South Warwickshire University NHS Foundation 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

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. We also checked there was a culture of learning and that when things went wrong improvements were made, that care environments were suitable and that medicines were appropriately managed.

At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

There was a positive culture of learning and people felt able to raise concerns. Managers investigated when things went wrong and there were processes for shared learning and the identification of improvements. There were enough staff with the right skills and experience. The environment and facilities were suitable and met the needs of people at the end of life. Staff had access to suitable equipment. Staff managed medicines well and took action to improve the availability of end-of-life care medicines to ensure delays were kept to a minimum.

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 service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

There was a culture of safety and improvement. There had been 57 incidents reported relating to community end of life care in the last 12 months. These included issues around prescribing and obtaining end of life care medicines.

The NHS Patient Safety Incident Framework was used across the trust and systems developed to learn and improve from safety incidents. All staff knew what incidents to report and how to report them. Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation when things went wrong. We reviewed incident records and saw that investigations were carried out and learning and improvements were identified. There was evidence that changes had been made as a result of staff feedback and discussions about improvements. This included the development of a protocol to ensure that end of life care medicines were available from the hospital pharmacy, for patients in the community when there were difficulties obtaining these from community pharmacies.

Incidents were reviewed at quality meetings to monitor trends and identify themes.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Staff made sure there was continuity of care, including when people moved between different services.

The service’s referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met. Patients and professionals could contact the single point of access line where they would be signposted to the most relevant service. This could be specialist palliative care or urgent care from district nursing teams, or rapid care where there were time sensitive requirements such as the need for anticipatory medicines for patients at the end of life.

Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care. Routine multidisciplinary meetings were held where referrals were discussed as well as continuity of care for existing patients. We observed services working together to ensure continuity of care. This included when patients required an inpatient admission when their needs were urgent. We saw that any concerns about systems, pathways and transitions were reported as incidents and learning identified to ensure improvements.

There was a shared patient assessment and care planning tool for use at the end of life. The Integrated Holistic Assessment and Individual Plan of Care for the Dying Person tool was used across regional community, acute and independent services to ensure continuity of care. This had been developed collaboratively to ensure continuity and contained continuous records relating to the individual’s care, multi-disciplinary decisions and discussions with the person and their family.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff caring for patients in the community were trained in safeguarding at level 2, they knew how to raise safeguarding concerns, and did that when appropriate. They could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. We saw examples of safeguarding referrals made for patients in the community where risk of harm was identified. Staff were able to articulate actions taken to protect patients.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies. Safeguarding was discussed as part of multidisciplinary and case review meetings.

Staff followed safe procedures for children visiting the service. Children visiting community inpatient services had to be accompanied by an adult. Staff had completed training in child safeguarding at an appropriate level for their role.
 

The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff communicated with patients so that they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties. This included the use of interpreters and visual prompts. Staff were focused on balancing safety and risks to ensure people received care that was appropriate, while focusing on quality of life for people at the end of life.

Staff assessed and managed risks to patients and themselves well. Risk assessments were routinely undertaken. This included risks to skin integrity, the risk of falls and infection and venous thromboembolism risks. We saw that assessments were completed and recorded in line with national guidance by community nurses and specialist palliative care staff as appropriate.
 

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

We visited patients receiving palliative and end of life care in their homes. We also visited 2 community hospital wards where patients were receiving palliative and end of life care. Where possible, patients at the end of life being cared for at community hospital wards were cared for in an individual room. The wards visited had suitable facilities to meet the needs of patients. They were visibly clean and tidy and had suitable equipment available for safe care. Staff carried out daily safety checks of specialist equipment. They ensured that emergency equipment and essential equipment such as syringe drivers (for continuous administration of palliative and end of life care medicines) were routinely monitored, maintained and accessible. Records of checks were maintained. Equipment was tested and appropriately calibrated. Single use sterile equipment was available and equipment checked was within the expiry date.

Specialist equipment was available for patients being cared for at home. Community nurses ordered equipment as needed. We were told that equipment was available quickly and was delivered directly to people’s homes. This included hoists, specialist beds and mattresses, as well as syringe drivers that community nurses would supply when needed. Staff told us there were no issues with requesting equipment to care for patients at the end of life.
 

