Herefordshire and Worcestershire Health and Care NHS Trust

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

This means we looked for evidence that people were protected from abuse and avoidable harm.
At our last assessment we rated this key question Good. At this assessment the rating has changed to Requires Improvement.

Requires improvement: This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety based on openness and honesty, in which concerns about safety were listened to, safety events were investigated and reported thoroughly, and lessons were learned to continually identify and embed good practices.

Between January and September 2025, Cherry Orchard ward reported 182 incidents, with 93% resulting in minimal harm. The 2 most reported incident categories were inpatient falls (78) and pressure ulcers (25). Lickey ward recorded 330 incidents, with 90% resulting in minimal harm. The 2 most reported incident categories were inpatient falls (95) and pressure ulcers (59). Cottage ward had 222 incidents, with 91% resulting in minimal harm. The 2 most reported incident categories were inpatient falls (58) and pressure ulcers (44). Across all wards, other incident categories included clinical deterioration, accidental harm, issues around staffing, violence, abuse and harassment and unsafe admissions. Staff we spoke to could give appropriate examples of when they would report something as a patient safety incident.

Staff and leaders gave examples of how learning had been embedded into practice. Most staff felt the trust placed emphasis on learning. Staff said learning from incidents and complaints was shared in team meetings and via email. We saw examples of improvements to the service following lessons learned from incidents. For example, the provider had improved systems for the identification and management of delirium in patients within community services and had implemented a new nursing care bundle. The “Delirium Care Bundle” aimed to provide a consistent approach in the management of delirium care in community hospitals, as the provider had identified those who experienced delirium were at an increased risk of hospital-acquired complications, such as falls.

We saw there were a higher number of incidents reported under the violence, abuse and harassment incident category on Lickey ward compared with the other 2 wards we visited. Incident data did not always clearly document what staff had learnt from incidents, and it was not always documented whether staff had been offered a debrief to discuss learning from individual incidents. The provider had acknowledged staff concerns and developed a staff bulletin in August 2025 to highlight support measures they had put in place. Support measures included the introduction of safety intervention training which was due to be rolled out to all clinical staff in October 2025. Although some action had been taken, further action was required to ensure that learning from this type of incident was well documented and embedded into practice.

The provider had policies and procedures in place that gave staff guidance about reporting, managing, investigating and learning from incidents. The trust’s Patient Safety Incident Response Policy met the requirements of the Patient Safety Incident Response Framework (PSIRF). PSIRF is focused on learning from incidents to improve patient safety. Staff we spoke with understood the patient safety incident response framework and they could tell us what incidents they needed to report and how to report them.

The trust used several learning response methods to investigate patient safety events. For example, some incidents were investigated using “Local Learning” which meant patient safety events were investigated by the service or team managers with learning being shared locally on the wards. Senior leadership teams would review safety actions and discuss this to determine appropriate action. The provider held a monthly integrated governance meeting whereby escalated risks from incident reports were discussed using a standardised meeting agenda. For multiple incidents with a similar theme, the trust could undertake a thematic analysis to identify patterns and potentially implement trust wide learning.

Patients, relatives, carers or visitors could raise a complaint. Complaints could be received in several formats and staff told us they would signpost people wishing to raise a complaint to the Patient Liaison Service (PALs.)

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. Staff ensured continuity of care, including when people move between different services.

The provider’s referral and admission processes ensured essential information was received to determine if the patient’s needs could be met. Staff and managers told us they had access to all information they needed to meet patient’s care needs from the point of admission to discharge. Inappropriate or unsafe admissions was an incident reporting category. We reviewed incident data and found levels of this type of incident were significantly lower than other incident categories across the 3 wards. We reviewed incident data and found actions taken were well documented for this type of incident.

The trust had an exclusion criteria listing several medical and rehabilitation needs that would not be suitable for the community hospitals. For example, people requiring acute mental health interventions. Patients were appropriately escalated to receive acute healthcare when showing signs of physical deterioration.

