South Warwickshire University NHS Foundation Trust

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

We looked for evidence that people and communities were always at the centre of how care was planned and delivered. We checked that the health and care needs of people and communities were understood, and they were actively involved in planning care that met these needs. We also looked for evidence that people could access care in ways that met their personal circumstances and protected equality characteristics.

At our last inspection we rated this key question as good. At this inspection the rating has remained good. This meant patients’ needs were met through good organisation and delivery.

People were involved in decisions about their care. The service provided information in different formats so that people could understand. People knew how to give feedback and were confident the service acted on any concerns. The service was easy to access and worked to eliminate discrimination. People received fair and equal treatment. The service worked well to reduce health inequalities and ensure people could access services. People were involved in planning their care and staff demonstrated a good understanding of integration and continuity and worked collaboratively with other local services to ensure ongoing care for patients.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The evidence showed a good standard. The service made sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

Patients were central to planning their care and making decisions. Assessment processes included understanding the person’s individual needs and wishes and we saw that these were taken into account when planning care throughout the community services.

We reviewed 9 care records and saw that people’s wishes were clearly recorded. This included their preferred place of care at the end of life. Data from the trust showed that 83% of patients at the end of life supported by community services achieved their preferred place of care at the time of their death.

We saw that people’s changing needs were responded to promptly and additional visits were provided when needed. We observed specialist palliative care nurses working in partnership with other services to meet the changing needs of patients, including when their condition had deteriorated or they were struggling to cope at home with their current situation.

Staff empowered patients to make their own decisions about their care and treatment. This included supporting them to make choices about treatment and the support they required. Staff told us of examples where patients had made decisions not to continue treatment, instead, deciding to focus on comfort and symptom management at the end of life. Staff were clear about their responsibilities to give people information so they could make informed decisions and ongoing assessment processes included checking in with patients about these decisions.

The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

Care and treatment was delivered in a way that met people’s assessed needs. The specialist palliative care team worked collaboratively with the acute NHS trusts across the county, hospices and other providers to ensure people’s needs were met and they received continuity of care.

Staff we spoke with shared examples of joined-up care across services. This included support for nursing homes caring for patients at the end of life. We were told of a case where a patient with complex pain management and other care needs was supported by specialist nurses and medical staff, along with care home staff and the patient’s GP. Teams worked collaboratively to ensure that staff had additional training and support to meet the patient’s needs.

Staff we spoke with had a good understanding of care needs of local people. We were told there were differences across the county. For example, we were told in the North there were higher levels of poverty and deprivation, and this presented more complexities, including where patients preferred to be cared for in hospital rather than at home. Staff within the SPCT were actively engaged with local systems to address inequalities and clinical leads and other staff were involved in palliative care network meetings. This ensured an ongoing understanding of local needs and actions to collaboratively address issues that may impact on continuity of care for patients.

The evidence showed a good standard. The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

People had access to information that was provided in a way they could understand and met their communication needs. Staff knew how to access translation services for people whose first language was not English and for patients who were deaf and needed signing support.

We saw patient and family information leaflets were available. These included guidance on ‘being with someone who is dying’, mouth care at the end of life, financial support and bereavement support. The service complied with the Accessible Information Standard. They made sure information was available in different formats and adapted these to the meet the needs of individual patients.

Information on how to complain was visible in community ward areas. Patients and those close to them told us staff kept them up to date about care and support. We observed staff communicating with people in a way that also checked their understanding of the information given.

The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They involved people in decisions about their care and told them what had changed as a result.

Patients knew how to give feedback about their care and experiences, including how to raise concerns. Staff told us they worked to address concerns immediately where possible and signposted patients to the formal complaints process when necessary.

Staff could access the trust complaints policy electronically. There had been 3 formal complaints about end-of-life care in the community in the last 12 months. There were no identifiable trends or themes. Complaints were investigated, and learning identified. For example, there had been an issue relating to a family being unable to move their loved one to a hospital bed once it arrived. Assistance with transfer from the ambulance service had been declined. Learning from the incident was that similar issues should be escalated to matron level in order to resolve.

Staff told us patients or family members making a complaint received feedback and where appropriate an apology. Staff knew how to handle complaints appropriately and outcomes of investigations were discussed at meetings.

The service had recently submitted Family Satisfaction with End-of-Life Care (Famcare) survey data. This is a survey tool used to evaluate the quality of care experienced by families. The questionnaire is sent out in the weeks or months following the patient’s death. Results were due to be made available in 2026.

The service made sure that people could access the care, support and treatment they needed when they needed it.

Staff made reasonable adjustments for patients, for example, people with mobility issues were provided with walking aids, and shower chairs. Staff told us there were no issues in obtaining necessary equipment for use in people’s homes.

People could access care and support in a way that worked for them. All patient requests for support at home went through the single point of access service where their needs were prioritised and they were referred to the most appropriate service. All patients on the caseload were reviewed at the weekly MDT. There was a duty responder within the specialist palliative care team (SPCT) who coordinated the shift and took responsibility for referrals. Handovers were held at the beginning and end of the shift to review patient needs and plan visits.

In the last 12 months the SPCT had received 1,432 referrals. The average length of stay on the caseload for patients at the time of our inspection was 38 days. There were 116 patients on the active caseload. In September 2025 there were 1,012 contacts between SPCT staff and patients across the county. At the time of our inspection the service did not collect response times to referrals. We were told a dashboard was in development, with plans to collect this information. Within the community service as a whole there was a 2-hour response time to visit patients with urgent needs, including patients at the end of life with symptom management issues. This visit was usually a member of the urgent/rapid response community nursing team, with the SPCT providing support for complex symptom management concerns as needed. We were told that the SPCT was in the process of review to ensure the appropriateness of referrals and their caseloads in relation to the capacity of the team.

There was adequate medical cover day and night. There were adequate arrangements for GP cover in community hospitals and agreed escalation protocols for patients needing additional support out of hours. There was a palliative care consultant on call for support and specialist advice overnight and at weekends.

The community SPCT had suspended their 7-day face to face service in 2024 due to staffing and capacity issues. Currently they provided a telephone advice service only at weekends. This was under review alongside a wider service and staffing review of the team, with plans to re-introduce the face to face 7-day service as part of development plans.

Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

Staff within the service and the wider organisation promoted a culture in which the people using the service felt empowered to give their views. Staff were aware of their responsibilities to ensure that patients were not discriminated against and that services and people’s experience of them were equitable.

Staff received training in equality, diversity, inclusion and human rights. They also completed training in learning disability and autism awareness and dementia awareness.

People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

Staff support patients to make decisions about their care and treatment and their future, for example do not attempt cardiopulmonary resuscitation (DNACPR). We saw that DNACPR decisions included clear records of discussions with patients and family members where relevant. Decisions included records of treatment escalation plans including where patients were to be cared for at home and not in hospital, in line with their wishes.

As part of patient assessments, staff identified patient needs, wishes and feelings. Staff in the community used the Electronic Palliative Care Coordination System (EPACCS), a digital system to electronically share information about a patient’s end of life care plan, wishes and priorities with relevant healthcare professionals.

Care for people who are nearing the end of their life was managed and communicated in a sensitive and dignified way. Staff ensured all relevant healthcare professionals and other relevant bodies were involved in planning the care and treatment of people with complex needs. We observed staff discussing future care needs of patients, including ensuring that patient’s wishes were central to decision making.