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Inspection Summary


Overall summary & rating

Good

Updated 27 June 2018

We saw improvement from the last inspection in 2015.

We rated effective, caring, responsive and well led as good, with safe being rated as requires improvement.

Inspection areas

Safe

Requires improvement

Updated 27 June 2018

Effective

Good

Updated 27 June 2018

Caring

Good

Updated 27 June 2018

Responsive

Good

Updated 27 June 2018

Well-led

Good

Updated 27 June 2018

Checks on specific services

Outpatients and diagnostic imaging

Requires improvement

Updated 13 December 2016

Overall the services within outpatients and diagnostic imaging services required improvement. Most of our concerns related to imaging within safety, effective, responsive and well led. Outpatients was broadly satisfactory.

Within radiology there were concerns with the safety of signage, out of date clinical items and the management of controlled drugs. Clinical imaging protocols and risk assessments were not fit for purpose.

Staffing levels within the renal unit did not comply with NHS England and British Renal Society guidelines. Appointment letters and patient leaflets were only available in English. There was no method of monitoring the length of stay of patients within outpatients to ensure they were provided with food and drink.

There was not a clear vision and strategy within the outpatients and radiology departments. There were clear governance structures and defined reporting systems in place in both departments. However, the governance systems within radiography had not highlighted the many safety concerns and shortfalls with protocols and risk assessments specified within this report. There was no ownership of who was responsible for ensuring the department worked within best practice professional guidelines and IR(ME)R regulations.

Patients spoke highly of the staff in both outpatients and radiography. Patients described caring staff that were supportive and treated them with dignity and respect. We observed that staff were courteous, polite and friendly when responding to individual patient needs.

Maternity

Good

Updated 27 June 2018

  • The service maintained good standards of cleanliness and hygiene. We observed all areas were visibly clean and clutter free and staff followed regular cleaning schedules.
  • There was a good hand washing culture in the department; hand cleansing gels were readily available and were regularly used by staff and visitors.
  • The service had an electronic incident reporting system. Staff received feedback from incidents they had reported and lessons had been learned.
  • Staff at all levels demonstrated a thorough understanding of the Duty of Candour. The Duty of Candour regulation requires health service bodies to act in an open and transparent manner when things go wrong.
  • Staff at all levels were knowledgeable about how to recognise abuse in children and adults and understood how to escalate concerns.
  • The service treated patients in accordance with National Institute for Health and Care Excellence (NICE) quality standards and guidelines for maternity services.
  • Staff had the necessary qualifications and experience to conduct their role effectively.
  • New staff were well supported by more senior colleagues.
  • We observed close multidisciplinary (MDT) relationships between all staff groups in the maternity department.
  • Trained staff supported patients and their families to cope emotionally with their care and treatment. Feedback from patients, those close to them and stakeholders was consistently positive about the level of tailored support staff provided.
  • Staff ensured patients and partners were actively involved in decisions about their care and treatment.
  • There was a well-embedded culture in maternity services to put patient care at the centre of everything staff did.
  • Staff were considerate regarding the individual needs of patients and provided support to minimise the distress of patients and those close to them.
  • Bereavement midwives provided patients with specialist support during and after a pregnancy loss or neonatal death in hospital and following discharge home.
  • Staff were highly motivated to offer patients the best possible compassionate and emotional care and showed determination to achieve this.
  • Staff were responsive to the individual needs of patients. Translation services were readily available for patients whose first language was not English.
  • A range of specialist support was available to patients with complex needs. For example, bereavement midwives and vulnerable women midwives, which included responsibility for providing teenage pregnancies.
  • The service also provided dedicated clinics for long-term conditions such as diabetes.
  • The maternity service held a Supportive Training Offering Reassurance and Knowledge (STORK) programme, which taught parents basic life support, choking management, Sudden Infant Death advice in addition to breastfeeding, diet and smoking cessation.
  • Maternity services had not received high levels of complaints from people using their services. The service took complaints seriously.
  • Staff understood and felt engaged with the strategy for the maternity unit. Leaders of the took into account the maternity challenges the Black Country was currently experiencing.
  • The maternity service was well represented at the trust board. The board had oversight of the challenges the department faced.
  • The department was working collaboratively with maternity units and commissioners in the Black County region to develop and implement a local vision for improved maternity services and outcomes.
  • The maternity service’s risk register included the main risks to the service.
  • The service continued to strengthen involvement of the local community by engaging with patients and families as part of the Maternity Voices partnership.
  • The trust set a high target for mandatory training of 95% and although this was not met on all occasions, in maternity services, 88% or more was achieved in all training modules, with some attaining 100%.

