University Hospital

University Hospitals Coventry and Warwickshire NHS Trust is one of the UK’s largest trusts and serves a population of about 1,000,000 across Coventry, Warwickshire and beyond. Inpatient services are provided from two hospital sites, University Hospital Coventry (the main site) and Hospital of St Cross, Rugby. In total, the trust has 1,250 beds and provides both elective and emergency care. A major trauma centre, University Hospital Coventry specialises in cardiology, neurosurgery, stroke, joint replacements, in vitro fertilisation (IVF) and maternal health, diabetes, cancer care and kidney transplants.

We carried out this inspection as part of our comprehensive inspection programme between 10 and 13 March 2015.

Overall, we rated University Hospital Coventry as ‘requires improvement’. We have judged the service as ‘good’ for caring. We found that services were provided by dedicated, caring staff. Patients were treated with dignity and respect and were provided with appropriate emotional support. However, improvements were needed to ensure that services were safe, effective, responsive to people’s needs and well-led.

Our key findings were as follows:

Cleanliness and infection control

• Patients in children’s services, the emergency department (ED) and maternity received care in a clean, hygienic and suitably maintained environment. Staff were aware of and applied infection prevention and control guidelines.
• We observed good practices in relation to hand hygiene and ‘bare below the elbow’ guidance and the appropriate use of personal protective equipment, such as gloves and aprons, while delivering care in children’s services, the ED and maternity. These practices were not so well embedded in the critical care, medical and surgery departments, where examples of poor infection control practice were observed.
• There was a pre-admission service within the outpatients department; however, no preoperative MRSA screening was undertaken during this consultation. Screening was done by the preoperative nurse, who only saw those patients who were a higher anaesthetic or operative risk, for example, patients with co-existing morbidities. Women were also not routinely screened for MRSA before elective caesarean section in maternity. This meant that not all patients undergoing elective surgery were screened preoperatively. Screening has been a Department of Health recommendation since 2007.
• Examples of poor infection control practices were observed in the radiology department. These included:
  • Poor hand hygiene with staff not washing hands between touching patients, bedpans and clean linen.
  • No robust training in scrub skills for nurses to support advanced interventional procedures. The nurses confirmed that although they had ‘on the job’ training, they were not aware of any advanced scrub practitioners from the operating department auditing or supervising the radiology staff’s scrub skills. This meant that there was no assurance that best practice with regards to infection control was being complied with and could have increased the risk of patients being exposed to an infection.
  • No robust procedure for identifying and isolating patients who attended the department who had a known infection that could contaminate other patients.
  • The bed wait area in CT and MRI was just large enough for three beds, separated by curtains. Again this was an infection control risk for patients who were in such close contact with another patient.

Records

• The standard of record completion varied across the services. In emergency services, critical care, surgical, neonatal and maternity services, we found that medical and nursing notes were structured, legible, complete and up to date.
• On the medical wards we found gaps in the completion of records relating to sepsis recognition, venous thromboembolism assessments, fluid balance charts, comfort rounds and individualised care plans.
• Records in most departments were stored securely in line with requirements. However, on some medical wards we found records to be easily accessible to others visiting. For example, on one ward, we saw that five sets of care records were left on a table in one of the bays, instead of being kept in a secure area.
• 44% (13 out of 29) of ‘do not attempt cardio-pulmonary resuscitation’ (DNA CPR) forms were incorrectly completed or had information missing. Incomplete or incorrect DNA CPR forms can lead to patients being subjected to attempts to resuscitate them when this is not appropriate or in line with their wishes.

