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

We looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of people who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

The vision and strategy were co-produced with staff, partners and people who used services. It closely reflected the challenges and met the needs of people who used the service and wider communities. All staff felt psychologically safe to speak up and raise concerns to help learn and improve. Staff were motivated and consistently felt well-supported by leaders. Governance processes were used to improve patient safety.

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 clear shared vision, strategy and culture. This was based on transparency, equity, equality, inclusion, engagement, and a strong understanding of the challenges and the needs of people and their communities. The vision, strategy and culture were co-produced with staff, partners and people who used services. It closely reflected the challenges and met the needs of people who used the service and wider communities.

The vision for the ED and PED was to provide the best possible patient experience. This was supported by a 3-year strategy to grow and stabilise medical staffing, stabilise the nursing workforce, and to extend the footprint of the department to meet the needs of the population. Staff at all levels were heavily invested in the redesign. They told us they had been consulted about the redesign of the estate. They said they felt listened to and their comments had been taken into consideration.

Staff told us they enjoyed working at Warwick Hospital. They were supported by their immediate teams, which they described as being like a family. One member of staff described the way the team works together as, “fantastic”.

Staff in the ED took part in regular team building activities designed to bring people together, including charity events such as a local boat race, spending a night in an old jail and sky diving, all to raise money to improve the department. In addition to this they had on-shift events, such as ED bake-off, ED baby photo competition and advent appreciation gifts throughout December.

The nursing staff spoke very highly about team cohesiveness, leadership, and psychological safety. Some staff described the staff hierarchy as flat, with the opinions of all staff being valued equally and nurses feeling well supported by the medical team. One nurse gave an example of escalating a child in mental health crisis trying to self-discharge and receiving immediate and thorough support from the clinical team to help manage the situation. Staff also told us there was a, “no blame culture,” when things did not go as expected they were seen as “learning opportunities.” We saw an example of staff (a nurse) feeling psychologically safe to act responsively and report poor practice (manipulation of a forearm fracture).

Staff told us their managers demonstrated they understood the challenges they faced and valued the work they did. Staff told us the senior leadership team helped with patient care during the busiest times to reduce pressure on other staff. Staff said they were grateful for this help. One member of staff described mangers as, “coming to save the day”. They told us managers also covered breaks during busier days.

Staff told us there had been changes in the department since their last inspection. They understood that many of the changes were because of their input into the inspection process, and these changes had made the department feel safer. This demonstrates the department was open and responsive to suggestions that improved patient safety.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The urgent and emergency care department was led by a triumvirate. Triumvirate leadership ensured a comprehensive approach to managing complex services, integrating clinical, nursing and managerial expertise. This structure aimed to balance competing priorities and ensure that decisions are clinically led but also operationally viable.

We saw evidence of strong leadership through the comments of the staff team. Staff told us their leaders gave them a sense of autonomy in their work, opportunities to learn, and a feeling of a sense of togetherness.

Staff told us their immediate managers, and also the trust senior leadership team, had an open-door policy, were approachable and visible. Resident doctors told us senior doctors were approachable and visible.

Following incidents of threatening, aggressive, or violent behaviour from patients or other members of the public senior leaders checked with staff to make sure they felt safe and supported. Staff were also given the option of wearing body work personal alarms at work. The trust had also implemented enhanced security overnight due to staff feedback and themes from complaints.

Leadership training was available for managers. We saw evidence of succession planning and support for aspiring senior leaders. Aspiring leaders were also given the opportunity to undertake development roles and complete a leadership course. Resident doctors were supported through the Royal College of Emergency Medicine (RCEM) emergency medicine leaders training.

Leaders told us they were creating strong foundations for a good workforce by investing in the current staff. In turn staff told us they were given opportunities to progress.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff and leaders acted with openness, honesty and transparency. Staff were encouraged to raise concerns and offer ideas; the culture allowed staff to be confident their voices were heard. Leaders and staff understood the importance of staff being able to raise concerns without fear of retribution. The freedom to speak up service was advertised across the hospital to encourage staff to share their concerns. Staff told us they understood how to access the freedom to speak up service, and in the 12 months before our inspection 3 issues had been raised with the service.

Staff told us when they shared concerns, they felt able to do so without fear of detriment. When concerns were raised, leaders investigated sensitively and confidentially.

Patients, their families and carers were provided with information to explain how they could raise a concern on the trust website. Senior staff in the department responded to immediate concerns or complaints with a view to resolution. There were policies to support the complaints process.

There were staff feedback boxes in the staff room so staff could give leaders anonymised feedback if they wanted to. There were regular staff meetings which gave staff the opportunity to raise their concerns which often led to practical change as discussed elsewhere in the report.

The service strongly valued diversity in their workforce. It had an inclusive and fair culture which had improved equality and equity for people who worked in the service.