However:

  • As at November 2018, the midwife to birth ratio was lower than the England average. However, a recent staffing acuity assessment had been conducted to review staffing establishment requirements. The service demonstrated all patients received one-to-one care when in labour.
  • Between September 2016 to August 2017, maternity staff had not met the trust target of 95% for either Mental Capacity Act (MCA) training or Deprivation of Liberty Safeguards (DoLS) training. However, the service had addressed this and as of February 2018, staff training compliance was above the trust target at 95.2%.
  • Medical staff were not trained to level 3 in children’s safeguarding. We found several examples where junior doctors had not completed the training and data provided indicated an overall compliance for level 3 safeguarding was at 0%. Following the inspection, the trust provided information assuring us they were taking urgent action to address this.
  • In the 2017 Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE) audit, the maternity departments stabilised and risk-adjusted extended perinatal mortality rate (per 1,000 births) at 7.11 was worse than their comparator group rate at 6.44.

Outpatients

Good

Updated 27 June 2018

  • The outpatients service was providing safe, effective, caring and responsive care and treatment and was well led.
  • The service was providing safe care to patients. There were appropriate processes in place to recognise and respond to patients who may have become unwell or required admission.
  • There was a positive culture of speaking up and raising concerns. Managers and staff embraced the incident and learning process and as a result, incidents were learned from, remedial action was taken and this reduced the risk of reoccurrence.
  • Medications were well managed and when we highlighted any issues to the service they were rectified immediately with long term and robust solutions.
  • The service was responsive to patients with additional needs and made every effort to ensure these needs were catered for.
  • Waiting times were not high, although the service missed the national target in some specialities. Where the target was missed it was due to additional patients being taken on from neighbouring trusts and the service had made every effort to reduce waiting times with initiatives and additional clinics.
  • Records were well completed and stored securely. The majority of patients had their full medical records when attending consultations.
  • Outpatient services were delivered by caring, committed and compassionate staff, who treated people with dignity and respect. We observed how staff interacted with patients and found them to be polite, friendly and helpful. Staff responded compassionately when people needed help and additional support.
  • Patients felt supported and say that staff cared about them. Staff involved patients and those close to them in aspects of their care and treatment. Patients we spoke with during our inspection were positive about the way they were treated.
  • Patients attending outpatient departments received care and treatment that was evidenced based and followed national guidance. Staff worked together in a multi-disciplinary environment to meet patients’ needs. Staff were competent to perform their roles and information relating to a patient’s health and treatment was available from relevant sources, before a clinic appointment.
  • There were safeguarding policies in place and clear procedures to follow if staff had concerns. Staff were aware of their roles and responsibilities and knew how to raise and escalate concerns in relation to abuse or neglect for vulnerable adults and children.
  • The trust employed competent staff and ensured all staff had access to relevant training that was appropriate for their roles.
  • The department was clean and equipment was well maintained.
  • Staff actively sought feedback from patients and staff and used this information to identify how the service could improve.
  • The service was well led with credible and visible leaders who were engaged with the trust wide leadership team and objectives.
  • There were areas of innovation and regular audit and research was used to improve services.

However:

  • There were issues identified with the patient transport services resulting in lengthy delays for patients in returning home. However, this was outside of the control of the trust
  • We saw that some higher risk medications were easily accessible to all staff, including domestic staff and healthcare assistants, because they were in a room that was only protected by a swipe mechanism. There were no restrictions to the swipe entry for the room. This was however rectified immediately by the trust.

Maternity and gynaecology

Good

Updated 13 December 2016

Overall we found the service was good although the domain of safe required improvement.

There were many good examples of the maternity unit being safe including incident reporting systems, audits concerning safe practice and compliance with best practice in relation to care and treatment plans. However emergency arrangements needed to improve.

Obstetric consultant cover was not adequate being below the required hours for the number of births undertaken annually.

Policies were based on National Institute of Clinical Excellence (NICE) and Royal College of Obstetrics and Gynaecology (RCOG) guidelines. People received care and treatment that was planned in line with current evidence-based guidance, standards and best practice.

The birth to midwife ratio was 1:30. The named midwife model was in place and women told us they had a named midwife. Midwives provided one to one care in labour.

Patients told us that they felt well informed and were able to ask staff if they were not sure about something. We saw limited patient information leaflets available.