Staffing levels

• The trust used the nationally recognised Safer Nursing Care Tool along with National Institute for Health and Care Excellence (NICE) guidance to assess required nursing staff levels.
• Vacancy rates, staff turnover and sickness were audited monthly. Daily checks were completed across all areas to check staffing requirements and availability against gaps in the rota. Vacant shifts were offered to bank or agency staff.
• All staff we spoke with, from the management team to healthcare assistants, recognised nursing recruitment as a major safety risk to the service. It was captured on the directorate risk register. Vacancy rates across the core services ranged from 13% in the surgical teams to 17% in the Cardiac Critical Care Unit (CCCU).
• The trust told us they were currently undertaking significant investment in attracting the right nursing staff to its hospitals and becoming an employer of choice. A rolling recruitment programme was ongoing with advertising websites, local media and universities. Plans were also in place to widen the recruitment drive internationally. All ward-based staff were aware of these initiatives and supported them. There was general agreement that recruitment and retention of nursing staff were seen as a priorities by the trust.
• We spoke with two medical students, who told us, “It’s a really positive experience working here. We get high-quality training and are integrated into the team.”
• In the ED, consultants were available and visible, and junior medical and nursing staff confirmed that this was usual.
• There was appropriate consultant obstetric cover on the labour ward weekly. This was consistently reported as 96 direct cover hours. The maternity service staffing levels for obstetric anaesthetists and their assistants were in line with Safer Childbirth (RCOG, 2007) recommendations.
• Care and treatment within the CCCU were led by consultant cardiac surgeons with support and advice, when required, from intensive care consultants. However, the arrangements for senior medical cover did not meet the requirements of core standards in intensive care.

Mortality rates

• Our ‘Intelligent Monitoring’ report of December 2014 showed that there was no evidence of risk for summary hospital mortality level indicators or for hospital standardised mortality ratio indicators. However, there was risk in: in-hospital mortality associated with dermatological conditions and trauma and orthopaedic procedures and conditions, and elevated risk for nephrological conditions.

Incidents

• The trust used a centralised web-based reporting system for staff to report incidents and near-misses. Staff who we spoke with during our visit included newly appointed junior staff who confirmed they knew how to use the system to report incidents.
• The trust’s attitude to the reporting of incidents was one of learning. Staff were encouraged to report incidents in the hope that lessons could be learned and further incidents prevented. This led to a high volume of incidents being recorded.
• Staff in the GP assessment unit said that, although they were aware of the incident reporting system, they did not feel confident in completing incident reports because they felt that “nothing gets done”.
• The trust told us each incident was managed through the trust’s significant incident group, which met on a weekly basis to review all serious incidents, monitor ongoing investigations and approve investigation reports. Trust root cause analysis leads were appointed to manage the investigations and actions were assigned to address the issues.
• Mortality and morbidity reviews were undertaken and discussed at the quality improvement and patient safety meetings. Minutes of meetings we reviewed showed that, when needed, actions were taken to improve practice.

Nutrition and hydration

• The trust had a rotational menu offering a wide variety of hot and cold choices and cultural needs were catered for: menu sheets took account of cultural and dietary requirements.
• Patients with specialist needs in relation to eating and drinking were supported by dieticians and by the speech and language therapy team. Red tray liners were used to help staff identify those patients who required support.
• The patient records we reviewed included an assessment of patients’ nutritional requirements based on the malnutrition universal screening tool (MUST). We observed on the medical wards that fluid balance charts were used to monitor patients’ hydration status. However, the records seen on two wards did not include the totals for ease of information for staff reviewing details on the MUST.
• The trust used national guidance for parenteral and enteral nutrition. Policies were in place to help patients who were unable to take oral nutrition or fluids to be given specialist feeds until they could be seen by a dietician. Patient records we looked at confirmed that these policies were in use. This meant that patients were protected against the risk of malnourishment.
• We noted that drinks and sandwich packs were available to patients in the ED. Patients admitted to the observation ward were provided with a full meal service in line with other ward areas within the trust. We saw patients waiting on trolleys in corridors in adult majors being offered drinks.
• As well as mandatory training, catering staff received annual training from the dieticians.