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

We reviewed staffing data that included a comparison of actual data and the identified staffing establishment across acute and community palliative care services. There was an establishment of 3.2 whole time equivalent (WTE) palliative care consultant posts, with 4 WTE actual posts filled. In addition, there were 20.6 WTE specialist palliative care nurses, with 22.77 WTE actual posts filled. The sickness rate for medical staff was 1.26% and for nursing was 8.12%. We were told there had been some issues with long term sickness within the community specialist palliative care team and that this had particularly impacted Rugby. Nursing staff we spoke with told us the teams in the North and the South of the county provided cover for the absence of staff in Rugby and that this has added to their workloads and created pressure within the team. However, at the time of our inspection there were improvements with staff returning to work as part of phased return programmes. There had been no agency nursing usage within the team and we saw that on average 12 shifts a month were covered by staff working additional bank shifts. Turnover within the team was zero within the last 6 months.

Managers had calculated the number and grade of nurses required. Senior nursing staff within the specialist palliative care service told us they had drafted a business case to increase the nursing establishment. Service leads told us there was currently a review of capacity and the service specification within the team. The aim of this was to ensure any additional resource allocation was based on the team managing patients who required specialist palliative care, rather than routine end of life care that was managed by other community nursing teams.

Medical cover was provided by palliative care consultants, this ensured 24-hour medical cover for palliative care advice for patients in the community. Medical cover for the community hospitals was provided by local GP practices, with specialist palliative care input when needed.

Staff had received and were up to date with appropriate mandatory training. Overall mandatory training achievement within the specialist palliative care team was 91%. The training was appropriate for the patient group using the service. New staff received a comprehensive induction, this included opportunities for development and shadowing colleagues within the team where staff were new to the palliative care role.

Staff received an annual appraisal. Current appraisal rates within the team were at 78%. We were told this had been impacted by staff sickness and changes in senior nursing and there were plans to increase this figure.
 

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff cleaned equipment after patient contact and labelled equipment to show when it was last cleaned. Clinical equipment was visibly clean, and I am clean stickers were in use to demonstrate this.

All ward areas were clean, had required furnishings and were well-maintained. Cleaning records were up to date and demonstrated that the ward areas were cleaned regularly. The ward environments we visited in the community hospitals were all visibly clean.

Staff adhered to infection control principles, including handwashing. They appropriately used personal protective equipment (PPE) and disposed of this correctly, including in people’s own homes. Hand hygiene audits were carried out. We saw these were at 100% achievement on Nicol ward at Stratford Hospital.
 

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happen.

Staff followed good practice in medicines management to ensure they were appropriately prescribed, supplied and administered in line with relevant legislation, national guidance and best practice. We saw there were systems for the recording, monitoring and disposal of controlled drugs (CDs). Controlled drugs are drugs that are subject to high levels of regulation as a result of government decisions about drugs that are classed as potentially habit forming, addictive or harmful. We saw that records were maintained appropriately in patient’s homes and on community hospital wards. Controlled drug audits were routinely carried out within community hospital wards and results of these were on display. Nicol ward at Stratford Hospital had a score of 100% for the most recent audit.

There were non-medical prescribers working within the specialist palliative care team. Anticipatory prescribing, where medicines were prescribed for use ‘just in case’ the patient experienced common symptoms at the end of life, was undertaken in line with national guidance. The service used local General Prescribing Guidance for the Dying Adult that was agreed for use across Coventry and Warwickshire. We saw that prescribing was in line with this guidance.

We were told that anticipatory medicines for usage in patient’s homes were obtained on prescription from community pharmacies in the area. However, there had been incidents where some medicines had been difficult to obtain when needed. As a result, the trust ensured that relevant medicines could be obtained from the hospital pharmacy in the event of supply issues in the community.

People and those close to them were involved in discussions around the use of medicines. This included changes to regular prescribing as well as for the management of symptoms. Staff provided advice to people and their carers. Some people were receiving medicines by syringe pumps (medicines delivered under the skin over 24 hours) and staff monitored these pumps and changed them when required. Staff knew how to raise and escalate concerns if there were problems with medicines or the management of symptoms.