University Hospitals Coventry and Warwickshire NHS Trust

University Hospitals Coventry and Warwickshire NHS Trust is one of UK’s largest trusts and serves a population of about 1,000,000 across Coventry, Warwickshire and beyond.

Inpatient services are provided from two hospital sites, University Hospital Coventry (the larger site) and the Hospital of St Cross, Rugby. In total, the trust has 1,250 beds and provides both elective and emergency care. A major trauma centre, University Hospital Coventry specialises in cardiology, neurosurgery, stroke, joint replacements, in vitro fertilisation (IVF) and maternal health, diabetes, cancer care and kidney transplants.

The Hospital of St Cross, Rugby provides a smaller range of hospital services, including an urgent care centre, general medicine including elderly care, elective surgery including a surgical day unit, and a range of outpatient services.

We carried out this inspection as part of our comprehensive inspection programme. We undertook an announced inspection of University Hospital Coventry and the Hospital of St Cross, Rugby between 10 and 13 March 2015.

We also undertook an unannounced inspection on 19 March at University Hospital Coventry and on 29 March at the Hospital of St Cross, Rugby.

Overall, we rated University Hospitals Coventry and Warwickshire NHS Trust as ‘requires improvement’.

We have judged the service as ‘good’ for caring. We found that most of the time services were provided by dedicated, caring staff. Patients were treated with dignity and respect and were provided with appropriate emotional support.

However, improvements were needed to ensure that services were safe, responsive to people’s needs and well-led.

Our key findings were as follows:

Cleanliness and infection control

In most areas patients received care in a clean, hygienic and suitably maintained environment. Staff were aware of and applied infection prevention and control guidelines. However, we saw poor infection control practices in the radiology department, poor maintenance of the environment in parts of outpatients and some poor cleaning practices.

We observed good practices in relation to hand hygiene and ‘bare below the elbow’ guidance and the appropriate use of personal protective equipment, such as gloves and aprons, while delivering care in children’s services, the emergency department and maternity. These practices were not so well embedded in the critical care, medical and surgery departments, where examples of poor infection control practice were observed.

There was a pre-admission service within the outpatients department; however, no preoperative MRSA screening was undertaken during this consultation. This meant that not all patients undergoing elective surgery were screened preoperatively. Screening has been a Department of Health recommendation since 2007 and is in line with the trust’s own policy.

There were 13 cases of MRSA bacteraemia affecting 11 patients reported between April 2014 and February 2015, with nine of these cases developing during the patient’s period of care within the trust.

We found detailed investigations of infection control incidents were not always undertaken and so the opportunity for learning and prevention of harm to patients from these incidents was lost.

The standard of record completion varied across the services: in some areas we found gaps in the completion of records and care plans were not always individualised.

Records in most departments were stored securely in line with requirements. However, on some medical wards we found records were not always kept in a secure area.

We found that do not attempt cardio-pulmonary resuscitation (DNA CPR) forms were not always correctly completed. Incomplete or incorrect DNA CPR forms can lead to patients being subjected to attempts to resuscitate them when this is not appropriate or in line with their wishes.

Staffing

Staffing levels at the time of the inspection were adequate, although there was significant use of agency and locum staff. The trust had taken action to ensure that agency and locum staff had access to the trust’s information systems; these staff were issued with smart cards if working more than 5 days and had to complete a 2-hour e-learning package.

The trust used the nationally recognised Safer Nursing Care Tool along with National Institute of Health and Care Excellence guidance to assess required nursing staff levels.

Vacancy rates, staff turnover and sickness were audited monthly. Daily checks were completed across all areas to check staffing requirements and availability against gaps in the rota.

Care and treatment within the Cardiac Critical Care Unit was led by consultant cardiac surgeons with support and advice, when required, from intensive care consultants. However, the arrangements for senior medical cover did not meet the requirements of core standards in intensive care.