Staff involved all the necessary health and social care services to ensure patients had continuity of safe care, both within the service and following discharge from the service. All patients were reviewed by their multi-disciplinary team, including doctors, nurses, social workers and physiotherapists. Discharge planning was a multi-disciplinary team approach. We observed a multi-disciplinary meeting on Cherry Orchard ward where continuity of care was discussed for all patients.

The trust had identified length of stay within their community hospitals was higher than other community hospitals nationally. The trust had launched a Length of Stay Reduction Programme in April 2025 to address this, with a view of reducing the length of stay and treating more patients in their own homes. Leaders told us the average length of stay was around 29 days and focused work would take place for those with a length of stay above 50 days. We reviewed integrated governance meeting minutes for September and saw that senior leaders had discussed length of stay and agreed multi-disciplinary action for those experiencing the longest stays in their community hospitals.

Staff on Lickey and Cottage ward told us patient acuity was higher on the wards than it had been in the past, which they felt accounted for a higher number of incidents. Patient acuity is a measure of the severity of a patient’s medical condition and the intensity of care they require. Leaders told us this may be attributed to an increased number of patients with cognitive impairment who were admitted for rehabilitation. Although both wards admitted patients with similar support needs, we observed there were a higher number of incidents of violence and aggression on Lickey ward in comparison to Cottage ward. However, from the evidence reviewed it was not clear whether there was a different admission criterion for the 2 wards.

The service did not always work with people to understand what being safe meant to them as well as with partners on the best way to achieve this. The service did not always concentrate on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, and did not always make sure concerns were shared quickly and appropriately.

The trust had policies on safeguarding adults and children at risk of abuse. All staff received training specific to their role on how to recognise and report abuse. All clinical staff undertook mandatory safeguarding adults and safeguarding children training, the level of which was dependent upon their role. Staff had training between a level 1 and a level 3. Cottage ward had 97% compliance for safeguarding adults and 97% for safeguarding children. Cherry Orchard ward had 96% compliance for safeguarding adults and 90% for safeguarding children. Lickey ward had 89% compliance for safeguarding adults and 97% compliance for safeguarding children.

Staff we spoke with had a good understanding about safeguarding and could give examples of how to protect patients from abuse and neglect. Staff knew how to identify abuse and the actions they needed to take if they suspected a patient may have experienced abuse. The trust had a designated safeguarding lead. Most staff told us they would speak to their manager in the first instance if they had any concerns. Contact details for the safeguarding lead were displayed on boards in the ward office.

Where patients lacked capacity to consent to being on the ward, a DoLS authorisation had been applied for and were in place at the time we inspected. These are legal procedures designed to protect people who may lack the capacity to make informed decisions about their care and treatment in hospital. We reviewed patient records and found Mental Capacity Assessments had been completed where necessary.

Some patients had ReSPECT forms in place, and these were located by patient’s bedside. This is a document that provides guidance for medical professionals when the person is unable to communicate their wishes, including whether to attempt resuscitation. However, we were not assured these documents were made in collaboration with patients and their relatives. We reviewed 6 RESPECT forms on Lickey ward and it was not documented on 3 of these forms that they had been developed through conversations with the patient and their relatives, as wishes and preferences were not always documented.

Although the provider had ensured compliance with safeguarding training and policies available to staff, we found staff were not always acting in line with operational policy. The provider’s Adult Safeguarding Policy stated, “Where there are allegations or there is evidence of abuse this is reported using the Trust Safeguarding Adult Pathway to include referral to the Local Authority Adults Service.” The Local Authority protect children and adults at risk from abuse and neglect by making enquiries into concerns and delegating services to conduct a Section 42 enquiry. A Section 42 enquiry is an investigation by a local authority to determine if an adult is at risk of, or experiencing, abuse or neglect, which is a legal duty under The Care Act 2014. We requested information on any safeguarding referrals made to external agencies across the 3 wards we visited and received data to suggest 0 safeguarding referrals had been made between January and September 2025.

