Warwick Hospital

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

Leaders had created a positive and proactive culture of safety-based openness and honesty. Concerns about safety were fully investigated. The managers’ ensured lessons were learnt to identify and embed good practices. There was a very positive learning culture with staff managing incidents and safeguarding patients well. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. Staff assessed risks to patients, acted on them and kept good care records. There were processes to ensure the service had enough staff with the right training, skills and qualifications to keep patients safe.

This key question has been rated good. This meant patients were safe and protected from avoidable harm.

We have not awarded this service a score for Safe.

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

The service had a proactive and positive culture of safety, based on openness and honesty. Staff knew how to raise incidents and concerns and they were reported on an electronic system and managers were alerted immediately. Incidents and complaints were reviewed daily at staff meetings and fully investigated. Lessons were learnt to continually identify and embed good practice.

Patients experienced care based on the latest updates and learning which followed national updates and safety incidents. Patients and staff were encouraged and supported to raise concerns. They felt confident they would be treated with compassion and understanding and would not be blamed or treated negatively if they did so.

Leaders had implemented the NHS Patient Safety Incident Framework to develop effective systems and processes to respond, learn and improve from patient safety incidents. Incidents were comprehensively investigated and there was clear analysis of incident data and trends with comparison with previous reporting periods. Incidents were discussed at the Quality Performance Group to review trends and lessons learnt.

There had been 33 incidents reported relating to end of life care in the trust in the past 12 months. Themes included medication errors, skin damage and discharges. All incidents were investigated and actions taken, including an increase in staff training.

Staff understood the duty of candour and applied this wherever necessary.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Staff made sure there was continuity of care, including when people moved between different services.

Safety and continuity of care was a priority throughout patients’ care journey. This happened through a collaborative, joined-up approach to safety that involved patients along with staff and other partners in their care. Patients care was discussed with the multidisciplinary team and planned to ensure all needs were met.

Patient assessment processes included the use of recognised tools to identify changes in a patient’s condition and potential deterioration. They used of the Integrated Holistic Assessment and Individual Plan of Care for the Dying Person care plan (IPOC). The care plan was a collaborative document used within the hospital, local trusts, the community and local hospices to ensure patient had the same documentation and continuity of care if they were discharged home or to another care provider. IPOC is a personalised plan for a patient nearing the end of life, which includes patient assessment, individualised care plan, family discussions and multidisciplinary team (MDT) actions. There was a nationally recognised AMBER care bundle used for patients’ to improve the quality of care for people whose recovery and prognosis was uncertain. We saw patients moving from the Amber care pathway to the IPOC when their condition had deteriorated.

There were clear processes and pathways for patient transfers, and collaborative arrangements with other local services to ensure safety and continuity of care. Leaders and staff worked closely with healthcare partners to ensure people were cared for in the most appropriate environment and in line with their wishes. A daily video conference call was held with the trust specialist palliative care team (SPCT), community services, local hospices and other healthcare providers to discuss individual patient care needs and to support patients wishes with their preferred place of care.

There was a discharge checklist for nursing and medical staff to use in the last weeks of life ensure a positive transition between services. This included information such as referrals to community services including district nurses and GP’s, equipment required, transport, medication and relevant documentation such as Recommended Summary Plan for Emergency Care and Treatment form (RESPECT) which includes resuscitation decisions.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff understood their safeguarding responsibilities and knew how to take appropriate action when necessary. The trust had a clear safeguarding policy which was available for staff to access.

All clinical staff were trained to level 2 safeguarding adults and level 2 children. The trust had safeguarding leads that staff could contact for advice.

Patients were supported to understand their rights, including their human rights, rights under acute services, the Mental Capacity Act 2005 and their rights under the Equality Act 2010. Staff understood the importance of supporting equality and diversity and ensured care and treatment was in accordance with the Act. Staff gave examples which demonstrated their understanding and showed how they had considered the needs of patients with protected characteristics.

The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Safety was a priority that involved everyone, including staff as well as people using the service. Staff made sure that people understood the care and treatment that was being provided.

We saw risk assessments such as venous thromboembolism, falls assessments and skin integrity were completed and documented in line with national guidelines. These were mainly completed by staff on the wards, but the SPCT would also document any assessments, care, treatment and conversations in the care plans. Staff closely monitored patients so they could respond quickly if their health deteriorated.

Allied health professionals, such as physiotherapist and dietitians who visited the patients were provided with written and verbal information to ensure that all staff involved in patient care were fully informed of the patients condition and care needs.

The service detected and controlled potential risks in the care environment. Staff on the wards made sure equipment, facilities and technology supported the delivery of safe care.

We visited 5 wards where patients were receiving palliative and end of life care. The wards visited had suitable facilities to meet the needs of patients.

The wards visited were visibly clean and tidy with appropriate equipment available to maintain safe levels of care. Medical equipment was appropriately tested and within date. Sterile equipment was stored off the floor on appropriate shelving and all equipment was in date. Sharps bins were available and were labelled correctly.

Fire extinguishers had within date service checks and there were signs pointing out fire exits throughout the service.

Staff carried out daily safety checks of specialist equipment, such as the resuscitation trolley. Resuscitation equipment was easily accessible and located in the unit. Resuscitation equipment had been checked daily and an up-to-date checklist confirmed all equipment was ready for use.

The chapel and multifaith rooms were available 24 hours a day for all staff, patients and relatives. These were quiet spaces that people could use. The chapel had a tree where people could attach messages.

There was a process to manage the safety, maintenance and repair of facilities, premises and equipment.