Mortality

Our Intelligent Monitoring report of December 2014 showed that there was no evidence of risk for summary hospital mortality level indicators or for hospital standardised mortality ratio indicators.

Incidents

The trust used a centralised web-based reporting system for staff to report incidents and near-misses. Staff had a good knowledge of this system and were encouraged to use it.

However, some staff did not feel confident in completing incident reports and said they did not always get feedback.

Serious incidents were managed through trust’s Significant Incident Group. Trust root cause analysis leads were appointed to manage the investigations and actions were assigned to address the issues. However, action plans following investigations were not always completed in a timely manner and learning was not always transferred to practice.

We found the trust risk register did not reflect the risks that were present within the services being delivered.

Nutrition and hydration

The trust had processes in place to meet patients’ cultural and specialist needs in relation to eating and drinking. Patients were supported by dieticians and by the speech and language therapy team. Patient records included an assessment of patients’ nutritional requirements based on the malnutrition universal screening tool.

The trust used national guidance for parenteral and enteral nutrition. Policies were in place to help patients who were unable to take oral nutrition or fluids to be given specialist feeds until they could be seen by a dietician. Patient records we looked at confirmed that these policies were in use. This meant that patients were protected against the risk of malnourishment.

As well as mandatory training, catering staff received annual training from the dieticians.

The systems in place for managing and storing drugs, including controlled drugs and oxygen, were inconsistent throughout the trust.

In some areas there was insufficient storage space for the quantity of medication, resulting in medication being stored insecurely. We also observed out-of-date intravenous fluids and oxygen cylinders available for use.

We found some patients who were in pain and had not been given their prescribed drugs when they needed them.

Anticipatory prescribing in end of life care was common, in line with best practice. This meant that pain relief and other medication could be started quickly if patients became unwell.

In the critical care unit we observed that intravenous fluid bags were used for preparing intravenous injection/infusions for more than one patient and were used for up to 24 hours. There was a risk that the bags could be contaminated by poor infection control practices, or maliciously while left unattended on trolleys on the units. This practice was escalated to the trust executive team during the inspection.

Flow and capacity

There were significant issues with flow and capacity within the trust and challenges in discharging patients to an appropriate place, resulting in patients staying longer within the emergency department than was appropriate. The trust’s performance had consistently fallen below the requirement for patients being discharged from the emergency department within four hours.

There were a number of patients requiring medical specialities care who were being cared for in other areas. This meant they were being cared for in areas that may not have been appropriate to meet their needs or by staff who did not have the right level of skill to provide their care.

At the time of the inspection there were 133 patients within the trust who could have been discharged. This involved more than 10% of the trust’s beds. This was affecting the trust’s ability to treat patients in a timely manner, with referral-to-treatment time for many services in excess of the required 18-week wait.

We saw several areas of outstanding practice including:

Outstanding practice in respect of trauma care: for example, the fracture patient pathway that encompassed effective pain management and integrated daily and weekend physiotherapy sessions to develop improved outcomes for patients.

The trust was working to improve the experience of older patients. Initiatives included blue pillowcases for patients with dementia, the screening of all patients aged 75 and over for dementia and the development of a ‘care bundle’.

The trust was using the ‘M’ technique as a means of holistic communication by touching the hands and feet of older people. It included the repetition of stroking and conventional massage through slow, constant and rhythmical pressure.

The head of midwifery had won the Healthcare Hero and Lifetime Achievement Award 2013/14 at the Coventry Telegraph’s Pride of Coventry and Warwickshire Community Awards ceremony.

The specialist bereavement midwife had received the National Maternity Support Foundation Award for Bereavement Care at the Royal College of Midwives Annual Midwifery Awards 2015. They had provided sensitive photographs for parents who had lost their baby in late pregnancy or soon after birth.

The trust had developed a specialist teaching centre that was using technology to allow staff to have enhanced training in surgical techniques. This unit is the only one in the UK and is accessed by staff from many organisations across the country.

Professor Sir Mike Richards

Chief Inspector of Hospitals