We reviewed further safeguarding incident data which documented action taken following 5 safeguarding incidents across the 3 wards and were not assured that they had been reported to the local authority. Leaders told us of the 5 incidents, 1 had been reported to the local authority and subsequently closed with no further action. They told us the other 4 had been investigated using a multi-agency approach, including discussions with a ward-allocated social worker (employed by the local authority,) the police and Integrated Care Board (ICB.) Leaders said integrated safeguarding staff used their professional judgement to determine that a referral to the local authority was not required. Although incidents were being investigated and referrals were considered, this meant that the local authority could not always determine whether a safeguarding incident met the threshold for a Section 42 enquiry.

The service did not always work with people to understand and manage risks by thinking holistically so that care met their needs in a way that is safe and supportive and enabled them to do the things that matter to them.

All care records we reviewed included a range of standard risk assessments relevant to the service including risk of falls, tissue viability (risk of developing a pressure ulcer) and risk of malnutrition. Risk assessments were completed using nationally recognised tools, such as the Malnutrition Universal Screening Tool (MUST) for malnutrition risks. Some patients had additional risk assessments such as the use of bed rails. The service had recently implemented the use of a “Delirium Care Bundle.” This was an additional nursing care bundle used in community hospital settings across the trust to support the assessment and care of patients with delirium and the associated risks.

Staff monitored patient’s food and fluid intake hourly and completed food and fluid charts which were stored by the patient’s bedside. Although most food and fluid charts were completed in a timely manner, we observed these checks were not always taking place, or it was not documented this was taking place, on Lickey ward. We reviewed 8 food and fluid charts and found that 1 had gaps over several hours, so it was not evidenced this patient was being offered hourly fluids.

Staff used a nationally recognised tool to identify deteriorating patients (the National Early Warning Score (NEWS) 2 scoring system) and escalated concerns appropriately. When a concerning score was calculated, the patient was escalated for a medical review. Staff demonstrated a good understanding on the use of this tool and how to escalate a deteriorating patient. The trust had a Recognition and Management of Physical Health Deterioration in Adult Patients policy, which provided information to staff on when to assess patient’s vital signs, escalate concerns and how to appropriately communicate those concerns. The policy also included information on the identification and management of Sepsis.

Although there were areas of good practice observed at this assessment, we were not always assured staff had access to the appropriate guidance in managing potential risks. We reviewed incident data and found there were higher numbers of incidents reported under the violence, abuse and harassment incident category on Lickey ward compared with the other 2 wards we visited. Staff told us they did not always feel supported in managing these types of incidents and felt this was putting patients and staff at an increased risk of harm. Staff had raised these concerns with the trust, and leaders told us they were addressing staff concerns by providing guidance to staff in patient records. Leaders told us staff were directed to the delirium care bundles in individual patient records for guidance in managing behaviour of those who are expressing distress or agitation. However, we requested the delirium care bundle relating to 3 patients who had been involved in incidents of violence and aggression. The trust told us those patients did not have a delirium care bundle in place as they did not have delirium, and that staff would therefore follow dementia care plans instead. We requested copies of these dementia care plans and received 2 that were limited in information and did not provide clear person-centred guidance for staff. We were not assured the provider had ensured the appropriate guidance was in place for managing the behaviour of those expressing distress or agitation.

Leaders told us they had a Therapeutic Observation Policy available to staff to provide guidance in managing behaviours of those expressing distress or agitation. We reviewed this document and found that it provided guidance to staff on ensuring all inpatients were safely allocated the appropriate level of observations. This policy did not provide person-centred behaviour management plans and did not address individual risks people may have been presenting with. For example, the policy aimed to provide a framework for all inpatients in accordance with their individual assessed level of risk and identified needs, however this was a generic document and did not provide specific guidance for each individual need. Therefore, we were not assured this document would provide the appropriate guidance to staff in managing violence and aggression in patients. The provider had taken some action to address this and had arranged safety intervention training for all staff, with a target of all staff being trained by the end of January 2026. However further action was required to ensure improvements were embedded into practice.

Staff shared key information to keep patients safe when handing over their care to others. All wards held a daily shift change handover where information on patients’ risks were shared. We attended a multidisciplinary meeting on Cherry Orchard ward, and this included all necessary key information to keep patients safe. However, staff on Cherry Orchard ward did not always feel involved in managing patient risks. One staff member told us they felt decisions were made without discussing with the staff who worked closely with patients daily.