Medicines management

• The systems in place for the management and storage of drugs, including controlled drugs and oxygen, were inconsistent throughout the trust. In children’s and young people’s services, outpatients, critical care, medical services and the ED, drugs were stored and maintained in line with regulations.
• In maternity we saw that community midwives were carrying medication without proper storage facilities, and that epidural drugs were overstocked and had been stored not only in an ‘epidural-only cupboard’ but also in a neighbouring cupboard.
• There were particular medicines management issues in the surgery wards and theatres, where we saw a drugs cabinet in one theatre had been forced open and could not be secured. This cabinet had been taken out of use. We saw packs of medication, which should have been in drugs cabinets, left out in theatres because there was insufficient space in the cabinets for the quantities to be stored. We asked a member of staff how they would know if drugs had gone missing because the area was unattended during operating procedures; they told us there would be no way to tell if stock had been taken. We also observed out-of-date intravenous fluids ready for use, and oxygen cylinders attached to anaesthetic trolleys that were out of date.
• On the surgical wards we also found some patients who were in pain and had not been given their prescribed drugs when they needed them. Staff reported having been unable to give a diabetic patient insulin because the drug was not available.
• Anticipatory prescribing in end of life care was common, in line with best practice. This meant that pain relief and other medication could be started quickly if patients became unwell.
• In the critical care unit we observed that intravenous fluid bags were used for preparing intravenous injection/infusions for more than one patient and used for up to 24 hours. This process had not been risk assessed and no protocol was available. There was a risk that the bags could be contaminated by poor infection control practices, or maliciously while left unattended on trolleys on the units. This practice was escalated to the trust executive team during the inspection and we were assured that this practice had stopped and would not recommence until there were suitable and appropriate assurances in place.

We saw several areas of outstanding practice including:

• Outstanding practice in respect of trauma care: for example, the fracture patient pathway that encompassed effective pain management, and integrated daily and weekend physiotherapy sessions to develop improved outcomes for patients.
• The trust was working to improve the experience of older patients. Initiatives included blue pillowcases for patients with dementia, the screening of all patients aged 75 and over for dementia and the development of a ‘care bundle’.
• The trust was using the ‘M’ technique as a means of holistic communication by touching the hands and feet of older people. It included the repetition of stroking and conventional massage through slow, constant and rhythmical pressure.
• The head of midwifery had won the Healthcare Hero and Lifetime Achievement Award 2013/14 at the Coventry Telegraph’s Pride of Coventry and Warwickshire Community Awards ceremony.
• The specialist bereavement midwife had received the National Maternity Support Foundation Award for Bereavement Care at the Royal College of Midwives Annual Midwifery Awards 2015. They had provided sensitive photographs for parents who had lost their baby in late pregnancy or soon after birth.
• The trust had a well-developed research programme and good links with local universities. There were excellent multidisciplinary education facilities that we observed being well used

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust MUST:

• The trust must improve the ability of the emergency department to consistently respond safely to the demands placed on it and to respond to patient needs in a timely way once they have arrived at the hospital and in a way that promotes patients’ privacy and dignity.
• The trust must ensure that there are sufficient numbers of suitably skilled, qualified and experienced staff, in line with best practice and national guidance, including Mental Capacity Act 2005 and Deprivation of Liberty Safeguards training.
• The trust must ensure all staff have a clear understanding of Mental Capacity Act 2005 and deprivation of liberties as they apply in practice to the service provided.
• The trust must review and reinforce staff knowledge of the ‘Assessing mental health in ED’ policy in order to better support staff to protect the rights of patients when any restraint power is used.
• Review medicines management within the medical division to ensure that controlled medicines are stored securely.
• The trust must ensure the practice of multi-use administration of intravenous infusions is stopped until assurance can be made that it is safe and appropriate practice.
• The trust should must that people who use services and others are protected against the risks associated with the unsafe management and storage of medicines. The trust should ensure that there is a system in place to prevent medicines of different patients being confused and/or ensure that patients receive or have access to all their medication when it was required.
• The trust should implement robust processes in place to ensure that intravenous fluid expiry dates were checked to ensure that they were within date prior to be administered.
• Ensure all patients attending for elective operations, including caesarean section, are routinely screened for MRSA before surgery.
• Ensure that its systems to review equipment and audit compliance are effective so far as they relate to checking resuscitation equipment and medical gases.
• Ensure there is a robust policy for transporting patients with an infection or who may be at risk of acquiring an infection in the hospital, so that staff are aware that special precautions need to be put in place to protect the patient and the public.
• The trust should ensure that ‘Do not attempt cardio-pulmonary resuscitation’ (DNA CPR) forms are completed accurately.