In March 2013 the maternity service at the Royal Wolverhampton NHS Trust achieved compliance with level two requirements of the Clinical Negligence Scheme for Trusts (CNST) Maternity Clinical Risk Management Standards 2012/13, scoring 46 out of 50.

There was an active maternity services liaison committee (MSLC), which met quarterly.

Medical care (including older people’s care)

Good

Updated 27 June 2018

  • The initiatives in place to recruit additional nurses had meant that the provision of staff throughout the medical unit had improved since our previous inspection.
  • Incident reporting was improved and established and staff felt concerns were adequately addressed and feedback and learning took place.
  • Caring had improved since the last inspection. Patients thought staff were kind and friendly and felt that their dignity and privacy were respected. We observed kind and compassionate care where staff were sensitive to the needs of patients.
  • The trust worked together with partners and commissioners to respond to the needs of the patients. We saw patient focussed approaches to care and treatment.
  • Waiting times for treatment were generally better than the England average.
  • Staff were positive about the standard of care they provided and the support they received from their managers.
  • Ward areas were clean and hygienic and infection control processes were in place to safeguard patients from harm.
  • The culture of audit and improvement within the medical services was now embedded and the trust had won various awards for their quality improvement.
  • There was good Multi-Disciplinary Team (MDT) working and relevant staff met regularly to discuss the needs of the patients in each area.
  • We particularly noted good progress and improvements in helping to keep patients safe. The trust was focussed on reducing the number of patients who developed pressure ulcers and reducing the number of falls patients were sustaining.
  • There was a local vision and strategy for medicine which was linked to the trust’s overall vision.

However, we saw areas in which the service needed to improve:

  • Not all equipment was up to date with servicing requirements and therefore it could not be guaranteed that this equipment was safe to use. Some equipment was not stored safely.
  • Not all cleaning and other hazardous products were stored as required by the Control of Substances Hazardous to Health (COSHH).
  • Not all medication was prescribed, administered and stored safely.
  • Not all records pertaining to the care and treatment of patients, including fluid/nutritional intake were fully completed to reflect what patients had consumed.
  • The trust did not always maintain patients’ records securely to ensure confidentiality in line with the data protection act.
  • In the discharge lounge staff did not identify that a patient’s condition had deteriorated.
  • Not all staff had received up to date safeguarding training to meet the trust’s target of 95%,
  • The trust did not have a consistent approach around the practice of mental capacity assessments and deprivation of liberty safeguarding assessments.
  • The trust had set a high target for the number of staff completion of mandatory training and whilst this had not consistently been achieved most staff had received the required mandatory training.
  • The average length of stay for patients in the medical unit was higher than the national average.

Diagnostic imaging

Good

Updated 27 June 2018

  • Safeguarding policies and procedures were in place. There was good compliance with safeguarding training and staff knew how and when to make a safeguarding referral.
  • Processes were in place to ensure patients received the correct scans. Staff followed “The Ionising Radiation (Medical Exposure) Regulations 2017”.
  • All areas were visibly clean. There were hand gel dispensers in place, staff wore personal protective equipment and were arms bare below the elbow.
  • Equipment was serviced in line with recommendations. Handover sheets were completed when equipment was out of action; staff had a good understanding of reporting faults.
  • Risk assessments were in place and contained relevant information. There was signage and information to advise patients and staff where radiation exposure took place. There were radiation protection advisors in post.
  • Processes were in place for women who were pregnant; the processes ensured that staff were aware.
  • Staff understood their responsibilities to raise incidents. There was evidence of a learning culture in relation to incidents; incidents were discussed in meetings and managers provided feedback to staff.
  • Root Cause Analysis investigations were completed when an incident met the threshold.
  • There were processes in place for the safe disposal of radiopharmaceuticals. Radiopharmaceuticals were kept secure. Staff monitored fridge temperatures.
  • The department audited conformity with “The National Institute for Health and Care Excellence” (NICE) guidelines, 2017. Local audits also took place such as hand hygiene and audits of radiology checklists.
  • Clinical support workers were multi skilled, rotating to other areas of the department as required.
  • Staff had opportunities to complete training and updates. Continuing professional development sessions were held in lunch hours. We heard of several examples of career progression.
  • There were systems in place for GPs to make a referral to the service electronically.
  • Staff gained patients consent before any procedure was completed. Consent was audited on a trust wide basis.
  • Staff had an awareness of the Mental Capacity Act 2005. Staff had a fob which contained information on DoLS.
  • Staff were caring, polite and considerate to patients. We saw that they protected patients’ confidentiality and treated them with dignity and respect.
  • Staff provided us with several examples of how they reassured patients who were anxious about having a diagnostic test.
  • Most facilities were suitable for use by bariatric patients.
  • A porter service was available to transport patients to and from ward areas. Additional porters were in place at busy times.
  • Staff understood and respected patient’s personal, cultural, social and religious needs. The hospital had an interpretation service.
  • An external company had been brought in to help reduce some of the backlogs; this had been successful.
  • The department investigated complaints quicker than in the trust policy. Patients received updates on their complaints and apologies. Complaints were discussed in staff meetings and staff could give examples of how practice had changed due to a complaint.
  • Leaders were knowledgeable. Staff felt informed and supported by their leaders, they felt that leaders were visible and approachable.
  • Leaders could identify challenges and plans were in place when challenges were identified.
  • There was a five-year plan in place to address how the department would achieve its priorities in 2015-2020.
  • There was a clear governance structure in place. Staff knew what they were accountable for.
  • The department had a risk register, risks were discussed at monthly clinical governance meetings; the meetings were well attended by key staff.