The service did not always detect and control potential risks in the care environment and did not always make sure that the equipment, facilities and technology supported the delivery of safe care.

The wards we visited had enough suitable equipment to help them safely care for patients including hoists, wheelchairs and physiotherapy equipment. The clinic room and sluice rooms were orderly and had adequate medical equipment and stocks of single use items. Clinical waste including sharps was managed appropriately and stored safely in staff only areas.

The provider carried out health and safety audits and inspections of the care environment; however, these were not always robust in identifying potential areas of concern and were not always completed regularly. For example, we reviewed a health and safety audit of Worcester City Inpatient Unit from November 2024, but we did not see evidence this had been completed for Lickey and Cottage ward in the 12 months preceding our assessment. We also reviewed the provider’s Planned Preventative Maintenance (PPM) schedule and found evidence that health and safety checks had not always been completed within the provider’s schedule.

We reviewed a fire risk assessment certificate of conformity for Worcester City Inpatient Unit for April 2024, which is an official document to state a building meets established fire safety regulations. However, we identified concerns relating to fire safety during our assessment. We observed fire doors across the 3 wards were held open with different objects including bins and trollies, and some fire doors were seen to be in a poor state of repair. Fire evacuation drills were not completed regularly. The provider could not provide evidence they had been completed for the 3 wards in the 12 months preceding this assessment. We were therefore not always assured fire risks were being appropriately managed within the care environment.

Staff on Cherry Orchard ward told us the allocated maintenance staff member had left earlier in the year. Staff reported the response time to maintenance requests had significantly increased, which they felt had an adverse impact upon safety and patient experience. One member of staff provided 2 examples of environmental work that had not been completed despite being reported to maintenance, however specific time frames were not provided.

Potential health and safety risks to patients were not always identified by staff. For example, in a communal area of Lickey ward, we found expired, mouldy and unlabelled food items in the patient and staff fridges. This posed a risk to patients as poor food hygiene practices increase the risk of foodborne illness. We also observed safe operating temperatures for fridges and freezers were not always monitored consistently. On Cottage ward, we observed an unlocked drawer in Activities of Daily Living (ADL) kitchen which contained a sharp knife and scissors. Leaders told us patients were unable to access the area and therefore the risk was reduced, however we observed a patient independently entering the kitchen at the time of our assessment. This posed potential risks to those who were able to independently mobilise around the wards.

Cherry Orchard ward had control access to enter and exit the ward, including access cards for staff. However, we did not find similar security controls on Cottage and Lickey ward and found they were easier to enter and exit, using door release buttons. During our visit we observed 1 patient leave the ward on two separate occasions and although this was quickly resolved, it demonstrated a lack of safety on the ward, particularly for those subject to DoLS. The provider had taken action to reduce these risks by attaching a piece of paper over the door release buttons to make them less visible. This was not documented as a risk on the provider’s risk register, so we were not assured the provider had taken the appropriate action to appropriately manage this risk.

All wards had accessible resuscitation equipment and emergency drugs that staff checked regularly. The records on checks on all resuscitation equipment were complete and up to date.

Health and safety training was part of staff mandatory training. We found compliance was above 90% across all 3 wards we visited.

The service did not always make sure there were enough qualified, skilled and experienced people, who received effective support, supervision and development and worked together effectively to provide safe care that meets people’s individual needs.

The trust had a recruitment policy in place which documented required information to be obtained for all new members of staff. This included verification of identity, proof of professional registration with the relevant body such as the Nursing and Midwifery Council, employment history and reference checks. Staff were also subject to an enhanced Disclosure and Barring Service (DBS) check. DBS checks provide information about details of convictions and cautions held on the Police National Computer.

Staffing boards displayed on each ward showed that the actual number of staff on shift matched the planned establishment levels for each ward for health care assistants and registered nurses. For example, we observed that Cherry Orchard ward had met safe staffing levels on the day of our visit. For a late shift, the agreed staffing level was 3 qualified staff and 5 health care assistants, and we saw that the actual staffing level reflected this. We reviewed staff rotas over a 3-month period across the wards we visited and found that staffing levels were consistently within the trust’s established safe staffing levels.

