Warwick Hospital

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

At our last inspection we rated this key question good. At this inspection the rating has remained good.

We looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

We rated effective as good. We assessed four quality statements. Staff assessed people holistically, so the care and treatment provided met their needs. This included both their mental and physical health and any personal circumstances that needed to be considered. Staff worked in a culture of evidence-based practice. The service told people about their rights around consent and respected these when delivering person-centred care and treatment. There were areas of good practice where staff, teams and services worked together with mental health services and with clinicians involved in the care of high intensity users. However, care and treatment was not always planned with people. Audit processes were not always completed or acted on.

We have not awarded this service a score for Effective.

Find out about when we will not publish a key question score and what we look at when we assess Effective.

We did not look at Assessing needs during this assessment. The score for this quality statement is based on the previous rating for Effective.

Care and treatment reflected current evidence-based guidance, standards, best practice and technologies, and staff used tools available to deliver evidence-based care. However, some audits were planned, but outcomes were not always actioned or carried out regularly to ensure patients received care that was evidence-based.

There was a comprehensive range of policies and standard operating procedures which reflected current guidance and evidence-based practice that staff knew how to access. Most were up to date. The trust monitored the guidance database and had systems to update them. Guidance updates were a standing agenda item in the monthly divisional meeting, and we saw they were reviewed.

We reviewed clinical guidance and found 2 of 3 were in date, however the diabetic ketoacidosis (DKA) was due to be reviewed in 2021 and had not been.

Staff could access microbiology guidance and had access to a microbiologist either in the hospital or at a local partner NHS trust. Staff were confident in identifying guidance or support from senior clinicians.

Triage questions were appropriate for patients and their needs for example, people presenting with emotional needs were properly and sensitively assessed in adults.

Focus groups were used to inform evidence-based care and treatment for children with learning disabilities and autistic spectrum disorder, to shed light on the kinds of reasonable adjustments that might follow a young person's path from ED.

There was a programme of audit and quality improvement (QI) for staff to follow to provide assurance that care and treatment was delivered in line with evidence and best practice. 8 audits were progressing, and 4 awaiting proposals but planned for the coming year.

Improvements were needed to provide appropriate assessment and treatment for patients with a mental health need in the department. We reviewed performance in the Royal College of Emergency Medicine (RCEM) mental health audit, however the trust did not provide dates the audit took place, so it was unclear whether the data provided showed recent compliance. There were 12 indicators, and the trust was performing better than national figures in 5 areas including overall mental health triage time. However, lower compliance than national figures was reported in the most recent year in 5 out of 12 indicators, with lowest compliance in adequate psychiatric and social history (38%) and documentation of drug or alcohol concerns (38%).

We reviewed the audit of performance in the RCEM standards for older people and found across the 3 standards (screening, action taken and safety rounds completed) performance had declined when comparing 2022-23 to 2023-2024 and was worse than the national figures in most indicators. Falls risk assessment completion and delirium management plan initiated were above national figures but had declined in the service.

The service last collected data to audit sepsis in September to December 2022, with findings shared in August 2024 which showed improvements and good practice in patient observations, lactate measurements and that most patients had the key investigations in ED. However, improvements needed in documentation, acting within 1 hour and the management of neutropenic sepsis. Recommendations were made included re-auditing with more recent cases. We did see evidence further or regular audits were completed to provide assurance that practice around sepsis had improved.

The department did not audit VTE assessments but planned to do so moving forward. VTE assessment is not mandatory until a patient has been admitted, however some patients waited in the department for a long time so they may require VTE assessment, and it was unclear how leaders were assured these assessments took place when the patient was not admitted but required prophylaxis.

Mortality was an agenda item and discussed as part of the monthly divisional meeting. All deaths in the emergency department are reviewed by the mortality lead. The last 3 minutes (November and December 2024 and February 2025) showed mortality was only discussed in December 2024. Learning was not shared routinely, or good practice identified in relation to the 3 cases discussed, and there was limited details in the meeting minutes to evidence how in depth the cases were reviewed.

Outcomes of mortality reviews were presented at the Emergency Medical Directorate meeting held monthly. There were brief details only for mortality reviews recorded for the Emergency Medical Directorate Meeting in December 2024 and mortality not discussed at all in November 2024 and February 2025 and noted mortality would be discussed at the following Month. The trust told us following the assessment that deaths were reviewed with the new RCEM guidance (February 2025) from May 2025.

The service worked well across teams to support people. Relationships were challenged because a high proportion of out of area patients attended. Whilst specialty staff reviewed patients following referral, their requirement for CT scanning delayed specialist care and slowed admission to a ward area. Professional standards were not based on values and behaviours, and relationships were challenged with some hospital specialities. Some staff were able to regularly engage with staff, teams and other services, relationships with paediatrics and specialist nurses were embedded and we saw staff made efforts to work well together.

Staff told us patients presenting from out of area was a challenge for the department, preferring to visit Warwick instead of their local ED as they believed they would be seen quicker, and other hospitals diverting patients at ED reception due to long waiting times. We heard treating out of area patients put pressure on patient flow as discharge to community services was more difficult on a cross-area, cross-organisational basis.