However

  • Not all staff were trained to level 3 in safeguarding children. Staff told us that when a child was due for a procedure a level 3 trained person is in attendance. However, in an emergency or out of hours we not assured that suitably trained staff would be available.
  • At the time of the inspection, the department had not signed up to the Imaging Service Accreditation Service (ISAS).
  • Mandatory training compliance rates for medical staff were low.
  • Handwashing amongst staff appeared inconsistent.
  • A dirty utility area was being used to store clean items such as sharps bins and cardboard patient bowls due to lack of storage.
  • Some consumable items had expired and this had not been recognised by staff.
  • Some policies and procedures needed to be updated.
  • There was a high number of radiographer vacancies within the department; however, the department were actively recruiting.
  • There was nothing specific in place to support patients with dementia or a learning disability and staff often relied on information provided by the referrer.
  • There were no processes or pathways for urgent referrals. Staff would mostly use their discretion or common sense.

Urgent and emergency services (A&E)

Good

Updated 27 June 2018

  • There was an incident reporting process in place and staff knew how to report incidents.
  • Staff supported and provided new staff with individual induction plan to ensure the skills they bought with them were recognised and any additional training required would be identified.
  • ED had an open and learning culture, fully focused on safe and high quality patient care.
  • The trust employed competent staff and ensured all staff were trained appropriately to undertake their roles.
  • Safeguarding procedures and processes were in place to safeguard and protect vulnerable patients from avoidable abuse.
  • Patients received a robust clinical assessment when presented to ED.
  • ED used a nationally recognised triage system; staff in triage were trained to use this system.
  • Infection, prevention, and control (IPC) measures were in place to ensure patients were protected against hospital-acquired infections whilst in the department.
  • The department was clean and some equipment was well maintained.
  • Staff followed evidence based pathways to ensure patients were cared for safely and effectively.
  • Medicines management and documentation were generally good.
  • The trust’s median time from arrival to initial assessment was consistently better than the England average.
  • There was a room available in ED for staff to assess adults and children with mental health conditions.
  • The trust had an observation policy and restraint policy.
  • The trust had a psychiatric liaison team, available 24 hours a day, seven days a week and an on call psychiatrist available 24 hours a day, seven days a week.
  • Regular governance meetings took place.
  • Staff actively sought feedback from patients and staff and used this information to identify how the service could improve.
  • We saw examples of positive local leadership in the emergency department.

However:

  • Managers had not ensured that all staff had completed their mandatory training;
  • Mental Capacity Act (MCA) training had low compliance rate.
  • Documentation was not consistent.
  • Temperatures for medicine refrigerators were not always recorded throughout the emergency department.

