Warwick Hospital

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

At our last inspection we rated this key question outstanding. At this inspection the rating has changed to Good.

We looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

We rated well-led as Good. We assessed six quality statements on leadership and governance. Leaders did not always demonstrate the skills and knowledge, experience and credibility to lead well. They demonstrated their integrity and honesty which was recognised by their staff. Governance systems were not always effective, and audits were not always in place to provide assurances or identify areas for improvement.

We have not awarded this service a score for Well-led.

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

The service had a shared vision, strategy and culture. This was based on transparency, engagement, and understanding challenges and the needs of people and their communities.

Staff understood the strategy, which was kept under review. The service was aware of the projected increase in the local population and was working with the ICS and other partners to develop a strategy to manage these demands.

The emergency department (ED) had a strategy for 2024-2028. There were 4 key aims to help the service to achieve being "the best Emergency Department for patient care, experience and staff"; a blended workforce with training and development for all levels and groups, minimise the time patients spend in ED, ensure patients are well informed of their journey in ED and have great patient experience.

The strategy had key deliverables identified in a timeline across 2024, 2025 and 2026-2028. During the assessment, staff could describe the key aims and how the service planned to achieve them, and leaders had a key focus on the infrastructure investment to achieve the aims in the department. It was early in the strategy to comment on progress at the time of the assessment, however it was aligned with staff views we heard, suggesting a shared direction in the service.

Service leaders were aware of the increase in demand on their service from other hospitals in the area and were working proactively with partners and the integrated care board to address system challenges, including continuing to achieve positive ambulance handovers and to support the wider system by taking patients being transported by ambulance which were due to be taken to other pressured emergency departments.

Leaders did not always display the skills, knowledge and experience to lead effectively. There was a mixed culture, and the leadership was not visible to all staff groups. The leadership team worked across the division, and we did not always see how they managed the ED as an individual area. However, staff felt supported and guided by their leadership team. The leaders were available when they were needed and led by example.

Leaders had oversight of the risks and issues in the ED, however we saw limited appropriate actions taken to manage them. We heard about a funding bid which would provide resources to address some of the key challenges, including the location of the CT scanner and the configuration of the department, but we did not see or hear about other appropriate steps, or what action would be taken if the funding bid was not successful.

Staff told us the leadership team was approachable, but most staff felt that concerns were not acted upon.

However, resident doctors we spoke with were not all aware of senior leaders and could not recall senior management visiting the department. They did describe senior doctors as very approachable and explained they have good oversight of patients in the department and would help resident doctors in times of increased demand.

The trust offered an internationally licenced clinical leadership course delivered to leaders and managers with the aim to take away a practical evidence-based skills toolkit to use immediately in practice, building on their resilience and talent management skills. Course dates for 2025 were full and the trust were enrolling into 2026. The trust also offered a recognised NHS leadership programme for first line leaders. It was unclear if ED staff had enrolled or completed the programmes, but it was available to those in leaderships role to support development of the skills needed to be a capable, compassionate and inclusive leader.

Assessment findings: Whilst staff were aware about Freedom to Speak Up, they did not articulate how to contact the guardian or how they could be supported. The service leaders did not always act on concerns raised by staff, and professional standards were not based on values and behaviours.

Staff felt comfortable to raise concerns with their immediate line manager and senior leaders in the department. They were aware of Freedom to Speak Up processes, however during the assessment we did not see any information available in the department to support staff in speaking up.

Staff told us there were issues in relationships between specialities and the ED and we did not hear that leaders were proactively addressing them. Professional standards we reviewed were not based on values and behavioursProfessional standards in health and social careoutline the expected skills, knowledge, and behaviours of professionals to ensure safe, effective, and ethical practice. Staff we spoke with told us they felt this was not being addressed well which meant there was a risk that this would affect the culture within the department.

A number of staff we spoke with told us that they had concerns about competencies for adult nursing and medical staff treating children. However, when they raised these concerns with senior leaders in the division, they felt that these concerns were not being listened to or addressed, and it was causing additional strain on staff working in the paediatric emergency department.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Governance structures did always not support the delivery of high-quality care. Information and data were not always available at department level to support decision making or for the oversight of performance. There were limited audits conducted so leaders were unable to effectively identify areas for improvement.

Governance structures were not always effective in the ED. Leaders described governance structures they had to feed information up to the board and down to department level, but staff we spoke with could not articulate how they were kept up to date. For example, senior leaders described key issues for the ED and they did not appear to understand the risk with some practices we identified, like non-clinical staff streaming patients, or oversight in the waiting room.

Minutes of the Emergency medicine directorate meeting showed that some performance metrics were discussed that related specifically to the emergency department. The Trust told us that performance data was regularly reviewed by senior managers and executives.

Safety performance data and themes and trends from incidents, concerns and complaints were at divisional level and there were no actions to address themes for the ED. For example, falls prevention and avoidable pressure ulcers were a targeted focus area in the report in February 2025 for the division, but it was unclear what actions were being taken in the ED to address these areas from the report, and only inpatient areas were included in the reporting, dashboard and meeting record.