Managers made sure there were enough qualified, skilled and experienced staff, who received thorough support, supervision and strong development opportunities. Staff worked together well to provide safe care that met people’s individual needs.

The service had enough staff to keep patients safe. All staff had a period of induction, worked supernumery and had supervision before commencing work.

The SPCT consisted of 3 palliative consultants of which 1 worked in the hospital and the community. There was 1 vacancy, however it was not at consultant level as this was to be downgraded to a specialty doctor and transferred to the Community Team. A clinical education fellow worked 50% clinical and 50% teaching, 2 Resident doctors on rotation. 3 lead nurses, 3 clinical nurse specialists (CNS) and an end of life practitioner who did 1 clinical shift and provided education for both hospital and community staff. All nursing staff working in the team had a relevant post registration course.

The SPCT worked Monday to Friday 8.30am to 4.30pm. Out of hours and at the weekend there was a consultant on call. The consultant on call rota included consultants from this trust, other local trusts, the hospices and community. Staff could call for telephone advice via one of the local hospices. Consultants had access to patient notes online and shared information with each team involved in the patients care.

The SPCT team had an average of 1.8% sickness in the last 12 months. There was one vacancy, however it was not at consultant level as this was to be downgraded to a specialty doctor and transferred to the Community Team with interviews planned and 1 vacancy for a CNS. Bank and agency staff were used; these were regular staff that were familiar with the service.

Every morning, there was a daily SPCT meeting which included the palliative care consultant, and lead nurse, clinical nurse specialist (CNS), medical staff and end of life care facilitator. They would discuss patients currently on the caseload including overnight reviews, received by the on-call palliative care consultant symptom management and any new referrals. Cases would be allocated to specific members of the SPCT to visit patients on the wards. The SPCT tried to ensure continuity of care by the same staff member visiting the patients and wards. Staff could raise concerns about staffing levels and any support they required.

Resident doctors told us they felt very supported and had opportunities to learn about palliative care, withdrawal of treatment and prescribing practices.

The team had support from allied professionals such as chaplains and other faith leaders, physiotherapy, psychologist, specialist nurses and dietitians.

The chaplaincy staff and volunteers would visit the wards daily and offer support to any staff, patients and relatives when required. Chaplains were on call 24 hours a day and would visit patients and relatives and offer support for those with or without any specific faith. They could access other faith leaders in the community as required.

The bereavement team worked Monday to Friday 9am to 5pm and offered support to relatives following the death of a loved one. Once a patient arrived in the mortuary, they would call the next of kin and begins supporting relatives. There was currently 1 vacancy within the bereavement team and some long term sickness. Staff told us they had support from other bereavement teams within the hospital such as the children’s and maternity staff and the SPCT.

There were champions from an end of life charity that volunteered in the hospital and could sit with patients and relatives to offer support.

Wards had end of life care champions who attended meetings, training and updates. They could support ward staff and link with the SPCT.

Nursing staff had completed their Nursing and Midwifery Council re-validation checks and updates to develop their competencies.

There were robust and safe recruitment practices to make sure all staff were suitably experienced, competent and able to carry out their role. Staff were employed in line with schedule 3 of the HSCA (RA) Regs 2014.

Staff received training appropriate and relevant to their role. All staff had an induction, and staff were provided with supervision as needed. Training compliance data showed 91% of SPCT had completed their mandatory training. The SPCT had recently carried out a learning needs analysis to understand the learning and development needs of the team.

The team assessed and managed the risk of infection. Staff detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

All areas in the palliative care department and wards visited were visibly clean, tidy and had suitable furnishings which were well-maintained.

The environmental cleaning was provided by housekeeping staff who had enough equipment and a daily checklist. Staff on the wards carried out daily cleaning of the equipment and environment. We saw cleaning and alcohol wipes were available throughout the hospital.

Staff followed infection control principles including the use personal protective equipment (PPE). Hand-washing and sanitising facilities were available for staff and visitors. We observed staff using PPE and hand sanitising gel appropriately during the inspection.

The SPCT would take part in any IPC audits on the wards when they carried out visits to the ward. Any concerns would be raised directly with the staff at the time.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Staff followed systems and processes to prescribe and administer medicines safely. Patients’ medicines were appropriately prescribed, supplied and administered in line with the relevant legislation, current national guidance or best available evidence.

Processes were in place for managing medicines and safe storage. Staff on the ward completed regular checks of medications and controlled drugs (CDs) in line with the policy. Medications were stored locked cupboards in locked rooms.

There were appropriate arrangements for the safe management, use and oversight CDs. Controlled drugs are drugs that are subject to high levels of regulation as a result of government decisions about those drugs that are especially addictive and harmful.

The CNS’ were nurse prescribers, we saw they prescribed drugs for patients and updated medication charts online and informed staff of changes. There was guidance for prescribing for the dying person. Anticipatory medication could also be prescribed for patient’s in hospital and those going home or to community settings.

Staff told us syringe drivers (for the continuous administration of medicines) were available and they would stay with the patient throughout their patient journey including if they went to a hospice or home. The syringe drivers had trackers to enable the team to identify their locations and retrieve them.

Fridge temperatures were monitored, and staff checked to ensure these were within the required range. We saw evidence these were monitored and recorded daily.

The National Audit of Care at the End of Life (NACEL) contains an element around medication where it looks at ‘the proportion of people who died with documented evidence in their clinical records that anticipatory medication was prescribed for symptoms likely to occur in the last days of life’. The trust scored 81.3%, which was similar to the national average.