Internal professional standards were implemented for all specialities, which met NHS England best practice guidance. All specialty referrals to the hospital were routed through ED, and patients waited for admission, even if emergency treatment was not required.

We reviewed the internal standards for surgical patients in the ED, which outlined key responsibilities for ED clinicians and clinicians from surgical specialities and the standards that should be achieved before a patient was transferred to a ward.

Staff told us there was friction with some specialties regarding patient referrals, particularly for scans.We heard surgical specialities would not come to the department to review patients without a CT scan, whether this was clinically indicated or not. There were processes to mitigate inappropriate referrals and between 1 November 2024 and 26 June 2025, 235 CT scans were rejected, with 48% of scans rejected and an “alternative investigation arranged”. We observed challenges in surgical referrals, for example where the difficulty in referring meant a patient had to wait overnight to be seen by the surgical team. The hospital were hiring a Band 4 youth worker to be based in ED to support and signpost children and young people presenting with mental health conditions to improve work between services.

There was a medical and surgical same day emergency care (SDEC), an early pregnancy assessment unit (EPAU) and frailty service. Referral to medical SDEC reduced the pressure from majors, however the surgical SDEC was more difficult to access because medical staff were not easy to contact.

The was a 7-day consultant led frailty service who proactively reviewed patients in the ED, offering advice and support to support discharge back into the community.

Ambulance staff described the ED team to be very good to work with. Staff worked well together to minimise handover delays to ensure patients were seen in an appropriate environment for their needs.

Leaders from the division attended a mental health partnership meeting with representatives from across the division and the mental health trust. We saw evidence the service worked with partner organisations to develop bespoke mental health risk assessments for adults and children, planned training roll out and support and service spending were all discussed, and actions monitored.

The trust hosted a high intensity user meeting with attendees from the wider trust, mental health trust and ambulance trust every second month. We saw evidence patients’ attendances were regularly reviewed and plans for their ongoing assessment and treatment were reviewed holistically.

Flow processes for young people aged 16-18 with learning disabilities and neurodiversity had recently been agreed, and there were discussions between the relevant paediatric and adult nurse specialists around bringing in a transitions service for people moving into adult learning disability services.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

The service monitored people’s care and treatment.

There were clinical governance systems to monitor and improve outcomes for patients and make improvements from audits and reviews, but they did not always function well.

Clinical excellence and audit were discussed as part of the monthly emergency medicine directorate meeting. Audit and SOPs, guidelines and pathways were a standard agenda item, and we saw that they were discussed most months. Changes were identified and actions allocated.

However, we did not see a structured approach to auditing and quality improvement to address issues and themes identified in the department. For example, we found some audits were not completed in line with trust guidance to provide assurance that patients were cared for safely.

Medical staff told us they were allocated an audit with a consultant supervisor to complete quality improvement projects (QIP). One told us about their QIP, and they could present findings and outcomes at a 6 monthly departmental audit meeting, however not all junior doctors were able to attend to share learning or practice.

The service took part in research, and there were 4 active research projects in the ED at the time of the assessment. We saw 2 were discussed in recent governance meetings.

The ECDS is a national data set used in England to collect information about urgent and emergency care. We reviewed the data between 21 April 2024 and 30 March 2025, which showed 31 out of 33 areas met the standard and compliance in the remaining areas was on an improving trend.

Performance data for waiting times for initial assessment, 4-hour waits and admission were monitored. The service did not meet the national target, but waiting times had improved. There was an action plan to address longer waits to improve outcomes for patients.

Patients generally told us they had been given pain relief when they asked for it.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment. Where consent could not be gained, for example in an emergency, staff promptly informed patients of the care they had received when they were able to do so. Staff understood and applied legislation relating to consent. Capacity and consent were clearly recorded. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation. However, audit processes to provide oversight and assurance were not always completed or acted on.

Staff understood their responsibilities in gaining consent. Practice was in line with national guidance and good practice.

Paediatric staff working with children and young people had a good knowledge of consent and we observed good practice.

We reviewed patient records and DNACPR (do not attempt cardiopulmonary resuscitation) decisions and they were made in line with legislation.

There was a trust wide policy for Restrictive Intervention and Restraint in adults which clearly outlined roles and responsibilities for staff when restrictive intervention or restraint was being considered, and outlined that level 3 conflict resolution training was available for staff in high-risk areas, including the ED.

The most recent consent and capacity audit was conducted in 2020 and only related to the capacity of patients and the Mental Capacity Act (MCA). It found a lack of understanding of the statutory principles underpinning the need to observe and record the MCA, and poor recording of specific documentation relating to MCA, although overall recording was found to be excellent. There was no evidence the outcome of this audit had been addressed.

We were not assured the provider made sure that staff who obtain the consent of people who use the service were familiar with the principles and codes of conduct associated with the MCA, and were able to apply those when appropriate, for any of the people they are caring for, because they did not provide training figures for MCA training or evidence that training had been provided to staff following the audit in 2020.