There was a risk register which highlighted risks across the service and controls outstanding were identified to address the risk. Each risk had an owner and review dates were recorded. On review of the risk register not all key risk we found during the assessment had been identified by the service. For example, there were a number of registered children's nurse vacancies, and the service were unable to meet the national staffing guidelines for children.Also, due to the lack of assurances recorded on the risk register, it was unclear how some of the risks were being monitored, for example through audits.

The service had an ED 2025 Performance Improvement Plan to address areas of concern in their performance. The plan was split into 4 main areas: assessment delays, exit block, estates and other. We saw most actions, which had realistic target timelines, action owners and were monitored using a red, amber green (RAG) rating system. Where appropriate we saw evidence that actions had been escalated.The actions were in line with some of our findings and evidenced leaders were aware of some key issues and addressing them to improve the departments performance, and in turn outcomes for patients.

Clinical governance systems and processes were managed through the monthly emergency medicine directorate meeting. We reviewed agendas and minutes from these meetings and found that key features of clinical governance were discussed in this meeting, which included performance, risk management, complaints, research and quality improvement (QI) and education and supervision. We saw limited evidence that patient experience (outside of formal complaints) was embedded in clinical governance systems. We saw evidence that actions were identified and monitored at the next meeting.

Formalised plans were not ready for the ED redesign which leaders told us addressed some key risks. We asked for the plans for the expansion and redesign of the ED, and we received a narrative response which described that the Emergency Access Project Board would oversee the development with 4 workstreams to support delivery with their own project teams allocated including clinicians, service leaders and a governor. A survey and audit had been carried out as part of the planning and the service had committed to actively engaging partners in the project.

There were audits and quality improvement projects however wider learning was very limited, particularly for junior staff who were not invited to governance meetings and did not receive updates on learning in the department.

We were not assured that systems and processes, including audits and risk management processes supported leaders and staff to make improvements to the service.

We saw evidence service leaders were supporting system concerns, for example through offering peer review on pathways that work well in the trust, to support a system-focused resolution of pressure in ambulance handovers.

There were regular multidisciplinary team meetings where local service leaders and practitioners came together to discuss patients with mental health and/or substance misuse needs who were frequent users of services within the system, including the ED. We saw that system pressures and service level pressures were considered when discussing individual patient plans and a coordinated approach was taken to ensure patients received the right level of care for their assessed needs, while services addressed the impact.

The service had a high proportion of out of area patients attend the ED. Out of 1938 average attendances in the previous 6 weeks in January 2025, 25% of patients attended from a different locality. We heard from patients and staff during the assessment that people chose to come to this ED because they received good quality care in a quicker than their local ED.

The service conducted an audit on 10 December 2024 where patients attending the department were surveyed to understand their behaviours and decision-making processes leading to their visit. The ED in Warwick was closest to home for 89 out of 128 patients (70%) who attended that day. The service recently undertook an audit of patient attendances at the emergency department. This included "missed opportunities" to identify cases where alternative care could have been used instead of ED, and explore why out of area patients preferred Warwick ED. However, there were no clear actions taken to address the findings to enable the service to work more collaboratively with their partners.

The service was planning a departmental redesign and planned to include community, stakeholder and partner views in the planning to align the plans with future service provision and the needs of residents. There were plans to hold stakeholder events with residents, healthcare partners, the Integrated Care Board (ICB), local councillors and MPs and the Trust's Patient Forum, governors and staff. It was too soon to assess how well these strategies would be used to inform planning, but it was positive that the service had considered these in the early stages of planning.

There was a focus on continuous learning, innovation and improvement in the department.

The department took part in clinical audit and quality improvement, however most efforts focused on tackling the capacity and flow through the department and did not address other areas.

One QI project carried out was shown to improve the uptake and delivery of fascia iliaca blocks which are performed when a person fractures (breaks) their neck of femur (hip). The QI project aimed to improve the care provided in the ED by emergency medicine doctors due to the increase delays the department has.

We were sent evidence of 2 QI projects for improving pain management. One was from 2021 and a further project from 2024. Part of the findings was there was no standard operating procedure to support staff to help manage pain for adults. This was then implemented, and results showed an improvement in the management of patient pain.

The service had a joint Quality, Service Improvement and Redesign (QSIR) programme which was co-delivered with another local NHS trust. QSIR aims to equip individuals and teams with the knowledge and skills to implement and sustain improvements in services, ultimately leading to better patient experiences and outcomes.

There were 26 trust-wide QSIR projects being undertaken in 2024 by attendees and delegates, and 50 QSIR projects by virtual delegates including an ED specific project, "patients will have a more positive experience on arrival to ED" and "E-triage in AE". At the trust, 17 out of 21 responding participants of the QSIR training had completed improvement work because of the training, and a further 2 had ongoing work. 33 projects had been completed, with benefits identified to quality, workforce, productivity and prevention and sustainability.