Most staff at Worcester City Inpatient felt that there were sufficient staff to meet the needs of the patients. At the time of our assessment, since the closure of Apple Orchard ward, some staff had been redeployed to Cherry Orchard ward, so we observed a high number of staff on the ward.

Despite staffing levels falling consistently within the trust’s established safe staffing levels, we heard from staff and patients on Lickey ward that staffing pressures were at times impacting on the staff’s ability to provide a good standard of care. We heard from several members of staff that the establishment for safe staffing levels were insufficient to meet the needs of patients, and that patients were frequently left without support. Staff on Cottage ward also told us that they did not always feel supported by safe staffing levels, however staff on Lickey ward placed particular emphasis on feeling “burnt out” and not always being able to meet patient’s needs.

Most patients on Lickey ward told us that although staff were kind and respectful, they were very busy, so support was not always received in a timely manner. One patient added that it can take a very long time to be supported to use the toilet and staff members also told us that this happened frequently. The ward used call bells, and we observed that these were not always responded to in a timely manner. Although we did not observe any impact on patients in relation to receiving medication, we did observe several patients waiting for support with their eating and drinking. We did not observe staffing levels having any impact on patient care on Cherry Orchard ward, despite similar patient numbers.

Staff on Lickey ward told us that the trust were not taking patient acuity into account, so although safe staffing levels were being met, this was not sufficient for the level of care each patient required. Staff also told us that there was confusion around roles and responsibilities across qualified staff and health care assistants. The trust had an action plan in place which had identified clarity of roles and responsibilities, review of staff skill mix, and effective allocation of work and coordination during shifts as action points. Work was ongoing around these actions points at the time of our assessments to address staff concerns around safe staffing levels.

The trust held a twice-yearly safer staffing audit which reviewed safe staffing levels. Information in relation to this was shared with staff on Lickey ward via a staff bulletin, however, did not address whether changes to safe staffing levels would be made.

We reviewed staff sickness rates for each ward and found that Lickey ward had higher rates of staff sickness over a 3-month period. Between April 2025 and September 2025 there had been 106 episodes of staff sickness, compared with 53 on Cottage ward within the same period. The percentage of staff sickness on Lickey ward in August 2025 was 14.4% which is both higher than the national average and the other 2 wards we visited. Staff turnover was also higher on Lickey Ward, with 5 leavers between April and September 2025, compared with 2 leavers on Cottage ward within the same period.

Staff told us that nursing and health care assistants shifts with gaps were filled with bank or agency staff. We reviewed staffing data over a 3-month period and found that Lickey ward consistently had a higher usage of bank and agency staff than Cottage and Cherry Orchard ward. For example, in September 2025 the total hours for use of bank staff on Lickey ward was 1060, compared with 772 on Cottage ward and 887 for Cherry Orchard ward. The trust had a policy for the induction of staff including temporary staff, which included information on a staff induction handbook that was available to staff on the intranet. However, 1 staff member on Lickey ward told us that bank staff sometimes arrived on the ward without adequate training. The trust had a temporary staffing reduction programme in place which aimed to reduce bank and agency spend within the trust by the end of the financial year (April 2026.)

Rates for supervisions were low across the three wards. We reviewed data and found that supervision rates were consistently below the trust’s target of 95%. For example, in August 2025 47.2% of Cherry Orchard ward staff had received clinical supervision. There was an improvement plan in place for Cherry Orchard ward which had identified the need for a structured, consistent framework for regular supervision. The plan stated that this had been achieved in May 2025, however we did not see evidence that improvements in this area had been embedded into practice. Rates for yearly appraisals were higher and mostly in line with the trust target of 95%. For example, in August 2025, the appraisal rate on Cherry Orchard ward was 97.1%.

Staff had received and were mostly up to date with appropriate mandatory training including safeguarding, moving and handling, infection control and equality and diversity. Compliance for mandatory training was above 90% for all 3 wards we visited.

The service did not always assess and manage the risk of infection, detect and control the risk of it spreading and share any concerns with appropriate agencies promptly.