The trust had a workforce disability network, a diverse inclusion network, an LGBTQ+ network, a veterans’ network, a speak up and wellbeing ambassadors’ network, and a faith group. The role of the networks included visible representation and acceptance of difference within the workforce, and safe space where people could access advice and information.

The hospital had a multifaith room that could be used by staff wanting to pray or have space for quiet reflection.

The hospital’s Workforce Race Equality Standard (WRES) data from 2024 showed there had been an increase in the number of ethnic minority staff working for the trust since 2023 (23.2% up from 22.1%), and the relative likelihood of being appointed from shortlisting showed near parity at 39.3% white candidates, 39.7% ethnic minority candidates, 38.37% from ethnicity unknown candidates. The data showed 52% of ethnic minority staff at the hospital believed the trust provided equal opportunities for career progression or promotion. This was lower than white staff (66.4%). Ethnic minority staff (23.4%) were more likely than their white counterparts (22.3%) to have experienced harassment bullying or abuse from patients, their relatives, and members of the public, and more likely (21.6%) to have experienced harassment bullying or abuse from colleagues than their white counterparts (18.5%). However, ethnic minority staff were slightly less likely to have experienced bullying or abuse from managers (7.3%) than white staff (7.4). Although only 4.9% of white staff reported to have experienced discrimination from a manager or other colleagues in the last 12 months compared to 12.6% of ethnic minority staff.

The ED had a high proportion of ethnic minority locally employed doctors (doctors not on a national training contract), who often had their first UK job at Warwick Hospital. The department had a consultant lead with timetabled time to support this cohort with particular support on being a new doctor in the UK and living in the UK in general. The department allowed flexible rostering for staff with overseas families; to allow them to take extended periods of leave to ensure they had time to travel to their home country.

The trust recognised they still had more work to do to improve the experience of ethnic minority staff and had ongoing and new plans to support positive change. These included training on civility in the workplace and a toolkit to help managers tackle incivility, the roll out of active bystander training, a trust values-based assessment for shortlisted applicants, a bias awareness assessment for recruiting to managerial roles, and an equality, diversity, and inclusion integrity tests for applicants for Band 7 and above posts.

Seventy-seven percent of staff that took part in the annual staff survey in 2024 recommended the trust as a place to work. This was the highest score of all trusts in the Midlands and the second highest in the country.

The service had clear responsibilities, roles, systems of accountability and good governance. Staff used these to manage and deliver good quality, sustainable care, treatment and support. Staff acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

There were structures, processes and systems of accountability to support the delivery of the service. The service had a meeting structure which gave senior leaders and managers regular opportunities to discuss operational issues. Leaders were clear on the links to trust-wide groups and committees to escalate risks and issues.

There were joint monthly PED and ED multidisciplinary governance meetings where incidents and learning from incidents were discussed to ensure learning and actions were shared and to provide additional input from specialists. There were separate mortality meetings to provide insights into the quality of care provided. The outcome of departmental meetings fed into divisional meetings, which fed into board level committees and meetings. There were regular meeting to look at incidents. The outcomes of governance meetings were shared with staff, so they had a clear understanding of operational priorities and their role in achieving these.

Governance was used to learn, improve and innovate. There was a wide range of data and information available to understand productivity, patient safety and flow,

workforce efficiency, and staffing costs. The data provided insights into how resources were used to deliver care, support operational efficiency and service sustainability. For example, the trust continuously collected data to understand the demand on the system and how they needed to flex operationally to meet demand. They collected and regularly analysed patient care indicators to improve effectiveness, safety, and overall patient satisfaction. Patient care indicators in the ED and PED include the 4-hour wait target, time to initial assessment/treatment, unplanned re-attendance rates, left without being seen rates, and patient experience scores from surveys. In addition, the department participated in benchmarking and in national audits like the RCEM audits to help identify areas of poor performance to help drive improvements. Benchmarking data shows the ED is one of the most efficient in England, with the 7th lowest cost per weighted activity unit (WAU) in England. A WAU is a standardised measure used by NHS England to compare clinical productivity and activity across different trusts on a like-for-like basis.

Governance meetings, including safety huddles, could be used to discuss innovation to improve patient safety. Staff gave us examples of innovation they had introduced from discussions in these meetings. Band 2 and 3 nursing staff recommended a midday swap from the waiting room to the clinical decision unit so they had a more equitable intensity of role across their shift. Another nurse led innovation was to introduce coloured lanyards for doctors to help staff identify what grade they were. A month’s trail of this initiative was taking place during our inspection and staff told us it was helping them identify who they needed to escalate their concerns to.

There were clear processes for reviewing and answering complaints made about the service by patients and their families. The complaints were shared at a regular governance meetings and assigned to named individuals for investigation and responding to the person who made the complaint. The themes and trends about complaints were included in the staff newsletter so learning could be shared across the staff group. The department received complaints from 0.09% of patients in the 10 months before our inspection (94 out of 99,500 patients). The most common themes were complaints about clinical care (16%), complaints about doctors (13%) complaints about nursing staff (11%), complaints about the discharge process (9%), and complaints about the attitude, values, or behaviour of staff (9%).