Surgery

Good

Updated 27 June 2018

Our rating of this service stayed the same. We rated it it as good because:

  • Staff were aware of how to report incidents; learning from trust wide incidents was shared via meetings and updates. Following never events that had occurred within the surgery directorate, actions had been put into place to prevent reoccurrence Staff were aware of the never events and spoke about changes made following these.
  • Staff understood how to protect patients from abuse. Staff were aware of safeguarding adults and children arrangements and provided examples of measures put into place to safeguard patients from harm.
  • In the main, infection prevention and control was to a good standard. Staff wore appropriate personal protective equipment and patient areas were visibly clean. However, we did notice on a small number of occasions, staff who did not wash or gel their hands upon entering ward areas.
  • Audit results showing patient outcomes were varied. Many measures showed the trust were in line with the England average for outcomes following specific surgery; however, the trust were worse than the England average in some standards.
  • Staff followed best practice and followed National Institute of Health Care Excellence (NICE) guidelines. Guidelines, policies and standards were available for staff to refer to when providing patient care and treatment.
  • Staff worked together well as a multidisciplinary team; referrals were made to appropriate professionals who ensured they shared relevant information within patient records and during ward rounds.
  • Staff treated patients with dignity and respect. Patients were cared for with compassion. Staff made effort to ensure patients were emotionally supported and kept informed of their treatment and care.
  • Patients individual needs were responded to; staff were aware of how to support patients with additional needs such as sourcing interpreters, and liaising with specialist teams within the trust.
  • The number of cancelled operations had reduced since 2016. During this time, all cancelled patients were re-booked within 28 days as per national standards.
  • During the inspection, we saw a positive culture of teamwork and support that mirrored the trust’s vision and values. Local leadership enabled shared learning and development; and encouraged an open approach to reporting incidents.
  • The surgical directorate were involved in a range of research and innovative projects with the aim of improving patient outcomes.

However, we saw areas in which the service needed to improve:

  • We noted some specific areas where the theatre department did not meet infection prevention and control standards. For example, we saw damage to the walls and floors and cleaning logs were not consistently completed.
  • Although the World Health Organisation (WHO) safer surgery checklist was generally completed to a good standard, we saw one occasion whereby one part (‘sign out’) was not completed. Auditing of the safer surgery checklist showed deterioration in compliance.
  • Mandatory training compliance, particularly for medical staff, did not meet trust targets for several modules. However, the target for compliance was set high at 95% and compliance levels were high in most subjects.
  • The risk of readmission following surgical procedures at New Cross Hospital was higher than the national average for elective admissions.
  • We saw on one occasion; an assessment of a patient’s capacity to consent to treatment had not been accurately assessed.
  • From December 2016 to November 2017 the trust’s referral to treatment time (RTT) for admitted pathways for surgery was consistently worse than the England average.

We observed some patient identifiable information was unsecured within ward areas.

Intensive/critical care

Requires improvement

Updated 13 December 2016

Critical care services required improvement to support safe care. There were significant risks posed by the infrastructure and environment of the integrated critical care unit (ICCU). Medical staffing was appropriate and there was good emergency cover. The storage of medicines in the integrated critical care unit (ICCU) required improvement to ensure secure storage facilities to reduce the possibility of misappropriation of medicines. We found intravenous medicines were mixed within the storage room visited which could lead to the misadministration of medicines to patients.

Staff told us they were encouraged to report any incidents which were discussed at weekly meetings. There was consistent feedback and learning from incidents reported. The service had procedures for the reporting of all new pressure ulcers and slips, trips and falls. The environment was visibly clean and most staff followed the trust policy on infection control.

The critical care service demonstrated good effective care. Patients received care and treatment according to national guidelines and there was good multidisciplinary team working to support patients. The service participated and provided data for the Intensive Care National Audit & Research Centre (ICNARC). This ensured that the practice was benchmarked against similar services. Policies and procedures were accessible to staff. However, we saw that some hard copies of policies were dated 2007 to 2014 with no evidence of review. Staff told us they were able to access up to date policies on the trust’s intranet system.

Patient’s pain was appropriately managed as was the nutrition and hydration of patients. Staff had access to training and had received annual appraisal. The critical care service had a consultant-led, seven-day service. Staff had awareness of the Mental Capacity Act (MCA) and the Deprivation of Liberty Safeguards (DoLS).

We observed good care within the ICCU. Staff cared for patients in a compassionate manner, with dignity and respect. They involved patients and, where appropriate, their relatives in the care. Emotional and spiritual support was also provided.

The critical care services were responsive to the needs of patients. Patients were admitted to and discharged from the unit at appropriate times. Patients had follow-up support from the outreach team.

Patients with a learning disability were provided with the necessary support. Staff also had access to translation services. Complaints were handled appropriately.

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We found that critical care services required improvement to be well-led. Most staff were not aware of the vision or strategy for the critical care service.

The ICCU held monthly clinical governance meetings where quality issues such as complaints, incidents and audits were discussed. However, there was a disconnect between the risks identified at unit level and those identified and understood by senior management. There were concerns about the impact on patient care and safety which were not identified on the risk register.