We saw that the environment was mostly visibly clean. Cherry Orchard ward appeared to need refurbishment and modernisation; however, the environment was visibly clean.

Staff followed infection control principles, including being bare below the elbow and using personal protective equipment (PPE.) We observed staff complying with hand hygiene best practice and washing their hands between patients. PPE was well stocked in storage rooms and hand sanitiser dispensers were situated throughout all wards we visited.

Patients who were tested as positive or showing any signs of infection, which could be passed to others, were isolated as soon as possible. Whilst visiting Lickey ward, 1 patient was diagnosed as being Covid-19 positive, staff took swift and appropriate action to minimise the associated risks to patients, including restricting access to the area and appropriate use of PPE.

Hazardous and clinical waste was not always responsibly managed. Although there were appropriate areas for disposal, we observed faeces in a bedpan within an unlocked sluice room on Lickey ward, posing infection risk to patients, particularly to those with cognitive impairment who may wander around the wards. Further hygiene risks observed were the storage of pillows on the floor within a storage cupboard on Cottage ward and bar of hand soap on the sink of a communal bathroom.

Communal areas on Cherry Orchard ward were carpeted, which had potential infection, prevention and control (IPC) risks to patients. The trust had confirmed there were no plans to replace the carpet due to the anticipated closure of the service. This was documented on the risk register, and the trust had taken the appropriate action to minimise this risk in the interim, including an increased cleaning schedule to manage associated hygiene risks.

The provider undertook IPC audits of the ward environment. The audit highlighted areas such as the environment, waste disposal, decontamination, hand hygiene, personal protective equipment and infection control practices. The most recent audits for all 3 wards we visited took place in August 2025. Although staff had identified areas of improvement on these audits, action taken was not always documented. For example, we reviewed the IPC audit for Cottage ward and the area “All high and low surfaces are free from dust and cobwebs” was documented as non-compliant, however there were no comments provided on how this would be addressed. We were therefore not assured that appropriate action was taken following the identification of risk.

Infection Control training was part of staff mandatory training. We found that compliance for this training was above 90% for Cherry Orchard and Cottage ward, however compliance on Lickey ward was lower at 83.8%, which was lower than the trust’s target of 90%.

The service did not always ensure that medicines and treatments were safe and met people’s needs, capacities and preferences by enabling them to be involved in planning, including when changes happen.

Staff followed the trust’s systems for the safe prescribing and administration of medicines. Across the wards we visited, staff demonstrated compliance with national guidelines, including those from the National Institute for Healthcare Excellence (NICE.) The trust had a medicines policy in place that was dated and version controlled. The policy set out the roles and responsibilities of all registered health professionals employed by the trust, including the prescribing, administration, ordering, dispensing and distribution of medicines. The policy provided links to further guidance, for example, in the event of a medication error.

Patients notes and prescription charts we reviewed had all necessary fields completed. Records demonstrated that staff administered patients prescribed medication within the correct time frame.

Emergency medicines and equipment were checked by ward staff and there was appropriate stock available, including oxygen cylinders. Ward staff checked clinic room fridge temperatures daily and stock was checked regularly and in line with policy. Staff had access to the appropriate PPE.

Most medication was stored safely and in appropriate areas, including controlled drugs. However, medicines ‘To Take Out’ (TTO’s,) which refers to discharge medication a patient receives when leaving hospital, were not always stored appropriately within the clinic rooms. The trust’s medicines policy states that “TTO’s should be stored in a locked medicine cupboard until handed over to the patient or representative,” however we observed across all 3 wards we visited that TTO medication was not being stored in line with policy. We also observed that some medication, including eye drops and inhalers, was not appropriately labelled with the patient’s details, which increased the risk of inappropriate medication administration.

Systems and process were not always robust in the identification of concerns within the clinic room. Although the unlocked TTO medication had been identified as non-compliant in a clinic room audit of Lickey ward in September 2025, we did not see evidence of this in the most recent clinic room checklist for Cottage ward, which was completed in September 2025. Furthermore, we were not assured that a recent audit had been completed on Cherry Orchard ward as we did not see evidence of this, therefore the identification of this risk and actions taken to manage this had not been documented.