South Warwickshire NHS Foundation Trust Quality Report Lakin Road Warwick CV34 5BW Date of inspection visit: 15,16,17,18 and 29 March Tel: 01926 495 321 2016 Website: www.swft.nhs.uk Date of publication: 28/03/2017 This report describes our judgement of the quality of care at this trust. It is based on a combination of what we found when we inspected, information from our ‘Intelligent Monitoring’ system, and information given to us from patients, the public and other organisations. Ratings Overall rating for this trust Requires improvement ––– Are services at this trust safe? Requires improvement ––– Are services at this trust effective? Requires improvement ––– Are services at this trust caring? Good ––– Are services at this trust responsive? Good ––– Are services at this trust well-led? Requires improvement ––– 1 South Warwickshire NHS Foundation Trust Quality Report 28/03/2017 Summary of findings Letter from the Chief Inspector of Hospitals South Warwickshire Foundation NHS Trust provides a • Nurse staffing levels and skill mix was planned and range of hospital and community health services to a reviewed in line with national guidance. Most areas community of approximately 270,000 in South had adequate staff to ensure patients received safe Warwickshire and the surrounding areas. The trust care and treatment. provides a full range of district general hospital services at • Although the trust had taken a number of actions to Warwick Hospital, community inpatient care at Stratford- promote the duty of candour to staff, some staff in the Upon-Avon Hospital, Leamington Spa Hospital and Ellen emergency, gynaecology and maternity departments Badger Hospital. The trust also provides neuro did not have a thorough understanding of this and rehabilitation to young adults at the Central England what this meant within their practice. Rehabilitation Unit (CERU), based at Leamington Spa • The trust had reported one never event (a largely Hospital. Community services for adult’s end of life care preventable patient safety incidents that should not and children and young people are also provided by the occur if the available preventative measures had been trust. implemented) in the 12 month period ending February 2016. Although still under investigation at the time of There are 441 inpatient beds within Warwick Hospital and the inspection early lessons had been learnt and 50 inpatient beds throughout the community hospitals. shared. We carried out an announced comprehensive inspection • The hospitals were seen to be clean and hygienic and of the trust from 15 to 18 March 2016. We undertook an most staff followed the trusts infection control policy, unannounced inspection on 29 March 2016. were ‘bare below the elbow’ and used personal protection equipment. There were some incidents of We held focus groups with a range of staff in the hospital poor hand hygiene. and community, including union representatives, black • All patients admitted to hospital were screened for and minority ethnic staff, governors, nurses, health methicillin resistant staphylococcus (MRSA) to assist visitors, trainee doctors, consultants, midwives, with isolation and treatment. There was limited follow healthcare assistants, student nurses, administrative and up of MRSA screening for patients admitted to the clerical staff and allied health professionals. We also medical wards where we found results of this spoke with staff individually as requested. screening were not routinely recorded in nursing Overall, we rated South Warwickshire Foundation NHS notes. Trust as requires improvement with three of the five • Cases of MRSA were low with the trust reporting zero questions we ask with safe, effective and well-led being cases between August 2014 and August 2015, however judged as requiring improvement. there were 17 cases of C. difficile reported during the same period. We have judged the trust as good for caring and • Mandatory training was, across most areas below the responsiveness. We found that services were provided by trusts target of 85% and 95% for safeguarding adults dedicated, caring staff. Patients were treated with and children and information governance. kindness, dignity and respect and were provided the • The level of safeguarding children’s training that staff appropriate emotional support. The trust was planning in certain roles undertook was in line with trust policy, and delivering services to meet the needs of patients. The but was not compliant with intercollegiate document emergency department and adult community services ‘Safeguarding Children and Young People: Roles and were rated as outstanding for responsiveness. Leadership competencies for Health Care Staff (March 2014).. for end of life care in the community was judged to be Therefore, we could not be sure that staff had the inadequate. sufficient knowledge and skills to safeguard children. Our key findings were as follows: • In many wards and departments we saw medicines in unlocked cupboards and drawers. Although some Safety medicines were left unlocked to allow rapid