Action the trust SHOULD take to improve:

• The trust should manage the expectations of the ambulance services in respect of corridor nurse assessment and care while they are queuing for clinical handover with patients.
• The trust should adopt a more effective approach to keeping patients informed while they are waiting in the emergency department.
• Should take suitable arrangements are in place to respond appropriately to any allegation of abuse in order to safeguard service users against the risk of abuse and that safeguarding concerns are reported to the local safeguarding authority in line with best practice requirements.
• Should ensure consistency in the use of the World Health Organization (WHO) surgical safety checklist, including standardising practice in posting identification of patients and procedures within theatres. This is something that is required as part of regulation 9(1)(b)(ii) and (iii) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. (ii) Planning the delivery of care and where appropriate treatment in such a way as to ensure the welfare and safety of the service user and (iii) to reflect published research evidence and guidance issued by the appropriate professional and expert bodies as to good practice. However it was considered that it would not be proportionate for the finding to result in a judgement of a breach of the Regulation overall at the location.
• Ensure that planning of care reflects all the needs of the patient, including any comorbidities or pre-existing issues. This is something that is required as part of regulation 9(1)(b)(ii) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. (ii) Planning the delivery of care and where appropriate treatment in such a way as to ensure the welfare and safety of the service user. However it was considered that it would not be proportionate for the finding to result in a judgement of a breach of the Regulation overall at the location.
• Review the admission process for the GP Assessment Unit to ensure that patients are appropriately referred to the service.
• Ensure that the access and flow of medical patients are improved, and delayed patient discharges managed appropriately.
• CCCU should contribute data to the Intensive Care National Audit & Research Centre (ICNARC), to ensure that comparisons and assurances could be made that the unit performed favourably with other critical care units.
• Improve arrangements for the handover between the critical care outreach team and the hospital at night team to ensure that deteriorating patients receive safe care.
• The number of practice development nurses should be increased to reflect core standards for intensive care units.
• Medical staffing in the cardiac critical care unit should meet the requirements of the intensive care core standards.
• Ensure all outpatient staff complete their mandatory training.
• Review discharge procedures for both rapid discharge, (in particular to Warwickshire) and routine discharge procedures for palliative care patients in the last year of life.
• Consider clearly defining medical and nursing management roles in the supportive and specialist palliative care service.
• The trust should support staff and develop their skills in promoting and creating personalised care plans for end of life care based on the individual preferences of patients and their families.
• Ensure that doctors (outside of the palliative care team) feel confident in discussing end of life care and DNA CPR decisions with patients.
• Consider how the waiting areas, particularly for radiology ‘bed’ areas could be used more appropriately.
• Consider the need for a more suitable waiting area for ambulatory patients whilst awaiting a CT/MRI.
• Plan caesarean section lists before the day of operation whenever possible.
• Ensure that staff carry out and document assessments of patients’ needs so that the planning and delivery of care meet those needs.
• Ensure that there is handover of ‘bed’ patients to staff when they arrive from the ward into the radiology department.
• Ensure there is a process in place so that vulnerable patients waiting for imaging are cared for as their needs dictate and this is recorded.
• Ensure the nurses in imaging receive adequate scrub training from someone qualified to do so and that it is maintained.
• Ensure all staff complete their mandatory training, particularly child safeguarding training, level 3 in the ED. Ensure that community midwives receive regular and formal safeguarding supervision.
• Ensure that fluid scores are completed and recorded appropriately so that patients who are at risk of dehydration are correctly escalated.
• Provide information leaflets and signs in other languages and easy-read formats.
• Develop robust processes to meet the estimated discharge dates.
• Ensure they have robust arrangements in place to meet referral-to-treatment times.
• Make sure that learning from incidents is shared across all staff groups.

Professor Sir Mike Richards

Chief Inspector of Hospitals