

We found that there was enough suitable equipment available and there were good systems in place to ensure regular monitoring and maintenance of equipment.

There were sufficient numbers of staff employed with the appropriate skills and qualifications to perform their roles. We found that staff had received ongoing training necessary to enable them to carry out their role effectively.

We found that staff received regular supervision and training with opportunities to develop their career. There were systems in place to ensure that mandatory training and other essential training took place. One staff member told us, 'We get good management support here. Management have a visible presence.'

The inspection team included an 'expert by experience' ' a person who has experience of using services (either first hand or as a carer) and who can provide the patient

perspective. We visited a number of wards and departments including the children's ward, the 23 hour ward, accident and emergency departments, the discharge lounge and pharmacy.

During the two days we were at Warwick hospital we spoke with patients and received many positive comments about the care and treatment provided by the hospital. One patient said, 'I cannot complain about the care on this ward. Staff have been very helpful.' Another patient said, 'Everyone comes in and makes you feel good and comfortable; the staff nurse was lovely.' A relative told us, 'I have been kept informed and involved with my husband's care and treatment all the time.'

Patients and relatives told us that their consent had been sought prior to any treatment being given to them. Some patients told us however that information about their treatment was not always given to them as quickly as they would have liked.

Patients and relatives spoken with thought that the hospital was kept clean. We were told, "The cleaning is very good I have no concerns" and 'The ward is very clean, it is done every afternoon.'

Patients said that they felt safe and there were usually enough staff on the wards.

Patients and relatives told us they would report any concerns they might have about their care to hospital staff.

We found that the trust was taking any complaints they received about the hospital seriously and took prompt action to improve the service when things went wrong.

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

Patients we spoke to were mostly very positive about their experiences of care and treatment. They told us they were kept informed about their condition and involved in making decisions about their treatment. Most patients said their care needs had been met satisfactorily and they had been treated with respect by hospital staff. One person said, 'Everyone has been very open and honest with me', when asked if they were given sufficient information about their care and treatment.

Patients and relatives we spoke to on both wards told us mealtimes were quiet and in general they were happy with the meals provided. They told us meals were hot when served to them and staff ensured they had sufficient to drink. Comments included;

'The drinks are nice, the way I like them'.

Some patients we spoke with however felt hot food could be warmer and not every patient we spoke with had been told that snacks were available if they did not want to eat a hot meal.

Warwick Hospital

All Inspections

18 April 2023

During an inspection looking at part of the service

20 August to 25 September 2019

During a routine inspection

5 Dec 2017 to 5 Jan 2018

During a routine inspection

15,16,17,18 and 29 March 2016

During a routine inspection

Professor Sir Mike Richards

26 February 2014

During a routine inspection

7 August 2012

During a routine inspection

20 March 2012

During a themed inspection looking at Termination of Pregnancy Services

31 March 2011 and 20 September 2012

During a themed inspection looking at Dignity and Nutrition