Staff in the PED told us their main concerns around risk were the lack of oversight of patients in waiting areas and children waiting to be seen in the adult waiting room when the children’s areas were full. This was a known estate challenge and risk, and the trust had a redevelopment plan in progress to tackle this. Staff in the ED told us their top risks were people waiting in the waiting room, and patients with a long length of stay. Staff told us they received emails about the department’s main risks. Senior leaders told us their main risks were overcrowding in the department, the environment for patients presenting in a mental health crisis, and risks around medicines.

The risk registers contained enough information for staff to understand the severity of risk and the level of potential or actual harm to people. Each risk was assigned to an individual so there was a responsible person to ensure agreed actions were carried out and the level of risk reviewed regularly.

There was a programme of regular audits and engagement with national audit submissions. Local audits included, health and safety, infection prevention and control, falls, and NEWS2 and PEWS. The findings of the audits were shared with staff and used to make improvements to the service. This was an improvement since our last inspection.

Staff in the service understood their duty to collaborate and work in partnership, so services worked seamlessly for people. Staff shared information and learning with partners and collaborated for improvement.

The ED and PED had high attendance from people who lived outside of the geographical area expected to be covered by the hospital. This was both for people making their own way to the hospital and people arriving by ambulance. Department leaders worked with the local ambulance trusts to demonstrate the impact having out of area patients was having on the department, the wider hospital trust, and on patients and their families. As a result, the ambulance trusts conveyed patients to hospital’s nearer to their homes and families.

The trust had introduced a frailty service that gave ambulance crews direct access to speak to a frailty consultant. This allowed the consultant to decide if the patient should be conveyed to the ED or not and what alternative treatment options they had. This avoided unnecessary ambulance journeys to the hospital and ensured patients received the right care at the right time.

The ED team worked alongside the trust’s safeguarding team and partnership agencies, for example, the local authority children’s social care teams, and the police, to use local and national intelligence to improve safeguarding processes and deliver safe care. For example, the national upward trend in dog bites from dogs from a dangerous breeds meant an increase would be likely to be seen locally. They mapped how many dog bites on adults and children had already been reported and saw there was an increasing upwards trend. To ensure staff knew what processes to follow if an adult was bitten and what to do if a child was bitten the ED, police, and safeguarding teams worked together to create flow charts to support staff to make the right safeguarding referrals.

The trust used social media to keep the public updated about the demand in ED. At times of the highest demand they posted messages to remind people of the types of injury and illness the ED is designed to help with, and what other services, such as GPs and 111 that can help with less urgent care.

The department had a lead for high intensity users. They worked with system partners to understand how this cohort of service users could be supported and directed to the most appropriate services to meet their needs.

The service focused on continuous learning, innovation and improvement across the organisation and local system. Staff encouraged creative ways of delivering equality of experience, outcome and quality of life for people. Staff actively contributed to safe, effective practice and research.

ED staff worked alongside the trust’s safeguarding team to improve use of the exploitation screening tool. The screening tool was 15 pages long and therefore difficult to complete during triage or during emergency treatment in the ED. The team worked together to reduce the screening tool down to one page by looking at what questions were most pertinent so they had enough information to make a decision in an emergency situation.

Staff had regular meetings where they could work together to resolve problems, review objectives, and assess performance. At these meetings staff were encouraged to introduce quality improvement projects that could simplify processes. Quality improvement was also an agenda item at huddles. Senior hospital leaders told us the trust was introducing changes to processes to make it easier (quicker) for staff to introduce change.

The ED ran a trial on overnight deflection. This was to reduce the number of people being treated in the ED overnight when the MIU was closed. People presenting with a minor injury overnight were given options about being seen, either a potentially long wait (due to low clinical acuity) to be seen in the ED or returning when the MIU reopened. The treatment outcome was reviewed for each patient who opted to return when the MIU reopened. The trial had identified that no patients had come to harm. The team were waiting for the governance committee to sit to discuss the outcome of the trial before any further decisions on implementing overnight deflection could be made.

Innovation had been used to improve medical staff levels in the ED. A tiering system had been introduced to ensure the competency of doctors on the rota matched demand rather than relying solely on seniority. Training opportunities were offered to support the tiering system, for example in anaesthetics, ultrasound, and life support. The recruitment process was also innovative and had improved both recruitment and retention. Rather than working 1 in every 3 weekends doctors could work 1 in every 4 by changing the way they were employed (they were employed part time substantively and part time as a locum).

To improve triage waiting times staff in the ED had begun a project to look at how they could significantly reduce waits for triage process. They were proposing the introduction of a short visual assessment of patients immediately after booking in. In the interim Band 5 nurses were being trained in triage so they could support triage at times of high demand.