There was a culture of support and respect for each other, with staff willing to help each other. Staff told us they were able to speak openly about issues and incidents, and felt this was positive for making improvements to the service.

Patients were engaged through survey feedback. The survey questionnaires showed that patients were happy with the care and treatment they had received.

Innovative ideas and approaches to care were encouraged and supported. There was positive awareness among staff of the expectations for patient care.

Services for children & young people

Good

Updated 13 December 2016

Overall we found the service to be good.

We found that there was a reactive culture in the service which responded well after events had happened. They shared learning to prevent an event re-occurring and responded to issues which had been brought to their attention.

Similarly the Trust Development Agency (TDA) had completed a review of the paediatric ward earlier in the year, they identified 77 minor issues. We saw evidence during our inspection that all the issues had been dealt with and interventions put in place to prevent them re-occurring, but again the issues were such that proper governance and supervision should have identified.

We found that services were caring and staff were dedicated and knowledgeable.

Services were based on recognised clinical pathways which meant patients received treatment based on the latest information and best practice guidance.

Patient care was individualised and designed to meet the physical and mental needs of each patient. The service responded to people’s needs.

The service needed to improve to identify failings and prevent issues occurring in the first place.

We saw instances of unsafe practice in relation to services provided to children and young people both in the paediatric day-case unit and the fracture clinic. These were escalated and dealt with immediately, but the service failed to identify the risks themselves.

 

End of life care

Good

Updated 13 December 2016

Out of the 94 incidents reported to the palliative team, we saw eight were in relation to low staffing levels. We noted some resulted in palliative patients not being attended to or observed as often as they required and “Care was compromised”. Staff on surgical wards told us they would struggle to ensure end of life patients received the care that they needed. However, they told us that the palliative team were aware of their pressures and were very supportive.

The palliative team were not solely responsible for end of life patients but they supported the medical and nursing teams in providing specialist advice.

We reviewed 20 medication administration records across the wards and units inspected and found these were consistently well completed. Although improvement was needed to ensure that controlled medicines were safely and appropriately administered.

We reviewed medical and nursing paper care records and Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) records and saw these were well completed.

The palliative team worked across both New Cross Hospital and Cannock Chase Hospital so we found similarities across both sites. On both sites we found staff were well engaged with education and training programs around end of life care and it has taken a priority to ensure the care of patients and families is enhanced.

The palliative care team had introduced a staff survey, the results identified how approachable, supportive and informative members of the team were.

The palliative team were in the process of implementing the Swan Project at both hospital sites as a care planning tool and guidance for patients in the last few days of life. Staff adopted practices of the Salford Royal NHS Foundation Trust such as: the Swan logo being placed on the curtains or the door of the side room to alert staff to be mindful, relatives were given canvas bags with the Swan logo with their relative’s belongings as oppose to a plastic bag, staff offered families of end of life patients keepsakes such as photographs (of hands) and handprints, locks of hair (taken discreetly from behind the ear and presented in an organza bag not as previously in a brown envelope) , staff returned jewellery in a small box, they were given the choice of the deceased being clothed in their own clothes rather than a disposable paper shroud and the hospital renamed the mortuary the Swan Suite for discrete communication in public areas. Literature on both hospital sites had been updated and rebranded such as: the advanced care plan, the ‘practical information leaflet’ and the feedback survey was redesigned to have the Swan logo.

The rationale for the Swan logo was to trigger a compassionate response and kind communication. All staff at New Cross Hospital and Cannock Chase Hospital were aware of the project and had recently started the project for the past few patients. During the inspection we found the scheme to be in its infancy stages although all staff were fully aware of the project, what to do and how to implement it should they be caring for a dying patient.

We noted there was easy access to the palliative care team and they were responsive in supporting ward staff.

On both hospital sites the staff developed a ‘Rapid Home to Die Care Bundle’ which facilitated a rapid discharge. Staff told us they had used this bundle several times and were able to discharge a patient with a complex package of care within 24 hours.

For both hospital sites the palliative team had a clear vision for their service. The leadership, governance and culture promoted the delivery of high quality person centred care. The team displayed good engagement and attendance at national/international conferences and the West Midlands expert advisory group for palliative care.

The palliative team felt the trust were engaged with topics around end of life care and were supportive in their efforts to improve the service. They told us the board staff members were visible and were engaged in best practice.

We saw the culture was a positive energetic one.