access in 2 South Warwickshire NHS Foundation Trust Quality Report 28/03/2017 Summary of findings an emergency in some areas all medicines were submitted due to staffing issues. Performance in unsecured, not just ones that required emergency national audits was generally the same or better than access therefore we were not assured that medicines the national average. Actions plans were in place to were stored in a way that prevented misuse, tampering address areas for improvement action. or theft. • Staff and teams worked well together to deliver • Processes and procedures had been developed for effective care and treatment. women on the postnatal ward to self-administer some • Overall, the trust appraisal target of 85% for all staff medication if they opted to do so. had been met with 100% of medical staff and 92% of • In the emergency department (ED) and minor injury non-clinical and clinical staff compliant. units, children with minor complaints were not seen in • Not all staff had full understanding of the Mental a secure paediatric area, they waited with adult Capacity Act 2005 and their responsibilities and role in patients which is not in line with national guidance. the management of patients with capacity concerns. During our unannounced inspection; we observed This includes appropriate formal assessment changes to the ED had been made. A paediatric sub processes and escalation of concerns. waiting room had been created within the main • The individualised care of the dying patient care plan, waiting area for paediatric see and treat patients, which was a replacement for the Liverpool Care although there were no robust procedures in place for Pathway, was designed to be used for patients in children to be observed for rapid deterioration while hospital and community settings. However, this was waiting in this area. found not to be fully embedded in the care of the • Patient records were not always stored securely. dying in the hospital and was not used by the • Patient risk assessments were not fully completed on community teams. admission and generally not reviewed at regular Caring intervals throughout the inpatient stay. This included incomplete risk bed rails risk assessments resulting in • Feedback we received from patients was consistently the use of bed rails without a completed risk positive about the way nursing and therapy staff assessment. treated them. Patients felt safe and cared for and staff • Management of the deteriorating patient was in place were respectful of their needs and preferences and in most areas of the trust through the use of early took time to understand personal requirements or to warning score (EWS) and paediatric early warning explain the care being delivered. score were used (PEWS). However there was no such • The need for emotional support was recognised and recognised tool in use in the special care baby unit. provided through a range of support mechanisms including a clinical psychology service. Effective Responsive • Care was delivered in line with legislation, standards and evidence-based guidance, however some local • The flow of patients into and through the hospital was and trust guidelines needed updating. well managed with all areas of the trust taking • The mortality rate as indicated by the Summary responsibility for this. Hospital-level Mortality Indicator (SHMI) was “as • The trust consistently exceeded the Department of expected” for January to December 2015, at 1.1 Health target for emergency departments of 95% of all against the England figure of 1.0. The trust Hospital patients to be admitted, transferred or discharged Standardised Mortality Ratio (HMSR) (for in hospital within four hours of arrival to the emergency deaths only) for January to December 2015 was department every month. The percentage of “within expected range”, at 108.0 against the England emergency admissions via ED waiting four to 12 hours figure of 100 from the decision to admit until being admitted has • Data was submitted for all national audits in 2013/ been consistently lower than the England average. 2014, with the exception if the Acute Myocardial This meant that patients could access services in a Infarction and other ACS (MINAP) audit which was not timely way. 3 South Warwickshire NHS Foundation Trust Quality Report 28/03/2017 Summary of findings • The percentage of admitted surgical patients that Well led started consultant-led treatment within 18 weeks of • The trust had a clear vision to provide high quality, referral was consistently below the 90% standard clinically and cost effective NHS healthcare services between September 2014 and May 2015. In June 2015 that met the needs of patients and the population that this standard was abolished. Between September 2014 they serve. However there was no service specific and August 2015 the trust’s performance for this written strategy for individual core services and measure was better than the England average in all specialties did not appear to have a shared vision or but two months. However, the trust consistently met aim.